Strategic aims

People's lives aren't neatly divided into health and care - and our services shouldn't be either. In Norfolk, we are committed to working more closely with health colleagues, alongside community and voluntary sector partners, to provide joined-up support that meets people's needs in the places they live. This includes both strategic collaboration through the Norfolk and Waveney Integrated Care System (ICS) and practical, local partnership working that improves people's day-to-day experiences and outcomes. 

Providers play a vital role in making integration real - through relationships with GPs, community health teams, and others who support people every day. We want to strengthen these links by embedding shared models of care, improving digital connectivity, and widening access to training, clinical expertise, and joint learning. By working together, we can prevent escalation of need, reduce avoidable admissions, and help people stay well and independent in their communities. 

Integrated working between health, care, and community partners is central to our future approach. We are moving towards a place-based system of support where professionals work together around individuals, families, and communities - learning from experience and adapting as we go. This means testing new ways of working, sharing insight across teams, and using evidence to understand what works best locally. Our aim is to build stronger neighbourhood networks that respond quickly when people's needs change and provide the right help, in the right place, at the right time. 

We will continue to invest in digital and technological innovation, strengthen local prevention pathways, and work with providers to develop neighbourhood-based approaches that make care feel seamless across health, care, and community services. 

Our ambitions

• Embed the enhanced health and wellbeing in care framework across the market to promote joined-up care that supports independence and prevents escalation of need
• Expand multi-disciplinary team (MDT) approaches in care settings, with access to training and collaborative working to manage long term conditions. Providing personalised care, improving outcomes and promoting independence.
• Strengthen place-based collaboration and shared learning - bringing health, care, and community partners together around local priorities to test new approaches and learn what works
• Strengthen prevention pathways in collaboration with health and voluntary sector partners - focusing on falls prevention, skin and wound care, leg and foot ulcers, nutrition and hydration, mental health, dementia, and early identification of deterioration
• Improve access to digital innovation and technology-enabled care - including remote monitoring tools and shared care records - to enhance communication and person-centred care
• Collaborate on workforce development opportunities, such as bite-sized training, e-learning, and champion networks across the system

What this means for providers

• You may benefit from integrated clinical input, health-led training, and digital innovation support to enhance your service delivery
• We will continue to strengthen collaboration between commissioners, providers, and health colleagues to streamline support and reduce duplication. Joining care planning records so that all information is held in one place and accessible to those who need it. 

What people can expect

• To experience joined-up support, with care that feels seamless across different professionals and services
• To stay well for longer, with better access to health advice, early intervention, and support in familiar settings

Proactive Intervention Programme - case study

Norfolk County Council is pioneering a new approach through its Proactive Intervention Programme, which aims to identify and support residents before their needs escalate. A key focus is preventing falls among older adults by connecting them to timely, personalised support within their communities.
The programme began rollout out at scale in August 2025, with plans to contact over 12,000 residents in its first year. It represents a shift toward data-led, person-centred early help, delivered through trusted local partnerships.

Tim and Jane (names changed for anonymity), a couple living in South Norfolk, were identified through the programme using a predictive model to gain insight from data held in social care and district records. Tim was flagged as being at risk of a fall and received a call from the South Norfolk & Broadland Help Hub. Through a holistic conversation, the team explored what support might benefit them.

Following the call, a handyperson visited their home to install grab rails at the top of the stairs and by the front door.

"I'm really happy they were fitted and think it will have a big impact on my life, making me more confident going up the stairs. We also had positive conversations around steps we can take to help prepare for older age. We didn't realise the help that was there for us."

Tim

This personalised, place-based approach is central to the programme's vision. Tim and Jane's story highlights the power of early support to improve wellbeing, independence, and confidence in later life.