Planning and delivering integrated health and social care: guidance

11. Best anticipate needs and prevents them arising

People should have access to support that helps them to stay well, manage their health and wellbeing and remain as active and independent as possible. This could include social support for people who are at risk of loneliness, peer support to help people manage long term conditions, and complex clinical support at home to avoid someone needing to go to hospital.

Planners will need to work with communities to think creatively about the future and make sure the right support and services are in place for local people. The third sector organisations, in particular, are well placed to inform and shape services that prevent poor health and wellbeing, as they have a wealth of experience both in representing communities and in providing care and support.

This principle means a radical change in the types of support and services that will be provided. These will be far more focused on helping people avoid or delay health problems or circumstances that impact negatively on their lives. Some people experience much poorer health than others and this is often linked to their wider circumstances, for example poverty, housing issues or employment. People who experience health inequalities will need additional support and investment.

Helping people stay well and planning for future needs requires good conversations between individuals (and often families and carers) and health and social care staff. This will include discussing people’s circumstances, concerns, aspirations and potential risks to their health and wellbeing (for example a condition that is likely to deteriorate or fluctuate) and putting in place plans to meet their future needs.

People will often need a range of supports, including from community or third sector organisations, and health and social care staff should have the knowledge and ability to signpost or refer on.