This innovative pilot was developed in response to rising emergency admissions and fragmented support for patients with long term conditions across Surrey Downs Place, with particular focus on the Winter period and beyond, when system pressures are at their highest. Patients with heart failure often present with one or more co-morbidities, which increases vulnerability and heightens reliance on acute services, particularly during winter months when conditions can exacerbate symptoms and trigger deterioration. Further to this, Surrey Downs was identified as an outlier in heart failure attendances at Accident & Emergency (A&E) in a recent national report. By using population health management tools, we were able to proactively identify high risk patients for tailored support.

The pilot adopted a proactive, population health-driven approach. High-risk patient groups, based on risk of deterioration, emergency department attendances and hospital admissions were identified using PHM tools, then prioritised for structured, holistic assessments and personalised care plans. Seven Integrated Neighbourhood Teams (INTs) delivered interventions, supported by multidisciplinary team (MDT) meetings and clear escalation pathways to specialist services. This proactive model was linked with the specialist MDTs and urgent care services such as virtual ward or Urgent Care Response Service to ensure a complete end to end pathway. Care delivery was co-designed by clinicians and carers across INTs and front-line staff received targeted training.

The programme delivered significant improvements in care for Surrey Downs patients with long-term conditions. From 2939 Heart Failure patients identified via population health risk stratification, 470 patients were selected for structured interventions which resulted in 1266 appointments carried out in their local neighbourhoods over a seven-month period.
Key findings revealed that holistic assessments and personalised care plans led to better patient engagement, improved self-management, and enhanced coordination across health and social care services. Patients reported feeling more supported and empowered, with many experiencing improved quality of life and reduced anxiety around managing their conditions.

From a system perspective, the pilot contributed to a measurable reduction in emergency admissions and avoidable hospital attendances. Early data suggests a positive trend in reduced demand on urgent care services (Patients who went through the programme had 50 fewer A&E attendances), indicating that proactive, integrated care can alleviate pressure on overstretched systems.

The impact extended beyond individual outcomes. Multidisciplinary collaboration across teams and partner organisations was strengthened, with primary care, community services, and voluntary sector partners working more cohesively and delivering a single plan for each individual patient. This encouraged a more sustainable model of care, built around prevention and personalised support.

The pilot which is aligned with NHS England health policy of shifting from sickness to prevention, demonstrated that using data-driven approaches to identify and support vulnerable patients can lead to meaningful improvements in health outcomes, patient experience, and system efficiency. These findings provide a strong foundation for scaling the proactive model for long term conditions through neighbourhoods across other areas, with the potential to transform care for people with complex needs.

Background:
Persons with mental health problems (PwMHP) face inequalities in timely access and utilization of health care services. Addressing these inequities requires integrated, person-centred approaches that connect mental and physical health, strengthen continuity of care, and promote self-management and prevention. Within the EU-funded CO-CAPTAIN project (GA 101104784), an intervention based on the Patient Navigation (PN) Model was co-adapted for primary cancer prevention and is being implemented to help patients ‘navigate’ health services, overcome barriers and adopt healthier lifestyles. Evidence on PN for primary cancer prevention among PwMHP remains scarce, especially across multiple countries, leaving uncertainty about acceptability, mechanisms, and early perceived impact. This study explores PwMHP’s perceptions, expectations and early experiences of engagement with the PN-based intervention.

Approach:
We conducted 28 semi-structured interviews with participants from the 288 PwMHP (9.72% of the sample) enrolled in a single-arm multi-centre interventional study across Austria, Greece, Poland and Spain. Interviews were performed 6-8 weeks after enrolment in the PN-based intervention targeting primary cancer prevention. Data were analysed thematically using an iterative and a combined inductive and deductive approach. All participants provided informed consent, and ethics approvals were obtained before study participation.

Results:
Participants were predominantly female (67.86%), aged between 20 and 67 years (mean 44.53 years). They joined the CO-CAPTAIN intervention mainly to improve health and lifestyles and to prevent illness, yet curiosity emerged as a dominant initial motivator. Additional motivations included contributing to research, improving quality of life, and accessing practical and trustworthy health information. Desired goals centred on modifiable risk factors (weight loss, smoking cessation, physical activity, diet) and self-care practices. Participants also aimed to establish new routines, gain knowledge about health and cancer, and engage in self-reflection on their behaviours. The PN was perceived as a trusted, culturally attuned, supportive guide, fostering a sense of continuity. Simple and regular communication via phone calls and text messages was considered optimal to maintain meaningful engagement. Early experiences often exceeded expectations particularly in terms of usefulness and empathy. Findings were consistent across countries, with only minor contextual variations in how trust was established.

Implications:
Curiosity can serve as a key entry point to engage PwMHP in preventive care. Participants’ goals clustered around modifiable risk factors (smoking, physical activity, diet, etc.) and self-care, indicating the importance of brief, behaviour-specific goal-setting, tailored health information, and motivational support as central components of PN for this population. PN interventions should prioritise low-burden onboarding, brief, focused behaviour-change interactions, and continuous, relational communication to sustain engagement over time. Given that early experiences of PwMHP within the PN-based intervention often exceeded expectations indicating potentially beneficial effects of the intervention at an early stage, health systems could embed PN within primary care and community mental health workflows, supported by standardised referral pathways and digital or remote communication. This could enhance accessibility and continuity of care. Future evaluations should assess changes in risk-factors, quality of life and assess cost-utility to inform scale-up and integration into health system practice.

Background: Poverty is about more than just finances: it affects housing, health, work, school, social connections, and both parents and children. Integrated care for families in poverty aims to helps parents and children with all of their needs. We studied what support activities are actually provided, and whether parents and children are involved.
Approach: This study was conducted in collaboration with 11 organizations in Rotterdam, the Netherlands, that provide integrated care to families in poverty. Nineteen professionals supporting 26 families experiencing poverty were followed over an average period of 3.5 months. We examined which activities professionals engaged in, and which life domains and family members were included. After each meeting with the parent, professionals sent an update to the researcher about the support provided during that meeting. These updates were compiled into case records, and analysed using a thematic coding approach. We grouped the activities performed by the professional into overarching themes from which life domains could be identified. Additionally, for each update, we coded which family members were included in the provided support. The study materials and design, including consent procedures and study duration, were evaluated and approved by people with lived experience of living in poverty, and by professionals providing support to families in poverty.
Results: A total of 240 updates were analysed. Of the support mentioned in these updates, 72% focused on parents, 17% on both parent and child, 7% on the family as a whole, and 4% on children specifically. The most frequently observed professional activities involved a) making practical arrangements (such as applying for financial aid and support with housing-related matters), b) contacting external organizations (such as the Tax Authority, municipality and utility companies), and c) conversations and advice for parents (including conversations about feelings and stress, finances, healthcare and housing).
A variety of life domains were represented, including financial, housing, work, mental and physical health, parenting, education, legal and social network domains. However, most support was provided in the financial domain, sometimes in combination with another domain (for instance with health, when contacting a health insurance company about payment arrears).
In terms of family members, support was mostly aimed at the parent. Child-focused support often indirectly benefited children (for instance through parenting advice). When children were directly involved, support was often practical in nature, and focused on financial and education domains (such as cancelling a child’s bank account).
Implications: In practice, professionals support families in various life domains, although support in the financial domain was most common, highlighting how poverty permeates every aspect of families’ lives. Additionally, support is mainly aimed at the parent(s). Although supporting parents indirectly benefits children, identifying the needs of children growing up in poverty is essential, as professionals are uniquely positioned to support children, help them thrive and buffer them against the negative consequences of poverty. These findings highlight the importance of strengthening child-focused approaches within integrated family support and are relevant for policy and practice.

Background:
Integrated care has been pursued globally as a means to improve people’s health and wellbeing, improve service efficiency and, more recently to address inequalities in health. In 2022 England’s National Health Service introduced Integrated Care Systems (ICSs): broad partnerships of health and care organisations given responsibility for planning local services, whose strategic aims include reducing health inequalities. This study will explore how ICS partners plan to work together on this issue, to gain insights into the role of integrated working in addressing health inequalities.

Approach:
A structured document analysis of all 42 English ICSs’ Strategy Documents published between 2022 and 2024 was conducted. An inductive approach was taken in line with Grounded Theory methodology. Themes were identified and developed following line by line coding of all documents, with joint coding of some documents. This study is the first element of a PhD and will directly inform stakeholder and public involvement in the next phase.

Results:
The analysis revealed the following key themes. ICS partners present integrated working on health inequalities as a necessity, reflecting that health inequalities are complex, multifactorial problems which they cannot solve alone. Local people and Voluntary, Community and Social Enterprise organisations are viewed as key partners in integrated working on health inequalities. Integration will primarily be organised on a geographical basis, with partnerships operating at ‘system’, ‘place’ and ‘neighbourhood’ level. Partners plan to work together strategically (by sharing information and developing common priorities on health inequalities) and operationally (by delivering joined up health and care services to those in need). They intend to collaboratively address health inequalities by reducing inequalities in healthcare (focusing on access), maximising opportunities for prevention, and addressing the wider determinants of health (including housing and employment). Finally, ICSs suggest that specific groups might benefit from integrated working to address health inequalities, with emphasis given to children, young people and families, people with serious mental illness, learning disabilities or autism, and people from minoritised communities.

Implications:
These findings illustrate how local care health and care leaders in England are interpreting a national policy requirement for integrated working to reduce health inequalities. Future work will explore how ICSs implement these ambitions in practice.

Background: Obesity is a major global health challenge rooted in genetic, behavioral, socioeconomic, and environmental factors. Although healthcare influences only twenty percent of health outcomes, most interventions still focus on weight rather than broader social determinants of health (SDH). Addressing obesity effectively requires intersectoral approaches that account for individuals’ life trajectories and bridge health, social, community, and policy domains; yet such collaboration remains limited. Launched in 2023 by a citizen partner and a clinical researcher, the COLLAB-INTER-360-Obesity participatory research aims to co-develop an intersectoral learning community uniting people living with obesity (PLWO) and stakeholders from health, community, political, civil society, and academic sectors to better respond to PLWO’s needs. Given limited evidence on how diverse actors engage in such initiatives, an environmental scan was undertaken as a preliminary step. Approach: To identify and characterize intersectoral interventions targeting PLWO in community and primary care settings we conducted a peer-reviewed and grey literatures. Following Arksey and O’Malley’s framework, a comprehensive search was conducted across three academic databases and grey literature sources (May 2024-February 2025). Eligible records described intersectoral interventions developed since 2006 for adults in Commonwealth countries, in English or French. Peer-reviewed studies and grey literature were reviewed through a two-stage process using Covidence and a bilingual Excel template, respectively. Duplicates were removed automatically, and discrepancies were resolved through team consensus. Data extraction followed an adapted conceptual framework based on SDH. Results were synthesized per PRISMA 2020 guidelines, with summary tables describing intervention characteristics. A bibliometric analysis using VOSviewer® refined the conceptual mapping. Results: Twenty-three studies were included (twenty peer-reviewed, three grey literature), mainly from the United States and focused on lifestyle modification programs. Obesity was primarily defined using weight-based metrics with little consideration for SDH. None explicitly defined intersectorality. Collaborations mainly involved health, academic, community, and faith-based actors. Community health workers emerged as key connectors between clinical and social domains. Most interventions targeted minority populations. Outcome measures remained largely biomedical, with minimal integration of SDH indicators. Intersectoral interventions for PLWO remain poorly conceptualized. Implications: Advancing equity and person-centered care requires integrating SDH into evaluation frameworks, formalizing intersectoral governance, and reinforcing the role of community health workers. Findings of this scan will inform community such as COLLAB-INTER-360-Obesity learning community, in designing co-creation workshops that foster integrated, intersectoral approaches to obesity management, an area still underdeveloped within healthcare systems.

This work presents the methodology and findings of a large-scale, co-produced engagement initiative undertaken to inform the development of the Integrated Urgent Care Strategic Plan for across an Integrated Care System in England. The project aimed to ensure that urgent care services are timely, appropriate, and inclusive—“first time, every time”—by embedding the voices of people and communities into strategic commissioning.
Methods
Led by the Suffolk and North East Essex Integrated Care Board (SNEE ICB), the engagement process was designed and delivered collaboratively with a 50-member Insight and Oversight Group comprising individuals with lived experience, community organisations, service providers, and commissioners.
A bespoke engagement toolkit was co-created, which included accessible surveys, community conversations, and an online “magic wand” ideas board. Between May and July 2025, 483 engagement interactions were recorded, encompassing diverse demographics and under-served groups. The engagement focused on generating ideas for improved urgent care access and inclusion, to ensure services are fit for the future and population as a whole.
A novel health inequalities mapping model was developed to extract data that highlighted participant ideas and suggestions for more accessible and inclusive urgent care services in relation to life experiences and identities - e.g. digital exclusion, transport limitations, language barriers, sensory impairment, being transgender, homelessness, alcohol and substance use, pregnancy, people with mental health conditions, learning disabilities, neurodivergence, and carers.
Findings
Service integration - Respondents called for seamless coordination between NHS 111, GPs, pharmacies, mental health services, and social care, supported by shared care records and joined-up triage systems.
Communication and navigation - Confusion about when and how to access urgent care was widespread. Suggestions included clearer signposting, visual guides, multilingual materials, and 'humanised' contact options.
Workforce and training - Strong support for increased staffing and training in inclusive communication, trauma-informed care, and lived experience-led education particularly for neurodivergence, sensory health, and LGBTQ+ inclusion.
Digital and non-digital options - While some participants supported AI-assisted triage and digital tools, many emphasised the need for non-digital alternatives, such as phone-based support and walk-in centres.
The Insight and Oversight Group also analysed responses from 12 priority groups stemming from the health inequalities mapping. Each contributing tailored recommendations, such as mobile urgent care units, quiet waiting areas, accessible diagnostics, and culturally sensitive services.
The resulting Strategic Plan is informing the co-produced development of a service specification and procurement of integrated urgent care services, for delivery from 2027.
Discussion
This engagement process demonstrates the value of co-production in integrated care system transformation. It highlights how inclusive, community-led approaches can generate actionable insights and foster trust between providers and service users. The findings are now being translated into commissioning priorities and service redesign, and demonstrate an example of strategic commissioning in its new form following national direction.
By centring lived experience and addressing inequalities, the Strategic Plan aims to deliver urgent care that is person-centred, integrated, accessible, and equitable. This work offers a replicable model for other regions seeking to embed community voice and co-production into urgent care planning and broader health system reform.