Implementing Neighbourhood Proactive Care in Leeds

The goal of Neighbourhood Proactive Care (NPC) is simple: help people stay well, independent and connected to their community for as long as possible. It is targeted specifically at people who are living with multiple long-term conditions, or are living with frailty, and their carers. At the heart of NPC are local connected multi-disciplinary teams, working together to provide personalised proactive care.

If you are interested in how Neighbourhood Proactive Care will help you, and your experience of health and care services, you can visit this dedicated web page.

This web page aims provides support to Local Care Partnerships and Primary Care Networks, and other health and care professionals, to embed NPC in their local communities. Below is a quick guide to NPC in Leeds. We have also produced a more detailed framework, which outlines the principles that are guiding the implementation of NPC in Leeds, as well as what will be delivered consistently across all neighbourhoods, and what needs to be developed locally to support local need. A PDF version of the framework is available to download.

A Quick Guide to Neighbourhood Proactive Care in Leeds:

(Also available as a downloadable PDF).

What is Neighbourhood Proactive Care?

Proactive care is about more than helping people cope with illness – it’s about enabling positive change and connecting them to the right support at the right time and place. By focusing on prevention and early intervention, proactive care aims to slow the progression of multiple long-term conditions and frailty, helping people stay well for longer. It is targeted specifically at people who are most at risk of needing unplanned care; those people who are living with multiple long-term conditions or moderate to severe frailty.

Here’s what sets proactive care apart:

• Early Identification and Intervention. NPC focusses on spotting needs early to keep people well, independent, and connected to their communities for as long as possible.
• Personalised Support. Care is built around what matters most to the individual, giving them choice and control over how their care is planned and delivered.
• Multi-Agency Networked Teams. Health and care teams work together to support people and their carers before they reach a point of crisis.

Central to this approach is Care Coordination, which considers the holistic needs of the person and their carer, and helps to bring the right services together around them to support them in achieving their goals. It particularly helps people who receive support from a range of services, removing duplication through focusing on what matters to them at that time.

How does Proactive Care benefit people?

• Early support, not just crisis care. Instead of waiting for problems to escalate, NPC focuses on spotting issues early and putting the right help in place.
• Care built around what matters to them. People and their carers are engaged in setting goals, preferences, and priorities to shape their care plan – giving them choice and control over how support is delivered.
• Access to a single point of contact. Most neighbourhoods will have at least one Care Coordinator, who is someone who builds trust with a person and their carer, and is a single point of contact and has overall coordination of their care.
• Improved coordination, communication and compassion. These are the three things that people have said matters to them most when accessing care. NPC will deliver improvements in all three of these areas.

How will Neighbourhood Proactive Care address the challenges we face in health and care?

Not only will Neighbourhood Proactive Care improve outcomes for local people, it will also help us address challenges we face in the health and care system. Whilst the target population for NPC is just 5% of the total city population, they account for:

• 50% of all unplanned bed days
• 19% of all outpatient appointments
• 80% of all social care packages
• 15 GP appointments per year on average

People in this cohort often report having worse experience of health and care.

By working with people to create personalised care plans, and taking a proactive care approach, we will help slow down deterioration and manage health issues before they reach a point where people need emergency health and care. By forming networked teams at a neighbourhood level, we can help connect people to medical and non medical support that is built around their needs, whilst reducing duplication, meaning we can use our resources more efficiently.

How is Neighbourhood Proactive Care being rolled out in Leeds?

By March 2026, every Local Care Partnership and Primary Care Network is expected to be providing Neighbourhood Proactive Care. To start with, they are being asked to have a Care Coordinator in place, who is connected to a networked team that meets the needs of their local population. They will also have in place personalised care plans for between 2 and 3% of people in their neighbourhoods who are living with 3 or more long term conditions or frailty. Over time, they will be expected to continue growing the number of people in their neighbourhood who are benefitting from NPC.

LCPs and PCNs will decide how they will embed NPC, which needs to be designed around the needs of their own population, based on local data, insight and intelligence. However, the fundamental principles of early intervention, care coordination, personalised support, and networked teams remain the same across all neighbourhoods. In some cases, where it makes sense to, we may develop city-wide models of proactive care for people with specific health conditions/needs.

What is the difference between Neighbourhood Proactive Care and Neighbourhood Health?

Neighbourhood Proactive Care is a vital component of Leeds’ journey towards Neighbourhood Health, but it represents just one part of the wider approach. Proactive Care focuses on a targeted model identifying individuals most at risk of a health crisis and intervening early. Neighbourhood Health takes a broader, community-based perspective, aiming to improve health and wellbeing for everyone within a neighbourhood.

Both share common values: delivering care locally, prioritising prevention and early intervention, integrating services, reducing health inequalities, empowering communities, and promoting a holistic view of health. The key difference lies in scope: Neighbourhood Health is population-wide, while Neighbourhood Proactive Care concentrates on those at greatest risk.

National evidence

In 2025, the Department for Health and Social Care and NHS England published a report, which outlines the importance of identifying frailty early, and the case for primary and community healthcare teams providing proactive care for people at risk of frailty. The report is available on the National Audit Office website.