Neighbourhood health can transform care – if power and funding follow
4 min read
Neighbourhood health could change the centre of gravity of health and care.
The promised “left shift” is more than moving appointments out of hospital: it means earlier help, prevention and continuing support organised around people’s lives.
The ambition is familiar. Lord Darzi’s 2024 investigation found that hospitals’ share of NHS spending had risen from 47 per cent to 58 per cent since 2006, despite repeated promises to shift care into the community. The government’s 10-Year Health Plan commits to reversing that pattern. The question is: what will make this attempt different?
Neighbourhoods could bring primary and community healthcare, social care, housing and voluntary support into a different relationship with people and each other. But they risk being asked to transform care while the decisions, budgets and incentives shaping that transformation remain elsewhere. As the Health Bill reaches the Lords, the issue is whether the wider architecture can enable the change expected locally.
The bill seeks clearer accountability, stronger strategic commissioning and simpler planning.
These address genuine problems. Yet clarity within organisations does not guarantee coherence between them. Integration brings services and teams together; coherence means distinct institutions can align purposes, resources and decisions, share risks and adapt together. The NHS and local government have different duties and sources of authority.
Those boundaries can be legitimate. The seams are where responsibilities meet: where joint decisions, resource flows and the resolution of disagreement require deliberate design.
The first test is whether resources can follow the shift. A council may fund support that avoids admission; a community service may need capacity before hospital activity falls. Costs sit in one budget, benefits in another, while hospital beds may fill again and fixed costs remain.
Building capacity ahead of savings requires funding both sides of the transition. Dutch research on long-term care documented cost-shifting between institutions with separate financing. New NHS payment mechanisms recognise part of this problem. How will funding and transition risks also be managed across the NHS–council boundary? Without that answer, neighbourhoods may inherit expectations without the means to meet them.
The second test is how partners make decisions. The bill proposes neighbourhood health plans prepared jointly by councils and integrated care boards (ICBs). Restored local-authority representation on ICBs offers a voice, but does not settle different statutory duties, priorities or financial pressures. Councils have their own democratic mandate, not merely an NHS delivery role. Health and wellbeing boards provide an existing forum. A practical question remains: what happens when material disagreement cannot be resolved? Local escalation, clear responsibility and transparency matter because unresolved tensions otherwise fall on neighbourhood teams and the people they support.
Neighbourhoods could provide proactive, continuing support shaped around people’s goals, recognising unpaid carers and connecting them to information, assessment and help
The third test is the model of care itself. A left shift measured mainly by hospital activity risks making social care an instrument of NHS efficiency. The published neighbourhood framework recognises wider outcomes; the issue is whether these carry equal practical weight. The Care Act’s wellbeing principle reaches beyond clinical measures to independence, relationships, participation and control. Its prevention and carers’ assessment duties offer an existing foundation. Neighbourhoods could provide proactive, continuing support shaped around people’s goals, recognising unpaid carers and connecting them to information, assessment and help.
This reaches beyond the bill. The Prime Minister has described a future National Care Service alongside the NHS: integrated, preventative and person-centred, without over-medicalising care. The Casey Commission has yet to settle the design. Neighbourhood arrangements established now may shape what that future settlement can achieve. Designing around NHS flows alone could constrain those choices before they are made.
These changes will unfold alongside devolution and local government reorganisation. Unless the transition protects existing partnerships and pooled budgets, neighbourhoods could inherit gaps in responsibility and capacity. Parliament should ask who will identify and correct failures between institutions, and how people can challenge them. The Lords’ scrutiny can therefore examine more than the new organisational chart: who can decide, who pays, who carries risk, and whose outcomes count?
The boundaries between institutions should be their problem to manage, not an obstacle left for patients, carers and communities to navigate.
Paul Burstow, as care minister, drafted the main provisions of the Care Act. He is a former Liberal Democrat MP.
