Neighbourhood Health Optimisation Service (NHOS)

Across Norfolk and Waveney, there are identifiable groups of people whose health is not being optimised consistently. Long-term conditions are not always managed to the best possible standard, and modifiable or reversible clinical and social risk factors are not always identified and acted on early enough to prevent deterioration.

There is significant variation between practices, Primary Care Networks and Places in how effectively proactive population health management is delivered. As a result, patients with similar levels of need may receive different levels of identification, engagement, review, intervention and follow-up depending on where they are registered.

This variation is likely to contribute to avoidable deterioration and greater use of unplanned care, including emergency admissions and bed days that could potentially have been prevented if the system had used the information already available to intervene earlier. Population Health Management analysis shows that a relatively small proportion of the population accounts for a disproportionately large share of unplanned activity. It also identifies a larger group whose risk is rising but remains modifiable, creating a significant opportunity for earlier intervention.

The ICB has an increasingly sophisticated Population Health Management capability to identify people whose clinical risk of unplanned admission to hospital is rising and potentially reversible. However, there is not currently a consistent delivery mechanism at sufficient scale to systematically engage those patients, coordinate appropriate interventions and track whether their risk subsequently reduces following intervention.

The Neighbourhood Health Optimisation Service (NHOS) is proposed to test a standardised, at-scale primary care led approach to identifying and addressing reversible risk of unplanned admission to hospital, initially in patients aged 65 and over, while their risk is still modifiable. By using Population Health Management to identify people with medium/high rising and reversible risk, the NHOS can intervene before people deteriorate, become frail or deconditioned, present in crisis, or require avoidable acute, ambulance, primary care and social care input.

Purpose of this notice

The ICB is looking to invite providers to participate in the development of the NHOS Phase 1 business case as development partners. A credible, costed business case to support the implementation of Phase 1 of NHOS cannot be produced by the ICB alone. It needs a provider perspective on the operating model, the workforce that can realistically be recruited and deployed in Norfolk and Waveney, mobilisation timescales, and the true cost of delivery.

Scope of services

The ICB is seeking development partners to work collaboratively with the ICB and relevant system partners to develop a robust and costed business case for Phase 1 of the Neighbourhood Health Optimisation Service.

The business case will need to be sufficiently detailed to demonstrate that the proposed service is clinically credible, operationally deliverable, affordable, safe and capable of mobilisation at the required scale.

The development partner will help with the development of the following:

• Service specification and operating model
• Patient identification and access
• Clinical model and standards
• Workforce and capacity plan
• Primary care delivery arrangements
• Mobilisation and implementation plan
• Open-book financial model
• Activity, capacity and demand assumptions
• Outcomes and performance framework:
• Evaluation and benefits realisation:
• Quality, clinical governance and safeguarding
• Information governance, data and digital requirements
• Risk and contingency arrangements
• Engagement and co-design evidence

The development partner will be required to participate in the joint Project Group, including attendance by appropriately authorised clinical, operational, financial and commercial representatives; completion of agreed actions; early notification of issues; maintenance of accurate assumptions and risks; and contribution to drafting and quality assuring the business case.

The ICB will retain ownership of the overall business case and responsibility for defining the commissioning requirement, confirming strategic fit, providing or validating population and baseline information, assessing affordability and value for money, completing relevant quality and equality assurance, managing conflicts of interest and obtaining all required approvals.

Provider Eligibility

Providers will meet the following criteria:

• A legal entity capable of holding an NHS Standard Contract for primary care led services;
• Demonstrable support from, or established delivery relationships with, GP practices across a substantial proportion of PCNs;
• Experience of delivering at-scale, primary care led services in Norfolk and Waveney;
• Capacity to commit clinical, operational and finance resource to the work at the provider's own cost.

Each party will meet its own costs of engaging and supporting the business case development; no payment, reimbursement or minimum income will be payable

A Memorandum of Understanding signed by the participating provider(s) and Norfolk and Suffolk ICB will underpin the period of engagement

Once the business case is developed appropriate governance will need to be undertaken to secure the funding. If funding is secured the ICB will work through the procurement options available to it and a provider selection process will be undertaken separately in accordance with the applicable legal and regulatory requirements.

This Prior Information Notice is to alert potential development partners to this opportunity and to request that they express an interest. To express an interest in this opportunity please contact [email protected] prior to the 16th October 2026.

For the avoidance of doubt no additional information or documents are available on the Norfolk and Suffolk website or…