U.S. and U.K. both need to go local for preventive care

At a church on the outskirts of Liverpool, older residents amble in for community lunch. In Sunderland, mothers swap stories as they are guided through play exercises with their babies at a local hub. On the St Matthew’s estate in Leicester, children spill out of school and onto a new football pitch.

These scenes are unremarkable, the everyday rhythms of community life. None of it looks much like health care. But this relational, daily support keeps people healthy and resilient outside of the clinical system — while remaining largely peripheral to how we fund, measure, and debate health.

The British and American health care systems are usually conceived as opposites: one universal and public, the other market-driven and insurance-based.

Yet both are shaped by the same biomedical mandate that privileges hospital-based, clinical interventions over the relational, generalist support that keeps people well in their communities. In an era of aging populations, spiraling costs, and emerging trends like chronic illness and loneliness, this bias is no longer sustainable.

In the U.S., fee-for-service remains an important model for paying providers, rewarding clinical activity more readily than prevention and incentivizing tests and treatments of dubious value because they produce billable work. Commercial incentives reinforce the ubiquity of the model. Hospitals, insurers, pharmaceutical companies, and manufacturers all benefit from a system organized around diagnosis and treatment; less so from one designed to prevent needs in the first place.

In theory, the U.K. should be better placed to resist this logic. The National Health Service is a publicly funded, centrally managed system with an explicit commitment to prevention. Two decades of plans and reviews have promised a “left shift” from late-stage acute interventions to earlier preventative work in communities — “neighborhood health” being the latest iteration. Despite those intentions, the proportion of the NHS budget devoted to hospitals increased from 47% in 2006 to 58% in 2022.

Underlying this drift in the NHS is a centralized performance-management system that prioritizes outputs over outcomes and holds providers accountable for short-term, measurable targets on diagnoses, appointments, and operations. It reflects a system in which power, opportunity, and innovation concentrate in clinical work, and the choices made by services tend to pull resources toward hospitals despite the intent of policymakers.

Across the pond, the limits of this clinical model are becoming clear. Aging populations and chronic conditions are straining health systems already struggling with rising costs, as life expectancy stagnates in the U.K. and continues to lag behind peers in the U.S. Meanwhile, deaths of despair and demand for mental health services have soared, as former Surgeon General Vivek Murthy warns of an “epidemic of loneliness” spurred by declining social connectedness.

In both countries, the default to biomedical responses means that clinics and hospitals are increasingly absorbing the costs of social problems they are not designed to solve.

The communities I work with show that there is an alternative. Over the past 15 years, the Big Local program gave £1 million each (about $1.3 million) to 150 different communities across England to invest in priorities of their own choosing, funded through the National Lottery. As a policy officer for Local Trust, the organization founded to deliver Big Local, I apply what we learn from the program to national policy issues.

Since 2012, Big Local areas have formed partnerships and worked directly with their communities to address the issues that mattered most to them. This radical experiment in community empowerment offers a vision for a different model of health and care, underpinned by connected, resilient communities that support people in everyday life. Despite the differences in the U.K. and U.S. systems, this model has the potential to transform both.

Tucked into the corner of an isolated housing estate in Gloucester, England, the Podsmead Big Local is a lifeline. On the back of a million-pound investment in 2012, the community has organized to restore life to a deprived area hit hard by austerity.

Twice a week, pensioners and families arrive to collect healthy food donations. Parents who once lobbied for safe play spaces now gather in a nearby park as their children clamber over obstacles, the ground refreshingly clear of litter or needles. Residents bond at community events, eating homemade Caribbean food and watching open-air movies.

These interventions are informal, rooted in relationships, and emblematic of a social ecosystem that keeps people supported and well in daily life. There are no eligibility requirements or administrators with checklists. From the perspective of our health systems, this work is nice-to-have but eclipsed by the gritty realities of clinical care. But if the NHS and the U.S. health system are to adapt to our current challenges, we urgently need a paradigm shift — to support communities with the tools they need to live healthy lives outside the clinical system.

To achieve that shift will require a fundamental redistribution of power and resources. This means investing in social infrastructure: the institutions, networks, and spaces that support shared civic life. From parks and libraries to voluntary services, this infrastructure is a vital part of the social fabric that connects us, allows us to proactively manage our health, and protects us from the drivers of poor health.

Across our Big Local areas, I see this support in practice. At a community hub in Dover, older residents drop in unannounced to share a cup of tea with a friendly face. Nearly all of our areas have invested in similar community assets and activities. As social isolation and loneliness grow, exacerbating our risk of an early death from all causes, these daily interactions centered around communal spaces are a lifeline.

And as populations age and chronic conditions become more common, our communities are helping residents build and sustain healthy behaviors. In Ewanrigg, chair yoga sessions help older residents stay nimble and prevent falls. In Bedford, residents organized diabetes support and therapeutic gardening groups — a service so valued that it was extended by the local general practice. Outside of the walls of clinics, interventions like these are helping to manage the high incidence of comorbid obesity, diabetes, and chronic conditions all too common in low-income communities.

For those struggling with poverty, exclusion, or inadequate housing, social and community infrastructure connects people to the resources they need to live healthier lives. That might mean advocacy to address a moldy home, access to safe green spaces, or trusted local advice in times of crisis. In Gloucester, it is a local sports hub where youth workers can reach young people in a space they already know and trust.

When this support is available locally, health systems rely less on hospitals and clinics to compensate for the conditions that make people ill.

In a model centered around prevention, this infrastructure should be available in every community. But making space for it will require health systems to become comfortable with work that does not look like traditional medicine.

Community and social support is diffuse, relational, and hard to measure. It seldom produces the metrics that health systems value, unlike a clinical model that appeals to the bureaucratic impulse to measure and control. Yet as the U.K. and U.S. systems each face rising bills and increasingly complex issues, these low-cost, relational interventions are ever more necessary.

To solve the existential challenges ahead, health systems need to work intimately with the communities they serve. Beyond investing in social infrastructure, they should provide long-term core funding for voluntary and community organizations on the ground; invest in social support; and collaborate with the range of social institutions in communities, from faith groups to schools, to identify needs and build localized solutions. In the U.K., these measures are crucial to ensure that “neighborhood health” reforms are not simply a relocation of clinical services, but a redistribution of power that allows communities to lead healthier lives.

Both the U.S. and the U.K. have fragments of a better model. In the U.S., Accountable Health Communities demonstrated that connecting Medicaid patients to community-based support reduced their demand for health care services. In the U.K., the Big Local program gave communities long-term funding to invest in priorities of their own choosing — and has since inspired a £5 billion government investment in neighborhood regeneration.

The challenge is to balance the center with the edge. Governments and health systems are essential to scale and legitimize community-led work, but with them comes a tendency to standardize and disrupt relational work that sustains population health over time. A paradigm shift needs to combine their virtues with the energy and flexibility that exist within our communities to build a health care system that is fit for the future.

Kyle Vanelli is a policy and data analyst at Local Trust, the organization established to deliver the Big Local program.