Embedded Bulletin | Edition 27 – Neighbourhood health is now about power, money and control
Neighbourhood health has moved into a different phase.
For the last few years, most of the debate has been about whether more care should move closer to home. That argument is largely over. The real question now is who controls the model, who holds the contract, who carries the risk and whether General Practice is strengthened or gradually worked around.
That is why the latest neighbourhood contract consultation matters. This is no longer a vague conversation about collaboration. NHS England is now consulting on new Single Neighbourhood Provider and Multi-Neighbourhood Provider contracts. That means neighbourhood health is becoming contractual, not just strategic.
That sounds sensible on paper. The problem is – what happens if the contract solves the system’s structural problem while weakening the very part of the NHS it needs most?
The lead issue – neighbourhoods are moving from policy language into contract design
NHS England’s consultation on proposed Single Neighbourhood Provider and Multi-Neighbourhood Provider contracts is one of the most important developments in primary and community care this year.
It asks for views on two new contract types designed to make it easier to commission neighbourhood health services. NHS England says the consultation does not propose changes to core GP contracts, but it does set out how Single Neighbourhood Providers could build on current PCNs, while Multi-Neighbourhood Providers could bring together services across larger populations.
That is the important shift. Neighbourhood health is no longer just a local partnership idea. It is being turned into a commissioning and contracting model.
There is a logic to this. If the NHS wants neighbourhood teams to manage complex patients, prevent deterioration, reduce avoidable admissions, support frailty, improve long term condition management and co-ordinate care across primary, community, mental health, acute, local authority and voluntary sector services, then collaboration alone will not be enough.
- Somebody needs to hold the contract.
- Somebody needs to receive the funding.
- Somebody needs to organise the workforce.
- Somebody needs to be accountable for delivery.
The difficulty is deciding who that somebody should be.
This is where the debate has become much sharper. HSJ has reported that neighbourhood providers could gradually replace PCNs. Pulse PCN has reported that NHS England is proposing PCN and Single Neighbourhood Provider contracts should not exist in the same areas. GPonline has reported that NHS England’s consultation sets out how the new neighbourhood contracts would work.
That is not a small technical change. It goes directly to the future role of PCNs and the position of General Practice inside the neighbourhood model.
PCNs were never perfect. Some work well. Some struggle. Some are clinically led and trusted. Others feel administratively heavy or patchy. But they are still rooted in General Practice. They are built around registered lists, practice relationships and local primary care leadership.
If neighbourhood contracts gradually displace PCNs, the NHS needs to be very clear about what is gained and what is lost. The risk is that the system creates a larger, more formal provider architecture that looks coherent from an ICB perspective but feels remote from practices and patients.
That would be a mistake. Neighbourhood health will only work if it is close enough to patients to understand them and close enough to practices to be operationally useful. It cannot become another layer of governance sitting above the real work.
The warning signs are already visible. GPonline has reported BMA concern that practices may feel pressured to sign up to neighbourhood proposals because of funding fears. Pulse has also reported BMA warnings that GPs must not be pressured into signing up.
A neighbourhood model built through genuine local agreement is very different from one where practices feel the money is being moved and they have little practical choice but to follow it.
Kent and Medway continues to be the useful comparison. Every GP practice there reportedly signed up to the local DES variation. That model appears to have worked because it was negotiated locally, backed by investment, built through existing primary care structures and made participation credible for practices.
That does not mean Kent and Medway can simply be copied everywhere. Local context matters, but it does show something important – General Practice will engage where the deal is clear.
The practical test for neighbourhoods is whether the model answers five basic questions.
- Who is the provider?
- Where is the money?
- What work is being moved?
- What happens to PCNs and core General Practice?
- Who carries the risk if the model does not deliver?
Until those questions are answered locally, neighbourhood health remains more fragile than the policy language suggests.
For industry, this is a major market access issue. Many pharma, medtech, device and digital propositions now depend on neighbourhood delivery, but ‘neighbourhood’ is not a single customer. It may mean a PCN, a federation, a trust led provider, a community provider, a pharmacy led service, an ICB commissioned pathway, or a Multi-Neighbourhood Provider.
If you do not know which version you are dealing with, you do not yet understand the route to adoption.
What to watch
- Whether Single Neighbourhood Provider contracts strengthen PCNs or start replacing them.
- Whether funding follows genuine delivery responsibility or becomes a lever to force sign-up.
- Whether hospitals, community providers and General Practice are given aligned incentives, not competing ones.
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The new Health Secretary inherits the hardest version of the job
Yvette Cooper’s appointment as Health Secretary matters because the NHS reform agenda is moving from announcement into delivery.
The timing is not gentle. She inherits neighbourhood contracts, ICB restructuring, GP Collective Action, workforce uncertainty, list validation, financial deficits, hospital performance pressure, medicines access reform, the CVD framework and the early stages of Integrated Health Organisations.
That is quite an in-tray. A polite understatement, but only just.
Pulse has already asked what the new Health Secretary will do for General Practice. The King’s Fund has described an overflowing in-tray. HSJ has also framed her biggest challenge around whether the system can move beyond the myths and assumptions that often sit underneath reform.
The issue is what she chooses to stabilise first because the NHS is trying to do several difficult things at once.
- It wants to shift care out of hospital.
- It wants to recover performance.
- It wants ICBs to become more strategic.
- It wants neighbourhood models to take shape.
- It wants General Practice to do more prevention and complex care.
- It wants pharmacy, diagnostics and digital models to absorb more activity.
- It wants financial control.
- It wants workforce recovery.
The problem is that these aims can conflict if they are not sequenced properly.
You cannot ask General Practice to be the foundation of neighbourhood health while it feels financially exposed and contractually squeezed. You cannot ask hospitals to support the left shift while their income, targets and performance incentives still reward activity and recovery. You cannot ask ICBs to redesign care while they are also trying to cut management costs, merge footprints and balance impossible finances.
The new Health Secretary’s challenge is therefore not simply political communication. It is operating discipline. She needs to decide which bits of reform are ready to move quickly, which need more design, and which need slowing down before they damage trust.
That is why the neighbourhood debate is such an early test.
If Government and NHS England press ahead with neighbourhood contracts in a way that feels imposed, GP opposition will harden. If they use the consultation to create a more credible deal with General Practice, community services, pharmacy, local government and trusts, then neighbourhood health still has a chance of becoming useful rather than decorative.
The phrase ‘collaborative approach’ is welcome, but collaboration is not a substitute for funding, accountability or contract clarity.
The new Secretary of State will be judged less by whether she repeats the three shifts and more by whether she makes them implementable.
Integrated Health Organisations could either align care or concentrate power
The first Integrated Health Organisation sites are now being confirmed (but not yet commissioned by the local ICBs), and GP leaders are already raising concerns.
The principle behind IHOs is easy to understand. If the NHS wants better integration, fewer handoffs, stronger population health management and more coordinated care across hospital, community and primary care, then more integrated provider models may help.
In theory, an IHO could make it easier to align incentives, pool capability, reduce duplication and redesign pathways around patients rather than organisational boundaries, but the concern from General Practice is equally easy to understand.
If IHOs become mainly trust led structures, there is a risk that General Practice is pulled into a larger provider model on terms it does not control. Pulse has reported that GP leaders have withdrawn support for the IHO model amid fears it will disadvantage practices.
The NHS has a long history of saying integration when it sometimes means consolidation. Those are not the same.
Integration should mean the patient experiences less fragmentation. It should mean the GP, specialist, community team, pharmacist, social care worker and voluntary sector support can work around the same patient with clearer responsibility and less duplication.
Consolidation can mean something different; bigger organisations, larger contracts, more central control and a risk that smaller providers lose influence.
The practical question is whether IHOs are being designed around pathway accountability or organisational convenience.
If they are designed around pathways, they could be useful. For example, frailty, heart failure, respiratory disease, diabetes, CKD, mental health, medicines optimisation and rehabilitation all need better coordination across organisational boundaries, but if IHOs simply move more power towards large trusts without protecting the voice and business model of General Practice, they will create resistance.
The IHO debate also connects directly to neighbourhood contracts. Both are about the same underlying issue: who owns the out-of-hospital model?
- Is it General Practice led?
- Is it trust led?
- Is it community provider led?
- Is it ICB commissioned through new provider collaboratives?
- Is it genuinely shared?
The answer will vary by place, but it cannot be ducked.
For pharma, medtech and device companies, the NHS customer map is changing again. It may no longer be enough to think in terms of ICB, trust, PCN and practice. In some places, the practical adoption route may run through an IHO, a neighbourhood provider, a multi-neighbourhood contract, a federation or a trust-led community model.
That creates opportunity, but also risk. Larger integrated providers may be better able to redesign pathways at scale. They may also be harder to access, more financially controlled and more politically sensitive.
The organisations that do well will be the ones that understand where local authority really sits, not where national diagrams suggest it should sit.
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Worth watching
- General Practice viability. GPonline has reported that half of GPs say NHS General Practice is not financially viable ahead of the Plan B vote. That is not background noise. It shapes how practices respond to every neighbourhood, shared care, CVD, LES and access proposal.
- Hospital versus primary care funding. GPonline has also reported concerns that hospital funding is growing faster than primary care funding. Whether or not every figure is contested, the perception matters. The left shift will not land if the money still feels hospital weighted.
- Single national formulary pilots. NHS England has confirmed the first 13 ICBs to pilot a single national formulary. This could reduce unwarranted variation and make medicines access more consistent. It could also change how pharma teams think about local formulary strategy.
- Local Enhanced Services. Pulse continues to highlight concern that practices feel pressured into take it or leave it LES packages to access funding. That links directly to neighbourhoods. If local service funding becomes a pressure mechanism rather than a proper contract, trust will fall.
- Inequalities and polypharmacy. Reports that people in deprived areas are prescribed double the number of medications should sharpen the neighbourhood debate. Complex need is not evenly distributed and neither is the capacity to manage it.
What this means in practice
- Neighbourhood health is now a contracting issue, not just a collaboration issue. Local systems need to define provider, funding, risk and accountability before asking practices to sign up.
- PCNs should not be treated as disposable. If new neighbourhood contracts replace them, the NHS must be clear about how clinical leadership, registered list knowledge and practice confidence are protected.
- The new Health Secretary needs to stabilise the platform before accelerating reform. Otherwise, neighbourhoods, IHOs and primary care policy will collide.
- IHOs may improve integration, but only if they are built around pathways and patients rather than organisational gravity.
- Industry needs to remap the NHS customer. The adoption route may now run through neighbourhood providers, IHOs, federations, community providers or trust led models, not only ICBs and PCNs.
Closing
Neighbourhood health is entering the difficult bit.
The NHS has moved past the policy slogan. It is now designing the contracts, deciding the provider forms and testing where power will sit locally. That is where the real reform happens.
If neighbourhoods strengthen General Practice, align hospitals and community services, and create funded pathways around defined patient groups, they could become one of the most important delivery models in the NHS.
If they become a way of moving money, work and control without a credible deal, they will fail quietly, then loudly.
As ever, I would be interested in what you are seeing locally, especially from practices, PCNs, ICBs and partners trying to make neighbourhood working real.
Sources
Neighbourhood health and new contracts
New Health Secretary
Integrated Health Organisations
Wider delivery signals
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Scott McKenzie helps pharmaceutical, medtech and device companies cut through NHS complexity and get their offers in front of the right decision-makers. In 2023, he helped launch 53 new NHS projects – and added another 28 in 2024. Behind those numbers is a system-level understanding of what actually gets approved, funded and sustained.
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