Londoners have been clear and consistent around their expectations and aspirations for improving health and care in London. Through a series of recent deliberative engagement events supported by Ipsos Mori and Imperial College Health Partners, Londoners have told us that they are looking for:

1. A consistent approach to how we respond to people and manage their needs across London, applying the same systems, technology and rules so people know what to expect and how to access help when they need it (including via digital channels such as the NHS App), and which take account of social as well as clinical factors.
2. A clear understanding of the choices available to them and the benefits of each, including options around self-care and support from charities and other community organisations as an alternative to statutory services where appropriate.
3. Integrated neighbourhood-based teams which deliver the same basic care across London, with continuity of care and clarity around support for specific local needs, all enabled by secure data sharing and the types of digital technologies that people experience helping them to manage other key parts of their lives.
4. Proactive care that is delivered in partnerships with communities, is regular and consistent, but is also respectful of people’s choices.

The findings reflect not just people’s aspirations for themselves and their loved ones for the future, but their experiences of trying to access health and care when they need it today.

Today, the experience of people accessing health and care services is highly variable, particularly when they need support to come from a range of different health and care professionals and providers – even if those services are theoretically operating as multidisciplinary teams.

The findings reflect not just people’s aspirations for themselves and their loved ones for the future, but their experiences of trying to access health and care when they need it today.

In a series of parallel engagement sessions across London, we have heard many good examples of improved neighbourhood and community-centred care, much led by individual clinicians, professionals and communities themselves.

However, whilst there has been considerable focus in recent years on developing person and community-centred care across England, including through the development of multi-disciplinary teams around key population groups such as frailty in older people, recent research published by National Voices found patients reporting that too often they:

• Have to repeat themselves in dealing with multidisciplinary teams.
• Do not feel involved in the decision-making around their care.
• Experience a loss of continuity of care as a result of shifts to multidisciplinary teams.
• Do not always know who the right person was to speak to, or understand what the role of the person they are speaking to is in their care.
• Are unsure what to expect from appointments.
• And are concerned that, paradoxically, the increased complexity of being supported by a multidisciplinary team means they have to invest more time and energy in navigating the care system and in advocating for themselves.

Feedback from GPs and others working in the community, highlights that these frustrations are equally part of the daily experience of professionals trying to support their patients in a more joined up way.

Bringing together key clinicians and professionals into teams which can take a holistic view of a patient’s assets, needs and outcomes will be critical to improving health and care in London, and many of our multidisciplinary teams are already leading the way.

However, the issues highlighted show not only the importance of addressing siloed-working and better integrating our teams, but of doing it in the right way, including the need for effective communication and engagement with patients and carers and between professionals at each stage of the process. Insights which apply at the level of individual patients are equally applicable in engaging with wider communities in London.

Whilst people understandably want and need high-quality local health and care services, the help that patients and carers need can in many cases be better provided by using non-medical services, including through London’s voluntary and community sector and resources within communities themselves. Yet, just as growing pressure on statutory services has created in too many areas a “vicious circle” of growing demand and decreasing ability to respond to that demand, so NHS providers and other statutory partners now need to find more effective and sustainable ways of working with communities at a hyper local level, over the short, medium and long term.

Growing public dissatisfaction with the availability of GP appointments (despite the real growth in appointments in recent years), has been highlighted both at a national level in the Darzi report and in local system and place work within London. Whilst there are issues in the current imbalance between capacity and demand, including as a result of practice closures, workforce challenges, the impact of the pandemic across our communities and services, as well as pre-existing disconnects between primary and secondary care, there are also opportunities to improve the systems and approaches to managing this work. In reality, the number of primary care contacts, if anything, have increased significantly in London, but not in a way which has kept pace with wider demands.

Building on the principles of “Modern General Practice” and the Primary Care Access Recovery Plan, many practices are already operating in a way that improves the management of administrative requests and can appropriately support patients to work with the right members of the practice team providing a timelier response and to create capacity to better support more complex needs. Others are working in partnership with other providers, including the London Ambulance Service, in addressing demand; or with community health and wellbeing workers to transform the approach to primary care within communities.

It is difficult to defend very different levels and systems for accessing appointments in London in the absence of clarity as to why these differences exist. Issues of capacity and the implementation of effective systems will require action across whole areas, potential redistribution of resources and standardisation of basic processes. Equally, developing better ways of supporting the needs of more complex patients, including through improved technology and data sharing to enable better proactive and preventative care, would, if implemented successfully, help free up capacity and time to support the wider population as a whole, (including those at risk of future ill-health, in the absence of effective and accessible primary and community-based support). However, the time period to realise these benefits has often acted as an inhibitor to change.

Continuity of care remains critical for both clinicians and patients. Previous Nuffield Trust research has highlighted that:

“Relational continuity of care in general practice is associated with a significant number of benefits to individuals and wider health systems, including: better clinical outcomes for an array of conditions; reduced mortality; better uptake of preventative services; better adherence to medication; reduced avoidable hospital admissions; and better overall experience of care amongst patients who prefer continuity and are able to obtain it”.

In recent years, professionals and patients across London have highlighted how much of this relational continuity has been lost.

To an extent, this has been replaced by informational and management continuity, however, it will be important to ensure that as services develop in the future, for those patients who benefit most from relational continuity, we are able to provide it. Although much current literature on continuity focuses on continuity of GP care, discussions across London in the development of this case for change have highlighted the important role that continuity of care provided by other health and care professionals and the voluntary and community sector plays in driving improved individual and population health outcomes.

Improving population health

The outlook for the health of the population without significant changes in lifestyle, economic opportunities, and more successful primary prevention is not positive.

The estimated prevalence of people with moderate to severe frailty in London is 12% to 26% in people aged 65 and above. The population in London in this age group is projected to grow from 1.2m in 2024 to 1.6m in 2034, with the very elderly (those aged 85+) growing at an even faster rate. This represents a challenge to healthcare but even more to the fragmented and economically challenged social care provider system that will need to change dramatically if these growing needs are to be met.

Modelling by the Health Foundation found that the number of people living with major illness is projected to increase by 37% – over a third – by 2040. This is nine times the rate at which the working-age population (20 to 69 year olds) is expected to grow (4%).

Much of this relates to conditions such as anxiety and depression, chronic pain, and diabetes which are generally managed in primary care and the community. This reinforces the need for investment in general practice and community-based services, focusing on prevention and early intervention to reduce the impact of illness and improve the quality of people’s lives. This is even more the case as frequent attenders use primary care at five times the rate of other patients, and their rate of use has been steadily increasing over time.

Sadly, many of these problems result in economic inactivity which in turn worsens health and wider inequalities.

The recent White Paper Get Britain Working reports that long-term sickness-related economic inactivity is at a near-record high. Disability prevalence is also increasing, with 2.6 million (38%) more people in the working-age population classed as disabled compared to a decade ago. Recent research as part of the Pathways to Work Commission led by Alan Milburn has highlighted how up to 7 in 10 of those engaged who were classed as economically inactive wanted to work. The Office for Budget Responsibility (OBR) calculate that an additional half a million people participating in the workforce would save £18.7 billion. This represents an important opportunity for the health sector to contribute to this wider goal, but at present, there is limited ability for the system to focus on dealing with these needs.

Children are perhaps even more of a concern. In England, over one in five children are overweight or obese by age five and a quarter have tooth decay. The demand for child and adolescent mental health services has grown enormously, with the number of under 18s referred to Child and Adolescent Mental Health Services (CAMHS) rising by 53% to over 1.2 million between 2019 and 2022.

Children are waiting an unacceptable time for support – with nearly 40,000 children experiencing waits of at least two years. A third (28%) of children referred to mental health services (270,300) were still waiting for support, whilst almost 40% (372,800) had their referral closed before accessing support.

Improved approaches to population health, better integrated teams and a more responsive approach to local needs combined with closer working between health and social care provide significant benefits to the social care system.

Recent research by the County Councils Network (November 2024), indicates that the costs of providing care and support for working-age adults and those with a lifelong disability is now the largest area of adult social care expenditure in England – (in 2023/24, 63% of all adult social care commissioned support, such as residential and home-based care, was found to relate to working-age adults) – with an increase from 2019 to 2024 of 32% or £2.6 billion pounds.

The research indicates that this is being driven by the complexity and type of care individuals are receiving, rather than increased numbers of people requiring support; whilst in children’s social care, figures from the Department for Levelling Up, Housing and Communities (DLUHC) show a second consecutive rise of 11% in real terms planned expenditure for 2024/25 to £14.2 billion.

In London, London Councils representing the 32 boroughs and the City of London has highlighted in recent research how spending on adult social care, children’s social care and homelessness has increased from 60% of net revenue expenditure 10 years ago to 84% today. Almost one quarter of London’s local authorities will need Exceptional Financial Support (totalling £430m) to balance budgets in 2025/26, and over £500m of savings will be required just to stand still.

In 2025, planned increases in employer national insurance contributions and the national living wage will impact the sustainability of care providers across London. There is no single, simple solution to the problems of growing social care funding pressures; but there are a number of exacerbating factors. These include a lack of access to timely, coordinated support for children and young people with complex needs; support for working adults who are at risk of becoming or currently classed as “economically inactive” for treatable health conditions; and older people, particularly those who are coming out of hospital and being directed into long-term nursing and residential homes due to a lack of community rehabilitation capacity.

Conversely, increasing access to, and the efficacy of, neighbourhood-based health and wellbeing services, and integrating bio-medical and social support, provides one of the few opportunities to start to address the ongoing and currently inexorable rise of social care expenditure and the concurrent pressures on local government finances across England.

Addressing persistent inequalities

The prevalence of the issues described in the preceding paragraphs is not experienced uniformly across the population.

Trust for London’s Poverty Profile highlights that once housing costs are considered, up to 24% of Londoners are living in poverty, rising to 34% of those of a non-white ethnic background and 47% of single parents.

The persistence and worsening of intractable health inequalities is driven by a range of factors that are outside the scope of traditional healthcare.

Healthcare providers will need to work with other agencies and professionals to support them in dealing with the underlying determinants of poor health and wellbeing. This requires a focus on place, an organised response, and the deployment of a wide range of skills and expertise. This will in turn lead to a more person-centred approach that will rebuild trust with those we are trying to help. The often atomised nature of provision in many places is an obstacle to this, and ways to create more coordinated approaches, aligned objectives, and joint working will support bringing the different strands of work in this area together more effectively.

Poverty, poor housing, and social isolation are significant risk factors for ill-health. NHS services have often not had strong links to local authority housing teams and housing providers, nor to organisations which can support with access to benefits, as well as to education and employment. To be really effective, London’s neighbourhood health service as elsewhere in England will need to work much more closely with these bodies to understand, plan for, and take action around wider socio-economic determinants of health and wellbeing, however difficult this may be.

There is a similar issue in the way that inequalities in access to healthcare are often driven by inequalities in access to transport. Therefore, links to transport planners and to organisations which may offer volunteer transport are also important.

Meeting the needs of the population and addressing inequalities will require a much better understanding of the different types of need in the population. To realise the ambition for prevention it will be important to be able to identify who is most likely to benefit from proactive approaches. This requires the use of methods for segmenting the population, predicting risks within the segments and linking this to elements of clinical work, so that patients who are at risk, or could benefit from an early intervention, can be identified.

Using a population size larger than the average practice for this analysis reduces duplication of effort and the call on scarce analytical expertise, but it can also identify opportunities to use the resources of the extended primary care team or other appropriate staff.

Working across a neighbourhood offers the opportunity to use place-based approaches and large group consultations or support groups for people with high levels of risk factors. This is critical to expanding the scope of primary care without placing additional burdens on practice staff, although it will be important not to undercut the role of GPs and practice staff in doing this.

The following section explores the implications for services of responding to these challenges and opportunities, as neighbourhoods, places, systems, and the London region as a whole.