Implementing Integrated, Preventative Care for Older Adults with Moderate Needs: Lessons from Seven English Local Care Systems

Background: Despite strong policy emphasis on prevention and integration in English care system, progress remains uneven and fragile. There is little evidence about how older adults with moderate care needs: those requiring some help with daily living but not eligible for statutory services, are supported across local care systems. The Models of Support for Moderate Needs in Older People (MSMOP) study sought to fill this gap by examining how local authorities (Adult Social Care, Public Health, Housing), NHS partners, and the voluntary and community sector (VCS) organise and deliver support, and what enables or constrains the development of preventative, integrated care models.

 

Approach: A qualitative process evaluation was undertaken across seven English local authority areas between 2021 and 2025. Sites reflected diverse geographies and system maturity, including both urban and rural contexts. Data included over 100 in-depth interviews with local policymakers, commissioners, NHS and public health managers, VCS leaders, and practitioners. Documentary analysis of local strategies, commissioning plans, and policy frameworks complemented the interviews, enabling triangulation across data sources.

 

Drawing on system thinking, the study explored system conditions shaping the implementation of integrated, preventative care, focusing on governance, funding, workforce, infrastructure, and inter-organisational culture. People with lived experience of providing and accessing support also informed the interpretation of findings through participatory workshops and advisory group.

 

Results: Across all sites, there was strong strategic intent to shift towards preventative, community-based approaches, supported by integration and partnership across stakeholders within local care systems. However, implementation was constrained by financial pressures, crisis-driven statutory priorities, siloed governance, incompatible data systems, and persistent professional divides between health and social care. New initiatives were frequently layered onto pre-existing programmes, resulting in duplication and operational confusion, particularly visible in the proliferation of navigation roles (social prescribers, link workers, and care coordinators) operating without coordinated system-level planning.

 

The VCS played a crucial role in delivering community-based prevention and supporting people with moderate needs, but its contribution was weakened by short-term, competitive funding and limited involvement in strategic decision-making. Persistent cultural divides between the NHS, local authorities, and community partners, combined with deficits in transport infrastructure, digital inclusion, and shared data systems, further hindered progress. Areas with strong cross-sector relationships, long-standing trust, and stable prevention funding demonstrated greater coherence and capacity for innovation, suggesting that relational and contextual factors are as critical as formal structures.

 

Implications: Embedding prevention within integrated care requires sustained, flexible, and ring-fenced investment; shared governance and accountability across sectors; and equitable partnership between the NHS, local councils, and the VCS. Progress depends not only on organisational structures but on trust-based leadership, joint training, and a cultural shift toward collaboration across statutory and non-statutory partners.

Addressing enablers such as digital inclusion, transport access, and shared data infrastructure is essential for achieving system-wide prevention. The findings offer transferable lessons for international health and care systems seeking to operationalise prevention and integration within complex, adaptive care environments, highlighting that sustainable change relies on both relationships and culture as well as policy design and funding.