Unpacking the neighbourhood health framework: the good, the bad and the puzzling

Since its publication, the 10 Year Health Plan for England has been criticised for being heavy on vision and ideas, but thin on delivery. It set out a direction to move more care out of hospital that few would disagree with, but left unanswered harder questions about what it would make it achievable, and whether the government was willing to confront the barriers that have held back similar plans in the past.

The long-awaited neighbourhood health framework meant to fill some gaps, offering the clearest account yet of how the shift from hospitals to communities will happen. But does it – and are we any more confident of the government’s vision becoming reality as a result?  

Here, we set out our take on the new framework, highlighting what’s promising, what’s problematic and what’s still unclear in the new guidance – and what we think it means for local systems trying to work out what comes next. 

1. The good

Broad conception of who neighbourhoods are for, and their potential benefit: First, there is much to welcome in the tone and focus of the guidance. There’s a version of this agenda that could have been framed much more narrowly around easing pressure on hospitals or saving money – with neighbourhoods positioned mainly as a way to reduce demand in A&E, bring down elective waiting times, and overall costs. 

The framework certainly leans heavily on admission avoidance and reducing overall hospital use as goals, but it also points to a broader set of benefits, including better satisfaction, access and clinical outcomes. 

While there is an understandable focus on people with frailty and/or chronic conditions, there is also a welcome explicit focus on other communities whose needs could be better served outside of hospitals, including people needing end of life care, and children and young people. In a field so often narrowed to eliminating long elective waits, the opportunities for these communities and the wider benefits of neighbourhood working can be too easily overlooked. 

This is important, because as the experience of other countries shows, of the benefits drawn from shifting care to communities, wait times or A&E pressure can be the slowest to improve – particularly when new models uncover unmet need and bring more people into contact with the service. 

Strong emphasis on local flexibility, at least in principle: There seems to be genuine good will from the government that neighbourhoods should be locally determined, and the form they take and how they are delivered to be decided by local areas who know their communities best. It resists prescribing what delivery model neighbourhoods should take, what services they run, or what make-up of skills or roles their interdisciplinary teams should have. In a system with a strong tendency to design from the centre, this is promising. 

However, that promise of flexibility may sit uneasily alongside the number of nationally mandated targets and a fairly prescriptive set of minimum objectives and metrics also set out in the framework – which build on objectives in the Medium Term Planning Framework and 10-year plan. While these targets are framed as a floor, not a ceiling for what neighbourhoods should achieve, in practice they are likely to leave limited time, attention and capacity for other local priorities – particularly when leaders are already preoccupied with wider system reorganisation (see below). 

And the real test for the government’s commitment to localism will come later, when progress is slower than anticipated, or when the pace of change starts to vary significantly between places. That is when it will become clear whether the centre can resist the instinct to standardise approaches or tighten control.  

2. The bad

Scale of ambition incompatible with current context: There’s also something to be said about whether systems are being set up to fail – even with the promise of local flexibility. 

The framework contains 17 objectives across three neighbourhood reform agendas, but offers little by way of prioritisation or sequencing. These goals don’t all match up and align, and achieving one won’t necessarily lead to another (for example, focusing on 18-week elective targets can crowd out capacity to deliver on outpatient reform). 

This leaves local leaders trying to navigate a long list of expectations without a clear sense of where to start. If the centre wants a wide-ranging agenda for neighbourhood health, it needs to either offer more direction about what to focus on first, or accept variation in what gets attended to. 

This pace of change is also difficult to reconcile with both the scale of disruption already underway and lack of new resources or transitional funding. Structural change crowds out delivery, and the NHS is now in the middle of a major reorganisation, with NHS England being abolished and both the centre and integrated care boards (ICBs) reducing staff by half. This is heavily absorbing leadership time, leaving less capacity to work through contract changes, delivery models and governance arrangements needed to establish neighbourhoods. 

Under-considered workforce gaps: Poor consideration of workforce challenges are an evergreen complaint with NHS implementation plans, and this framework is no exception. A new workforce plan is expected soon, and this framework leaves it to deal with the sharpest pain points. It’s hard to see how this agenda really takes off without more serious attention to some of the workforce challenges or inconsistencies that could hold it back. 

The framework references “a fundamental reimagining of roles” and need for new skills and ways of working across health, but says too little about whether the right solutions are in place to build a workforce that can deliver more care in the community. 

Ireland, for example, included much more deliberate efforts in their similar health reform for how they would move more staff into the community, including the use of “50/50” contracts for consultants and advanced nurse practitioners to split their time in community settings, and revising training plans to ensure nurses and other key roles had more exposure to community work as part of their education. 

Neighbourhood models will depend on staff with the right skills, training and experience to work across organisational boundaries, and these roles are in short supply – for example, the number of district nurses dropped by 43% between 2009 and 2024. 

Part of the problem is that community-based work is still often seen as the lower status option, with fewer opportunities around progression and pay. The neighbourhood workforce also depends on staff from sectors that may not be clearly addressed through the NHS’s workforce plan, including those working in the voluntary sector and those in social care. If neighbourhood health is to move beyond rhetoric, implementation will need to grapple much more seriously with these realities.  

Attitudes towards risk: Neighbourhood working will require a much bigger shift in how the system understands, shares and manages clinical risk than current policy design seems to recognise. As one example, delivering care though multidisciplinary teams and across organisational boundaries often requires staff being managed by, or accountable to, people outside of their profession or employer. In practice, these arrangements can be difficult to make work and require changes to organisational and professional identities that have undermined similar efforts in the past.

There are also deeper cultural tensions at play. Hospitals are designed to contain and control risk, while community and primary care services are required to anticipate it and manage it, often with less immediate backup. These different approaches to risk can create friction within teams and services, particularly when responsibilities are unclear or familiarity with community-based pathways is low. 

A framework would never be expected to solve these cultural tensions on its own, but there should be greater policy appreciation for them, and clarity on how regulation and clinical governance are meant to work in a neighbourhood model (stay tuned for more Nuffield Trust analysis to help policymakers think through different types of risk associated with the neighbourhood shift).  

3. The puzzling

Measurement: This brings us to one of the framework’s more confusing elements: measurement, and who is responsible for the performance of neighbourhoods. 

As one example, there are targets in the framework to increase the number of people identified as approaching end of life by 10%, and reduce non-elective admissions or bed days of one day or over for people at the end of life. The framework sets that “we aim” to achieve these outcomes – but is that target meant to apply nationally, to each ICB, place, or to every neighbourhood? In several places, it is unclear who is meant to deliver against the metrics it sets out, what unit of analysis these metrics will be measured and judged, and who will measure them – leaving also unclear who is accountable for them, and how well we’ll understand progress.

Acute dominance? The framework sets out more details on integrated health organisations (IHOs), stating that these contracts will only be held by NHS trusts. Limiting contract-holding to NHS organisations makes sense: opening the door to a wider range of providers would provoke controversy if it created the possibility that local health systems could be led by non-NHS bodies. 

But that design choice also creates an interesting tension: it excludes GP practices – as independent organisations – from holding these contracts. So, in places where IHOs are established (and the general sentiment does seem to be that should be moving towards this model over time) it is likely that – at least for now – large NHS trusts will take a more prominent role in coordinating neighbourhood care. In theory this could mean a community or mental health trust, but in practice it’s likely to be acute trusts given their organisational dominance. 

There is something uncomfortable about a policy intended to shift care out of hospital potentially being led, in many places, by the NHS’s largest acute organisations. At the same time, an acute trust holding a contract does not mean delivery itself will become less community or neighbourhood focused – indeed, hospitals already manage many community services. Still, it is a question mark looming over the framework, and one that will matter if neighbourhood health is to feel different from previous NHS reforms that failed to redistribute power, resources and decision-making to make care more collaborative and integrated. 

What do outpatient standards mean in practice? The focus and commitment to improve outpatient care is commendable. Again, it suggests a broader appreciation of the role neighbourhoods can play rather than simply cutting elective waits or avoiding admissions, and recognises that reform also has to change how specialist care is delivered.

But some of the specifics are unclear or present challenges. The framework seeks to reduce the number of referrals being made to outpatient care, and to transform the way that outpatient care is delivered for those who need it. On the first, single points of access will be created to channel GP referrals, hopefully offering better coordination of care. But GPs will be concerned that these routes are effectively gatekeepers, explicitly tasked with rejecting or ‘diverting’ an eye-wateringly high 25% of referrals – limiting the care available to patients, challenging the professional judgement of GPs, and increasing workload for general practice. 

The framework states a welcome intention to deliver more outpatient care in communities, but how this will be done is unclear. Is the expectation that more specialists will work within GP practices and community settings, or that more specialist care will be delivered remotely (truly ‘from hospital to home’), or that will GPs be taking on responsibility for appointments that would previously have been done by hospital specialists? 

The latter implies shifting care that would have previously happened in outpatient clinics onto general practice, and there is little acknowledgement that this would necessitate additional resource, or plans to bolster general practice to cope. 

Is anything really going to change with finances? This isn’t the first time the NHS has attempted to shift more resources to communities. Truly succeeding would be new though, and for confidence to be boosted, a credible plan – and set of changes to financial architecture – are needed. 

The framework is clear that there is no new money for neighbourhoods, and that plans must be funded by rebalancing existing resources. It’s also clear that ICBs will be expected to move funding from the acute sector into neighbourhood services. But there’s insufficient detail on how this will happen, and how and to what extent ICBs will be held to account on growing the share of community spend. 

Promises to take a permissive approach when neighbourhoods propose change to money flows or contractual approaches are sensible, but new neighbourhood contracts haven’t yet emerged, and this may be another area where a lack of clarity from the centre limits the pace of change. Moving resources into the community will not happen automatically, and nine months on from the 10-year plan’s publication, we remain little the wiser about how financial levers will be aligned or designed to do so. 

Conclusion: what comes next for local systems?

Taken together, the neighbourhood health framework is neither a clear breakthrough nor an empty gesture. It reinforces a broadly persuasive vision for care closer to home, recognises a wider set of benefits than previous reform efforts, and signals towards greater local flexibility. But it also lands in a system already stretched by reorganisation, workforce shortages and financial constraints, and asks local leaders to deliver a wide-ranging set of reforms without resolving some of the most fundamental questions about prioritisation, incentives, accountability and risk.

Whether this framework marks a turning point will depend less on the guidance itself, and more on what follows. Will the centre genuinely allow local systems the freedom to adapt, learn and move at different speeds? Will contracts, workforce policy and funding start to line up better behind this shift? And will local system leaders be given real room to make trade-offs rather than simply being handed a longer list of must-dos to deliver? We’ll start to see better if the government is putting more of these conditions in place with the forthcoming workforce plan, and as the details of the new neighbourhood and IHO contracts become clear. 

Until then, there is a risk that neighbourhood health follows a familiar NHS pattern of ambitious rhetoric, constrained delivery and inevitable redesign before local systems are given a fair chance of delivering the scale of the change promised.