Integrated Neighbourhood Working

Primary care

Supporting Integrated Neighbourhood Teams

Contents:

4-5 Introducing Optum 6-7 Integrated neighbourhood teams: a new model for care 8-9 Enabling integrated care delivery 10-11 Folkestone, Hythe and Rural: enabling integrated working across organisations 12-13 Using population health

management to enable strategic commissioning and prevention

14-15 Trent PCN: enabling strategic commissioning and prevention through data

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Introducing Optum

At Optum, our mission is clear: helping people live healthier lives and helping make the health and care system work better for everyone. Bringing together advanced data and technology capabilities, deep clinical and industry expertise, along with our cross-industry relationships, we’re helping our customers tackle healthcare’s biggest challenges. We enable clinicians to operate at the highest level of their expertise by reducing administrative burdens, streamlining workflows, and providing intelligent decision support. We’re supporting the delivery of care through great technology, enabling neighbourhood working and the shift to prevention, optimising medicines, and driving equitable and ethical clinical research.

#1 clinical system supplier in:

Primary care used by 4,600+ GP practices*.

Community pharmacy used by 5,700+ pharmacies*.

A&E acute care used by 30 trusts*.

#2 clinical system supplier in:

Community care used by 37 trusts*.

Acute hospital pharmacy used by 63 hospital pharmacies*.

*Source: Optum

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Integrated neighbourhood teams are transforming how care is delivered across England. These place-based teams bring together primary care, community services, mental health, social care, and voluntary sector partners to support their local populations through joined-up working. To work effectively, they need shared information, connected digital systems and tools that that enable coordinated, person-centred care. That means joining up services and teams — so professionals can work together seamlessly to deliver the right care, in the right place, at the right time. Optum helps make this happen. We provide the technology, data and decision support that support neighbourhood teams to work as one. Our solutions help teams plan care around people, not services, and respond to what communities really need. As market leaders in primary care, community services and community pharmacy, and with our ability to integrate with social services and the voluntary sector, we ensure no part of the system is left behind. Integrated neighbourhood teams: a new model for care

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Core capabilities that enable integrated neighbourhood working

Enabling integrated care delivery

Real-time collaboration and communication

Shared access to patient records Clinicians across settings can view and contribute to a single patient record, with write-back functionality to the registered GP practice — supporting safe, informed care and continuity. Shared appointment booking and scheduling Enables hub models and cross organisational scheduling, helping teams manage demand and improve access across services.

Facilitates seamless working across primary care, community services, social care, and voluntary sector partners — supporting joined-up care delivery. Workforce and capacity planning Provides live insights into team availability and service pressures, enabling proactive resource allocation and service design. Contract and activity management Automates claims, reporting, and contract tracking — reducing administrative burden and ensuring accurate service monitoring.

Our integrated technology is designed to meet the demands of neighbourhood working — helping systems respond to rising demand, limited GP capacity and fragmented services. We enable smarter, more scalable ways of working by connecting care teams, simplifying information sharing and supporting real-time collaboration. And because every system is different, we work closely with you to tailor solutions that fit your local context — helping you deliver joined-up care that works for your teams and your patients.

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Folkestone, Hythe and Rural: Enabling integrated working across organisations Folkestone, Hythe and Rural PCN redesigned its service model to enable integrated working across practices, supported by our technology. A centralised triage hub directs patients to the right practitioner — GP, nurse, pharmacist, or allied health professional — using real-time demand and capacity data. With EMIS Web, teams gained shared visibility, improving workforce planning and unlocking 10,000+ extra appointments. The model enhanced access, reduced GP pressure and embedded community pharmacy to manage minor ailments and medicines queries.

Key highlights

Centralised triage hub: Patients are directed to the most appropriate practitioner based on real-time demand and capacity. Shared visibility: Enables better workforce planning and reduces duplication. 10,000+ additional appointments: A significant increase in capacity and access. Interoperable systems: Surfaced data intelligence to support dynamic, neighbourhood-wide working. NHS England recognition: Their transformation team collaborated to document lessons learned, especially around the technical solution. 11

We provided the digital infrastructure and data tools that made this transformation possible. NHS England recognised the success and worked with the PCN to capture lessons, especially around the innovative tech that supports cross-practice and neighbourhood working.

Using population health management to enable strategic commissioning and prevention Population health management (PHM) is essential for neighbourhood teams to understand local needs, target interventions, and shift resources upstream. Optum enables PHM by providing advanced analytics, segmentation tools, and commissioning platforms that turn data into action. Our solutions help systems identify risk, reduce unwarranted variation, and make the case for investing in prevention. By enabling neighbourhood teams to plan strategically and intervene earlier, our technology supports care that is proactive, personalised, and sustainable. PHM also underpins strategic commissioning — helping systems move from activity-based contracting to outcomes-focused investment. Optum’s tools allow commissioners to see where interventions are needed, quantify impact, and align funding with population needs.

By supporting both strategic planning and frontline delivery, we’re helping neighbourhoods deliver care that keeps people well, reduces demand on hospitals, and improves outcomes across communities.

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Trent PCN: Enabling strategic commissioning and prevention through data Trent PCN used our advanced analytics platform, PHM Pathfinder Analytics to identify patients at high risk of emergency admission. Link workers engaged these patients with tailored support, connecting them to clinical and community services. Within six months, emergency admissions dropped by 58%, A&E attendances by 41%, and mental health activity by 37%. This wasn’t just a clinical success — it was a strategic one. The data enabled the PCN to demonstrate a 3:1 return on investment, making a compelling case to shift funding from reactive hospital care to proactive community support.

Our tools helped the PCN act on real-time insights, personalise care, and measure impact. The programme showed how PHM can support strategic commissioning — identifying where resources are needed and justifying investment in prevention. By enabling neighbourhood teams to deliver smarter, data-driven care , we’re helping systems redesign services around keeping people well, not just treating illness.

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Get in touch

If you’d like to find out more about how we can support you, speak with your local account director today, or get in touch at:

uk.info@optum.com

optum.co.uk/tech-enabled-services

Egton Medical Information Systems Ltd (t/a Optum) is a company registered in England and Wales. Registered number: 02117205. Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. © 2025 Optum. All rights reserved.