Early Help and Prevention

Our prevention journey in Somerset began with the launch of Somerset Community Connect in 2018, a place based, strengths based approach designed to help people stay independent and well by connecting them to support in their communities at the earliest opportunity. Somerset Community Connect brought together Adult Social Care, health partners and the voluntary, community, faith and social enterprise (VCFSE) sector around a shared commitment to community l ed practice, prevention and early help, with a focus on information, advice, community solutions and problem solving close to home. This approach was formally embedded across the system through partnership activity and events from 2018–2019, including countywide engagement and development activity.

Building on this strong foundation, Somerset Community Connect evolved into Connect Somerset as the approach matured and expanded. Connect Somerset reframed community connect from a programme into a whole‑system way of working, bringing together Somerset Council, NHS partners, education settings and VCFSE organisations to increase access to early help, strengthen community capacity and reduce reliance on crisis and long‑term statutory interventions. It is explicitly described as “not a service but a way of working together,” with community hubs, champions, social prescribing, community agents and local partnerships at its core.

This journey has directly underpinned Somerset’s Prevention and Early Help strategy, providing the practical infrastructure through which prevention is delivered and sustained.

Through Connect Somerset, residents are supported earlier through accessible information and advice, community‑based solutions, and coordinated multi‑agency responses, helping to delay or avoid the need for formal care and support. The approach enables local problem‑solving, strengthens partnerships, reduces duplication, and supports demand management by resolving need at the earliest appropriate point, all of which are central to Somerset’s strategic ambition to promote independence, resilience and wellbeing.

Somerset’s Village and Community Agent service has been delivered through a joint commissioning approach with the NHS Integrated Care Board (ICB) since 2017, reflecting a shared commitment to prevention, early help and personalised care. The service forms a core part of Somerset’s integrated social prescribing and community‑based prevention offer, supporting residents through place‑based, strengths‑based conversations and practical coordination of support across health, social care and the voluntary, community, faith and social enterprise (VCFSE) sector. This joint approach aligns with Somerset’s wider Connect Somerset model and the ICB’s personalised care priorities, enabling early intervention and reducing escalation to crisis service.

Following a formal review of the Village and Community Agent service, the model was recommissioned in 2023 as the Connector Support Service to strengthen consistency and drive continuous improvement in terms of delivering outcomes and integration across neighbourhoods.

The recommissioned Connector Service retained the core preventative principles of the Village Agent model while clarifying roles, strengthening governance and performance management, and enhancing alignment with Connect Somerset, neighbourhood working and social prescribing pathways. This ensured the service continued to evolve in response to learning, demand and system priorities, while maintaining a strong focus on early help, independence and community‑based solutions

Families and residents can access the Village Agent service by requesting a call back from their local Village Agent or visiting a local Talking Cafe tun by Village Agents. Thrive have over 35 Talking Cafes across Somerset and in 2025 there was an average of 118 visitors to Talking Cafes across Somerset each week. Village Agents supported with over 800 referrals in 2025 and found that the most prevalent support needs they assisted with were:

• Sourcing care
• Accessing community/ activities
• Accessing health/ care support
• Benefits and finance
• Sourcing micro provider care

Somerset Council actively supports and shapes its micro‑provider market to increase local care capacity, choice and personalised support. Since 2014, the Council has operated a structured micro‑provider support programme that helps individuals and community groups to set up, develop and sustain small, independent care and support services. This includes providing clear information and guidance, operating a registration and brokerage system, promoting the Somerset Quality Standard, endorsing local micro‑provider networks, and integrating micro‑providers within the wider health, social care and Connect Somerset system. Through this approach, Somerset strengthens community‑based provision, supports prevention and early help, and offers people greater flexibility and control over how their care and support is delivered.

Somerset Council’s Independent Living Centres (SILCs) support people to live safely and independently by providing free, impartial information, advice and practical solutions to everyday challenges. The centres enable residents, carers and families to try out equipment, adaptations and Technology Enabled Care that can support daily living, mobility, safety and wellbeing. SILCs are an Occupational Therapy‑led service and form a key part of Somerset’s Prevention and Early Help approach, helping people to remain independent, reduce the need for formal care and access the right support at the right time.

Case Study 1:

In 2025, Thrive worked with a client who has significant health needs and caring responsibilities. They store lifesaving medication in their fridge, which one day suddenly stopped working. With no financial capacity to replace it, the client was distressed, at risk of harm and struggling with the pressures of caring for others within the home.

To ensure the client was safe the Village Agent rapidly assessed the urgency and secured a £300 grant through the Household Support Fund within days to ensure that the essential medication could be stored safely and preventing a potential medical emergency. Whilst this funding was secured, effective interim risk reduction steps were put in place to support the family by providing a temporary solution to store the medication safely.

The agent also already had an existing relationship with the client due to their caring responsibilities which enabled them to immediately reassure them and provide them with emotional support during this crisis. The responsiveness from the agent meant that the client’s needs could be directly addressed and they were able to stabilise their home environment.

By working in partnership with other organisations and having a good knowledge of community resources meant that the grant could also be secured so quickly. The outcome of this did not only support the client in the interim or short term as the warranties and guarantees with the new fridge has now provided the client with long term reassurance also.

Case Study 2:

In May 2025, Thrive worked with an adult with complex needs who has a learning disability and a history of legal and safeguarding complexities to support their wishes in regaining independence by moving into their own home.

Despite long‑standing attempts to source appropriate support, previous care arrangements had been successful.

Therefore, Thrive supported by identifying a provider who could meet specific gender‑based care requirements, ensuring both emotional safety and safeguarding compliance where a full 35-hour package of supported was secured which met both the clients personal care and community engagement needs. This was effective in enabling the client to sustain independent living.

When working with the provider, the agent carefully facilitated introductory meetings to make sure the provider was a good fit for the client and ensured that the client’s voice and their aspirations were key to shaping this care planning. By co-ordinating this with Adult Social Care it also enabled the package to transition to a commissioned service which strengthened the oversight, governance and continuity of this support.

This well-led work meant that the client successfully moved into their own home with an appropriate care package in place and was very grateful for the support Thrive offered which enabled a major improvement in their life.

Case Study 3:

In Spring 2025, Thrive worked with a client who suffers with a visual impairment, severe isolation and hoarding behaviours who were living in unhabitable conditions. The home had mould and broken furniture and these living conditions including the hoarding prevented carers from delivering safe support. The client also had significant emotional attachments to belongings and fractured family relationships.

Therefore, the Village Agent worked with a micro-provider to provide a safe home environment for the client to declutter at the client’s pace, remove mould and arrange replacement furniture including an appropriate hospital bed. By working effectively with partners including Age UK, Somerset Sight and the Library Service, they were able to create a holistic support network to address both the practical and emotional needs of the client.

The Village Agent utilised a trauma-informed approach and built trust with the client over time and ensured that sentimental items were respected. All the work from the Village Agent and partners were also structured entirely around the client’s goals of improving the home conditions, maintaining treasured items and reconnecting with family.

With the Village Agent coordinating this approach and by working with multiple partners they enabled safe access for care teams and improved long-term sustainability for the client. The client now lives in a safe, clean, accessible home, receives regular social contact, enjoys increased comfort and quality of life and has re‑established family connections. Carers can now deliver support safely and effectively and the client can be supported at home.

Through data supplied from Thrive and analysis of case studies we have illustrated many examples of where support from the Agents Service has helped reduce demand on social care teams and avoid the need to go into longer term care. Although these cannot be attributed only to the work of the Agents, the evidence shows that demand and costs relating to them are positively affected. This would include:

• Increased use of community solutions that prevent or reduce the need for paid for support, reduce dependency and increase independence
• Referrals resolved by Agent actions with no onward referral to Adult Social Care
• More people able to go home from hospital
• The number of people who are able to remain in their own homes after leaving hospital has increased
• The number of people placed in long term care placements has reduced
• Better reported outcomes – customer feedback / customer experience is positive
• Increase in number of carers identified and supported
• Reduced emergency admissions to hospital

Somerset Council have worked in partnership with the market to develop robust assurance boundaries, clear quality standards, and strong, demonstrable outcomes that the system delivers to individuals, the health and care system, and local communities. Somerset operates the only structured quality‑assurance model for micro‑enterprises in the UK.

Somerset holds centralised activity, utilisation and outcomes data at scale and Somerset maintains one of the most comprehensive datasets in England for a non‑regulated care marketplace:

• 4,948 new enterprise start‑up enquiries to the CMEP since 2019, categorised by service type and workforce background.
• 10,872 care requests submitted through the Find a Micro‑provider brokerage tool over three years, tracking request type (self‑funded, Direct Payment, PHB) and including a built‑in quality and satisfaction feedback loop.
• 31,122 hours of support delivered weekly by micro‑providers, supporting 5,903 individuals, giving clear visibility of scale, reach, and capacity.
• Two in five people leaving hospital are supported through micro providers and community options. In 2022 alone, micro providers directly supported over 1,000 hospital discharges.
• Outcomes data is fully present: a comparative survey of 141 Direct Payment recipients supported by micro‑providers versus 367 agency‑supported recipients showed higher scores across every outcome measure for micro‑providers, including kindness, being listened to, confidence, and control Outcome Map Outcome Map; Micro-provider Feedback Form .docx.

Important context for data limitations:

Direct Payments and self‑funded arrangements are private contracts. Councils have no legal right to require demographic reporting or detailed activity returns. Micro‑providers are legally exempt from CQC registration unless delivering regulated personal care. This is a national regulatory position, not a Somerset design choice.

Additionally, the term micro‑provider is used informally across the independent care sector in Somerset, regardless of registration status. Somerset formally registers and assures approximately 50% of this market—the highest number of any local authority in the UK.

Price and choice

The report suggests that Direct Payment (DP) rates restrict choice. The evidence does not support this.

• While the average micro‑provider cost is around £20 per hour (above the £18.15 DP rate), Somerset routinely agrees enhanced rates in areas where alternative provision is unavailable.
• Increased choice and a more vibrant local market have contributed to a 119% increase in Direct Payment uptake over the past six years (Connect Somerset Community Partnerships Report 24.25.pptx)

The micro‑enterprise model has expanded—not constrained—choice and control.

Monitoring, quality assurance, and safeguarding

Somerset operates the only structured quality‑assurance model for micro‑enterprises in the UK.

• Registration requires DBS checks, insurance, safeguarding knowledge, and full compliance with Somerset’s Quality Standards.
• Providers breaching standards or crossing into regulated activity are removed and referred to CQC—a stronger escalation route than most councils (CMEP Quality Assurance Process).
• Safeguarding referrals remain low, consistent with evidence of high wellbeing outcomes, long visit lengths, continuity of support, and community‑based delivery.

Somerset is nationally leading in assuring the unregulated care market.

Seldom‑heard groups

The design and operation of Connect Somerset and the CMEP intentionally enhance access for seldom‑heard groups through local, relationship‑based, community‑led support.

Village Agents, Talking Cafés, and micro‑providers routinely reach individuals who do not engage through statutory routes. Evidence shows that access patterns, rural engagement, and community‑based referrals demonstrate increased reach, not exclusion.

In short: claims that the model disadvantages seldom‑heard groups do not reflect its purpose, delivery, or documented reach.

Neighbourhood working is substantial and expanding

The report appears to reference inconsistency, yet Somerset’s neighbourhood model is long‑established and highly developed.

• For 12 years, Somerset has had 60+ Village Agents, 30+ weekly Talking Cafés, and a strong community grants programme.
• In 2024, this network supported 18,854 people, with 81% reporting improved wellbeing and 73% increased confidence.
• Talking Cafés and community hubs received 5,819 visitors (Thrive Impact Report).

The CMEP stimulates the rural economy, sustaining local micro‑businesses and creating 728 jobs. It builds social capital and has enabled the formation of neighbourhood care collectives such as Wivey Cares, Wincanton Cares, Wells Community Support Network, and Blackdown Hills. Somerset invested £660,000 in co‑produced community‑led models in 2025.

This is a mature, high‑performing neighbourhood system.

National leadership

Somerset hosts the UK’s largest LGA Community of Practice for self‑directed support, supporting 78 local authorities and 220 commissioners.

Peers consistently cite Somerset as a national leader. As Staffordshire County Council notes: “Somerset is a national leader… providing real choice and control.”

Somerset has co‑authored Skills for Care guidance on self‑employed carer types and is a contributing partner in the national Direct Payment Forum employment status guide

Open Mental Health Alliance

In 2019, the NHS committed to equal priority for physical and mental health services. Somerset was selected to transform community mental health by creating Open Mental Health—a partnership between statutory and voluntary sectors. Somerset Council redirected Mental Health Wellbeing Services funding to this Alliance.

A 2023 recommissioning exercise awarded a five-year contract to Rethink Mental Illness, allowing the Alliance to build on its progress and improve outcomes. The goal is to provide timely, appropriate support for people with mental health problems through specialist services, housing, employment advice, volunteering, peer support, and activities to enhance wellbeing. The partnership aims for a “no wrong door” approach for anyone seeking help.

• 80,000 interventions delivered in 2024-2025
• 35% drop in number of bed days in an acute hospital
• Mental Health re-admission rate 4%- half the national average
• Mental Health A&E attendances reduced by 15%
• Mental Health inpatient admissions reduced by 18%

Impact Report 2024/5 – Open Mental Health

Step-Together

For the past 7 years, Somerset Council has contracted Step-Together to deliver under the Creative Solutions for Complex Individuals contract, a service supporting people who are homeless or at high risk due to factors such as mental illness, substance misuse, or criminal history.

With the contract ending in March 2026; a recommissioning review confirmed that Somerset still needed support services for those facing multiple disadvantages and exclusions. A new contract which places an emphasis on a trauma informed approach and innovation was awarded beginning of this year following a tender exercise to Second Step (the incumbent provider)- the service will remain known in Somerset as the Step-Together service.

• Over 1000 referrals made to the service
• 100% of individuals supported were homeless or at high risk of becoming homeless
• 50% of the individual supported had Mental Health needs
• 35% substance misuse
• 22% with historical and active offending behaviours
• 34% recorded and MH and substance misuse
• Homelessness prevention:
• 71% sustained housing whilst in the service
• 54% moved into a tenancy (RSL/Private) and almost 30% into supported housing
• Only 15% recorded as becoming homeless when previously housed

Mental Health Step-Down Service

The Step Up and Step- Down mental health services were developed jointly by Adult Social Care and Somerset Trust in response to the Covid pandemic. Step Up prevents hospital admissions, while the eight-bed Step Down unit supports safe discharges from acute wards, helping those needing extra recovery time or housing support. Both services are now core parts of Somerset’s mental health pathways. In 2022, SFT took over funding for Step Up, and Somerset Council assumed responsibility for Step Down. In 2026, Rethink Mental Illness was directly awarded the contract under the Provider Selection Regime.

• Over 30 individuals use the service each year.
• Average stay is 87 days.
• 38% of discharge delays stem from finding suitable accommodation.
• 57% of clients are rehomed by Somerset Council; 21% return home with added support.

These services mainly assist people facing multiple disadvantages, offering trauma-informed care and aftercare to support successful transitions and recovery, often collaborating with community groups like Thrive.

Move to Independence

The service is a jointly commissioned piece of work, led by Somerset Council Adult Social Care. High level data headlines from 2024/25 are captured below.

The Community Single Point of Contact (SPOC)

This is jointly commissioned by Somerset Council, Somerset Foundation Trust and Somerset ICB. Somerset Council take the lead commissioning role, working in partnership with The British Red Cross and Thrive Village Agent Service.

In the Academic year 2024/25 the Community SPOC received 5013 referrals, averaging 9 referrals per day.

Other partners we work with

A Strong, Integrated Partnership Model

Connect Somerset Champions play a pivotal role in linking local organisations, providing practical local intelligence, and enabling shared problem-solving across neighbourhoods. In 2024:

• 92% of Somerset schools engaged with Champions, deepening joint work between education, Early Help, health services, and community organisations.
• 21 VCFSE partners contributed data to the Transform data lake, demonstrating high levels of trust and mature information sharing.
• Multi-agency collaboration flourished across community hubs (e.g., Boden Centre, Minehead Eye), Primary Care Networks, and local town and parish councils, enabling more coordinated service delivery.

This strengthened network has empowered practitioners, improved local service alignment, and created more accessible pathways for families, children, and residents.

System-wide Benefits Across Health and Social Care

Close collaboration between statutory services and the VCFSE sector has delivered measurable system benefits:

• Red Cross and Village Agents supported 5,013 people to return home safely from hospital, reducing delays and relieving pressure on acute settings.
• Community SPOC work shows high-quality outcomes at low cost, with an average referral cost of £94 and average daily cost of £10.44.
• Community-rooted approaches funded through Adult Social Care mobilised 16 neighbourhoods to create hyperlocal solutions that increase independence, reduce isolation, and support unpaid carers.

Primary Care Networks report improved access, reduced inequalities, and expanded preventative work due to increased community partnerships facilitated by Champions.

Strengthening Communities and Local Capacity

Investment of £7.7 million into the VCFSE sector has significantly expanded local support options. Through shared spaces, coordinated neighbourhood meetings, and new community-led activities, Connect Somerset has:

• Increased the range and quality of preventative support.
• Enabled early years, youth, maternity, mental health, and education services to be delivered in more accessible, community-rooted settings.
• Fostered stronger resident and community engagement.

A Culture of Collective Responsibility

Across sectors, there is clear evidence of a cultural shift toward shared responsibility for early help and community wellbeing. Partners consistently report:

• Better awareness of local services
• Faster access to support
• Improved relationships and communication
• Greater efficiency and reduced duplication
• Connect Somerset is now widely recognised as a model of effective place-based partnership working, underpinning Somerset’s achievement of Sector Led Improvement (SLI) status.

Governance and Monitoring

The effectiveness of our Prevention Strategy is monitored through Somerset Council’s formal contract management arrangements and joint oversight with the NHS Integrated Care Board (ICB). This includes regular contract management meetings, structured management reports and performance monitoring against agreed Key Performance Indicators (KPIs) and service standards, as set out in the Connector Support Services contract.

Performance data, outcomes, risks and learning are reviewed routinely, with clear mechanisms for escalation, improvement planning and continuous service development through change control processes where required.

The Connect Somerset Steering Group provides strategic oversight and direction for the Connect Somerset programme, which delivers early help and prevention through a whole‑system, partnership‑led approach.

The Steering Group brings together senior representatives from Somerset Council, health partners, education and the voluntary, community, faith and social enterprise (VCFSE) sector to steer delivery, manage risks, and ensure alignment with agreed priorities. Its role includes overseeing programme plans, performance, commissioning activity and system learning, supporting collaboration across organisations, and promoting Connect Somerset as a consistent, county‑wide way of working to improve outcomes for families and residents while enabling local flexibility and innovation.

For this jointly commissioned service, assurance is further strengthened through shared governance via the Joint Commissioning Board, which provides system‑level oversight, reviews performance and quality information, and agrees collective actions where improvement or service development is required.

Continuous Improvement for Governance and reporting

As part of the current contract arrangements, we are working with the Connector Service provider and system partners, to co-produce an outcomes‑based framework that clearly demonstrates the added value and wider impact of our collaborative, preventative approach through Connect Somerset. Building on the jointly commissioned Connector Support Service and its role within neighbourhood working, the framework will focus on shared outcomes rather than activity alone, capturing the collective contribution of health, social care, VCFSE and community partners. Through agreed outcome measures, qualitative insight and shared learning, we will be able to evidence how coordinated, strengths‑based support improves individual wellbeing, strengthens community capacity, reduces duplication and prevents escalation into statutory services. This approach will be embedded within existing governance, contract management and partnership forums, enabling continuous review, shared accountability and a clear line of sight from early help and prevention activity to system‑wide impact.