NEIGHBOURHOOD HEALTH
Across 123K patients: 125K fewer A&E attendances a year, and around ~£22m of acute cost avoided.
Joy is the infrastructure behind the numbers: 83,000+ live community services, referral routes from any care setting, and outcomes from the GP record and validated instruments. Your plan is judged on whether demand moved, and whether you can prove it. Joy does both.
Richmond, last 12 months
GP appointments in the supported cohort
people connected to community support
Illustration, synthetic data
THE STRATEGIC CASE
Bend the three curves.
Every system plan is trying to bend the same three curves: outcomes, demand, and cost. They are one chain, not three projects. Better outcomes for the people the system reaches least lead to less acute demand, and less acute demand lowers cost. Joy contributes to each curve alongside the rest of your system, and measures each one in the GP record.
Better outcomes where inequality bites hardest.
Community referral reaches the people clinical pathways miss: 1.4x as many referrals reach the Core20 most deprived fifth of neighbourhoods as their share of the population, and the most deprived tenth is reached at 4.3x its population share. The improvement shows up across the whole validated instrument set, not one measure.
16,806 paired journeys, 73% of people improved. The same pattern holds across validated instruments.
Source: Joy platform database, July 2026
Less acute demand, measured, not modelled.
When the underlying need is met in the community, people stop arriving at the front door of acute care. Joy reads the change straight from the GP record, before and after, per neighbourhood. Community referrals keep rising (516,400 in the last 12 months) while acute demand per patient falls.
From 1.61 to 0.60 per patient per year, whole measured cohort of 123,617 patients.
Source: Joy platform database, July 2026
Lower cost through referral productivity.
Every avoided contact is clinician time back, and every avoided attendance is money against published NHS unit costs. The saving follows from the first two curves; Joy makes it a live number per neighbourhood, with the attribution stated, never hidden.
In the last 12 months, measured from live Joy activity: about £12m of clinician time at the £49 published PSSRU unit cost, with an explicit attribution band (80% central, 60 to 100%).
Source: Joy platform database, July 2026
The chain runs one way: better outcomes for underserved groups lead to less acute demand, and less acute demand lowers cost. Figures as of July 2026, whole-cohort framing unless stated.
INTEGRATED NEIGHBOURHOOD TEAMS
The community-referral layer for your INT stack.
An integrated neighbourhood team already runs population health analytics, clinical systems and case-management tools. Joy does not replace any of them. It moves people into live community capacity and reads back what changed, so the referral and the outcome sit on one record.
Help find the cohort.
Case-finding inside the clinical system: frequent attenders, repeat fit notes, long-term conditions drifting, frail and pre-frail people. Or take a feed from the population health tools you already run.
Connect them to community capacity.
83,100 live community services on the Marketplace, listed and taking referrals today, open to professionals in any care setting and to self-referral.
Run the referral work in one place.
Caseloads, appointments and outcome capture sit on the same record as the referral, alongside the case-management tools your teams already use.
Measure the impact.
The change is read from the GP record, before and after, for each neighbourhood. Every figure links back to where it came from.
What we can case-find and measure.
The worklist covers the cohorts a neighbourhood plan is marked on: frequent attenders, people on repeat fit notes, long-term conditions drifting (CVD, diabetes and COPD, the national 10% goal areas, tracked through weight, blood pressure and HbA1c in the GP record), Core20PLUS5 clinical priority groups, and need driven by the QOF registers every practice already keeps.
Frailty is where teams move fastest: the middle band, people becoming vulnerable or mildly frail and still living independently, is where community support changes the trajectory. Joy works from what is already coded in the GP record, including the Clinical Frailty Scale where practices record it, so the team starts with a worklist, not a data project. Where formal frailty coding is not yet in place, Joy can also draw on related coded indicators already in the record to proxy earlier frailty signs, so teams can reach people before a frailty code is ever assigned.
Population health management, running in general practice.
NHS England's own guidance estimates 1 in 5 GP appointments are for non-medical reasons. Joy surfaces the rising-risk cohort inside the clinical system: multiple long-term conditions, high deprivation, high avoidable demand, no community support around them. A worklist your teams action today, feeding the tools they already work in.
Source: NHS England social prescribing guidance
Bring the acute numbers down, and prove it.
Across 123,617 patients, the measured reduction is ~124,900 fewer A&E attendances per year and, for high-dependency patients, 40% fewer GP contacts (17.5 to 10.5 a year), a banded ~£22m of acute cost avoided at the £180 published NHS unit cost (attribution band: 80% central, 60 to 100%). Those numbers are a live read from the GP record, per neighbourhood, not a one-off evaluation PDF. Joy surfaces them automatically as you refer.
Source: Joy platform database, July 2026; unit costs: Published NHS unit costs
The 10% clinical outcomes goal, instrumented.
The national goal is a 10% improvement in clinical outcomes for CVD, diabetes and COPD by March 2029. Joy measures weight, blood pressure and HbA1c change in the GP record after community referral. In the current cohort, average HbA1c falls from 48.3 to 46.9 mmol/mol: back below the diagnostic threshold.
Source: Joy platform database, July 2026
Show who the shift actually reached.
Reach and outcomes reported by deprivation decile and Core20PLUS5 priority group, so you can see exactly which groups benefited, not only the totals.
Board-ready evidence, per neighbourhood, whatever your stack.
Reported quarterly for each neighbourhood, with every figure linked back to its source, whatever analytics and records stack you run.
More than a directory.
A directory lists services. Joy moves people into them and records what happened next. Your teams can be referring within weeks, with NHS IM1 integration already in place.
Measured from real records.
Service use from the GP record, wellbeing and mental health from validated patient-reported measures, and clinical change from GP-record biometrics. Each figure shows where it came from.
fewer GP contacts, high-dependency patients (17.5 to 10.5 a year)
fewer A&E attendances after referral
fewer fit notes issued after referral
average HbA1c in mmol/mol after referral, down from 48.3
wellbeing improvement (ONS4), 16,806 paired journeys, 73% of people improved
average PHQ-9 depression score after community referral, 71% of people improved (325 paired assessments)
average weight after community referral, read from the GP record (1,265 paired readings)
average systolic blood pressure after community referral, read from the GP record (1,791 paired readings)
These are before-and-after comparisons from our own referrals. Independent research finds the same direction of travel: 28% fewer GP consultations and 24% fewer A&E attendances where social prescribing is effective (University of Westminster).
Sources: Joy platform database, high-dependency patients, GP record before and after; Joy platform database (Effectiveness foundation), July 2026
MODEL NEIGHBOURHOOD
These figures are from real neighbourhoods. We can measure yours.
The ~124,900 avoided A&E attendances and ~62,000 fewer fit notes a year are read from GP records across the existing Joy cohort. The same measurement runs per neighbourhood: your cohort, your GP records, your acute numbers. The Model Neighbourhood tool shows what a fully resourced neighbourhood service would look like in your own Primary Care Network, and gives you a two-year return projection anchored to local population data.
Source: Joy platform database, July 2026; Model Neighbourhood calculator: Joy Model Neighbourhood calculator (WayMaker), representative London PCN, July 2026
See the model for your neighbourhoodGO DEEPER
Start with your own neighbourhood.
See what a fully resourced neighbourhood service would look like in your own Primary Care Network, then take the step-by-step guide for standing the team up.
INTERACTIVE MODEL
Your Model Neighbourhood
See what a fully resourced neighbourhood health service would look like in your own Primary Care Network: demand, link-worker capacity, community services and avoided acute contacts, already modelled.
See your neighbourhoodGUIDE
Neighbourhood Health SOP guide
A practical standard operating procedure guide for standing up neighbourhood health teams, from first huddle to steady state.
Get accessGuides and reports are free for NHS and public sector teams: tell us who you are and we will email you a personal access link. Browse all resources
Working with neighbourhood teams, councils and community partners across England
Live community capacity, and the evidence to prove what changed.
Speak to our team about the community-capacity and evidence jobs in your neighbourhood health plan.