Embedded Bulletin | Edition 23: Neighbourhood health is becoming real – but the NHS is still searching for delivery models that can withstand operational pressure
For years, the NHS has talked about care closer to home, neighbourhood health, prevention and stronger community based delivery. Those ambitions remain firmly in place, but the conversation is starting to change. The question is no longer whether neighbourhood health is the right direction of travel. The question is how systems make it work in practice.In this edition of the Embedded Bulletin, I look at significant developments in Kent and Medway, where a locally negotiated variation to the PCN DES has created a funded neighbourhood health model built around general practice, defined patient cohorts and existing primary care infrastructure.
Whether it succeeds or not, it represents one of the clearest examples so far of neighbourhood health moving from policy ambition into a practical operating model.
At the same time, the wider NHS continues to expose the challenges sitting underneath reform. PCNs are being asked to deliver more while questions remain about workforce flexibility.
Advice and Guidance is attracting increasing scrutiny around accountability. ICB variation continues to shape what services are funded locally. Hospitals are showing signs of recovery while remaining financially fragile. And general practice appears to be moving from frustration into more organised resistance around workload, funding and contractual trust.
Taken together, these stories point to a common theme. NHS reform is becoming much more local, operational and contested. Success will increasingly depend on whether systems can turn broad strategic ambitions into funding mechanisms, workforce models, contracts, governance arrangements and pathways that people on the ground believe are deliverable.
For pharma, medtech and device companies, the market access lesson is equally important. Alignment with national policy is no longer enough. The organisations that gain traction will be those that understand how reform is being translated locally, where operational pressure sits, who owns delivery and how their offer helps make change possible in the real world.
For quick access, click the links below to access the topics of interest:
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- What’s new in the world of NHS market access
- PCNs are still being asked to deliver more but the workforce model remains unresolved
- Neighbourhood health is now moving from ambition into contested delivery
- ICB variation is becoming a major market access issue
- Advice and Guidance still needs clarity on accountability, not just activity
- Hospitals are showing improvement, but the financial and operating model remains fragile
- General Practice is moving from frustration into organised resistance
- The wider reform agenda is still expanding, but delivery capacity remains the constraint
What’s New In The World Of NHS Market Access
NHS England has approved Kent and Medway’s request to offer GPs a local variation to the Network Contract DES. The variation will support GP led single neighbourhood care through existing PCN arrangements.
It has been developed jointly by NHS Kent and Medway ICB and Kent LMC, with the stated aim of simplifying arrangements, reducing fragmentation, strengthening continuity of care and unlocking nearly £10 million of new annual investment for patients with the most complex needs.
The model will begin with around 92,000 patients in the most complex cohorts, including care home residents, people on palliative care registers, housebound patients and people living with severe frailty. Although this group represents around 5% of the Kent and Medway population, they account for around 30% of hospital admissions.
In Kent and Medway, the Single Neighbourhood model sits at PCN level and is GP-led, focused on proactive and ongoing care for complex patients. Multi-Neighbourhood teams provide additional support at scale, including urgent response, home visiting and enhanced multidisciplinary input.
That separates proactive continuity based care from wider urgent and multidisciplinary support. It also recognises not everything can or should sit inside an individual practice or PCN.
I think this is more than a local contracting story. It may become an early signal of how neighbourhood health could be made operationally real, not by creating entirely new structures everywhere but by locally varying existing contracts, investing in general practice, focusing on priority cohorts and building neighbourhood delivery around the parts of the system patients already use.
A lot of neighbourhood health discussion has felt as though general practice would simply be absorbed into a wider neighbourhood structure. Practices have worried about loss of autonomy, unclear accountability, additional workload and unfunded responsibility.
The Kent and Medway approach appears to take a different route. It keeps GP core contracts in place, uses the existing PCN framework, builds in GP leadership, and creates a local variation designed with the LMC rather than imposed onto practices.
That suggests neighbourhood health does not have to mean replacing general practice. It may mean strengthening general practice’s role as the clinical anchor for complex, proactive neighbourhood care.
This fits with what I am increasingly seeing across systems. There is still strong support for the left shift, proactive care, prevention, better management of frailty and more integrated community support, but there is also growing nervousness around how much general practice can realistically absorb.
The Kent and Medway model seems to recognise that neighbourhood delivery needs more than aspiration. It needs a deal.
That is the lesson for industry too. If a pharma, medtech or device company wants to support neighbourhood health, it cannot simply say its product aligns with the left shift. It needs to understand the local operating model. It needs to understand which patient cohort is being prioritised, where the workload sits, what funding mechanism is being used, who owns delivery and how the offer reduces pressure rather than adding another layer of activity.
What to watch / what this means in practice
Watch whether:
- Practices opt in, and whether the promised investment is enough to build confidence.
- The model reduces fragmentation or simply creates another layer of reporting and co-ordination.
- The Single Neighbourhood and Multi-Neighbourhood distinction becomes a useful template for other ICBs.
- The initial complex cohort focus produces measurable reductions in admissions, delayed deterioration or avoidable hospital use.
- Other ICBs follow Kent and Medway by using local PCN DES variations rather than waiting for entirely new neighbourhood contracting structures.
Most importantly, watch whether this strengthens general practice or stretches it further. That will determine whether the model becomes a genuine neighbourhood delivery platform or another well intentioned demand transfer mechanism.
Sources
Embedded Conversations Podcast – Real discussions about what’s shaping the NHS
In the latest episode of Embedded Conversations, Scott is joined by David Thorne, an experienced NHS leader with more than 45 years in the service, bringing a clear and practical perspective on system change. In this episode, he shares his views on value-based healthcare, outcomes-focused commissioning and the role of data in moving from strategy to delivery.
PCNs are still being asked to deliver more but the workforce model remains unresolved
The latest reporting on ARRS spending reinforces one of the unresolved tesnions sitting underneath the PCN mode. PCNs were created to provide additional capacity, multidisciplinary working and a platform for more integrated neighbourhood care. In many areas, they have helped bring new roles into primary care and supported wider delivery around care homes, access, medicines optimisation, frailty, enhanced access and population health.
But GPonline reports just £1 in every £12 of the ARRS budget is being spent on GPs. The NHS continues to ask PCNs to carry more delivery responsibility but the workforce model underneath them still does not always match what practices feel they need most.
PCNs are now being positioned as one of the key building blocks for neighbourhood health. They are being asked to support prevention, proactive care, complex patient management, access improvement and integration, but if the workforce available through PCNs does not properly align with clinical workload and local operational need, the model will remain under pressure.
The risk is that national funding rules create roles that are technically additional, but not always the roles practices would choose if they were designing around workload, risk and clinical demand.
A multidisciplinary team only works if the roles fit the pathway, the practice workflow and the needs of the patient population.
This is not an argument against multidisciplinary teams. Many additional roles are valuable. Pharmacists, social prescribers, care co-ordinators, first contact physiotherapists and other roles can make a real difference when they are properly integrated into practice workflows.
The issue is whether PCNs have enough flexibility to shape the workforce around the work they are actually being asked to do.
PCNs remain central to the NHS’s neighbourhood and primary care strategy, but there is continuing debate about how ARRS funding is being used and whether it gives practices the workforce flexibility they need.
What’s being underestimated
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- The leadership time required to integrate ARRS roles properly.
- The importance of flexibility in local workforce design.
- The difference between additional workforce and usable capacity.
- The clinical risk created when workforce models do not match workload.
- The role PCNs are now being asked to play in neighbourhood delivery.
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What I’m seeing on the ground
I continue to see PCNs trying to make complex workforce models work in practice.
Where the model works well, roles are integrated into clear pathways, practices understand how to use them, and patients experience a more joined-up service. Where it works less well, roles can feel bolted on, difficult to supervise or poorly aligned with the real pressure practices are facing.
The systems making progress are usually the ones that treat workforce as part of pathway design, not as a separate funding exercise.
What to watch / what this means in practice
Watch whether:
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- National policy gives PCNs greater flexibility over workforce mix.
- ICBs use PCNs as genuine neighbourhood delivery platforms or simply ask them to absorb more system work.
- ARRS roles become more tightly linked to specific pathway outcomes.
- PCNs can retain enough clinical leadership capacity to deliver the neighbourhood agenda.
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Practical implications
For NHS leaders. PCNs cannot be treated as unlimited delivery vehicles. Their workforce model needs to reflect the clinical and operational work they are being asked to carry.
For commissioners and ICBs. The question is not simply how much ARRS funding is being spent, but whether that funding is creating usable capacity inside local pathways.
For commercial and system partners. PCNs may remain important access points, but engagement needs to recognise workforce pressure, supervision capacity and operational bandwidth.
Source
Neighbourhood health is now moving from ambition into contested delivery
Neighbourhood health continues to move from policy ambition into operational reality and that is where the debate becomes much more difficult.
Most people across the NHS broadly support the idea of more integrated local care. More prevention, better co-ordination, stronger multidisciplinary working and more support closer to home all make sense, but the latest neighbourhood reporting shows the practical tensions now becoming clearer.
Pulse PCN’s argument that neighbourhood health will not be delivered by goodwill alone captures the point well. The NHS is not short of ambition. It is short of the funding, workforce, governance and delivery infrastructure required to make neighbourhood care work consistently.
At the same time, HSJ is reporting that ICBs are facing a clash between PCNs and neighbourhood health. Pulse also reports BMA concern that trusts may be likely to run general practice under emerging neighbourhood models.
The issue is whether the model being built strengthens primary care, or whether it gradually shifts control, responsibility and workload into new structures that general practice does not fully own.
Neighbourhood health is central to the NHS’s wider reform agenda. If it works, it could help shift care closer to home, improve support for complex patients, reduce fragmentation and create better links between primary care, community services, mental health, social care and hospitals. If it doesn’t, it risks becoming another layer of meetings, governance and expectation on already stretched services.
What’s being underestimated
- The level of concern inside general practice about loss of autonomy.
- The risk of creating conflict between PCNs and neighbourhood models.
- The amount of trust required between organisations.
- The importance of funding and workforce clarity.
- The danger of relying on goodwill as a delivery mechanism.
What I’m seeing on the ground
I continue to see strong interest in neighbourhood working, but I also see growing nervousness.
General practice is worried about autonomy, workload and accountability. PCNs are trying to understand whether they are the foundation of neighbourhood delivery or whether they will be replaced by something larger. ICBs are trying to interpret national policy while managing local financial and workforce pressure.
The systems making progress are usually the ones that start with the patient cohort and pathway problem before designing the structure.
What to watch / what this means in practice
Watch whether
- Neighbourhood health is built around existing PCN infrastructure or whether new structures begin to replace it.
- Trusts become supportive partners or dominant delivery organisations.
- How ICBs manage the relationship between PCNs, neighbourhoods and wider providers.
- Whether local models follow the Kent and Medway approach of working through GP led PCN contract variation or move toward more trust led delivery models.
Practical implications
For NHS leaders. Neighbourhood health will only work if the operating model builds confidence rather than anxiety.
For commissioners and ICBs. The challenge is to align PCNs, neighbourhood footprints, funding and governance without destabilising general practice.
For commercial and system partners. Neighbourhood health creates opportunities, but only where offers fit the local model and reduce pressure.
Sources
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ICB variation is becoming a major market access issue
The latest reporting on spirometry, Local Enhanced Services and ICB spending rules shows how much local variation is now shaping delivery. This is one of the most important practical issues for anyone trying to understand NHS market access.
National policy may describe what should happen but increasingly, the real decision sits locally; whether an ICB funds the service, how much it pays, what specification it uses, what level of risk it expects providers to carry and whether it prioritises the pathway at all.
The Pulse report that a quarter of ICBs did not pay GPs to offer spirometry last year is a good example. Spirometry is clinically important, particularly for respiratory diagnosis and long term condition management. It fits perfectly with prevention, earlier diagnosis and care closer to home, but if a significant number of ICBs are not paying practices to provide it, then the policy ambition is not translating consistently into local delivery.
The wider Pulse investigation into the LES lottery makes the same point. Local Enhanced Services vary significantly across systems. Some areas fund activity properly. Others don’t. Some schemes are worth taking on. Others leave practices carrying unfunded workload and operational risk. Local variation remains significant.
LMC demands for fairer LES funding are therefore not just about money. They are about whether local commissioning models are fair, transparent and deliverable.
The HSJ report on an ICB issuing tougher spending rules for local trusts adds another layer. ICBs are under increasing financial pressure and are becoming more interventionist around spending control. That has consequences for service development, innovation, pathway redesign and local provider behaviour.
This creates a postcode lottery in implementation. A service may be clinically justified, nationally aligned and operationally sensible but still fail to scale if the local ICB does not fund it or if the contract does not reflect real delivery costs.
For general practice, this helps explain why frustration is rising. Practices are repeatedly asked to support prevention, diagnostics, access, neighbourhood care and long term condition management, but the funding arrangements vary widely.
For industry, this is a core market access lesson. The NHS is not one market. It is a series of local decision making environments with different financial pressures, priorities and commissioning behaviours.
What’s being underestimated
- The extent of ICB to ICB variation.
- The impact of underfunded LESs on general practice willingness to participate.
- The difference between strategic support and actual funded commissioning.
- The effect of ICB financial pressure on innovation and service redesign.
- The importance of full cost recovery for local service delivery.
What I’m seeing on the ground
This is one of the most common issues I see. A pathway makes sense clinically. The case for earlier diagnosis or care closer to home is strong. General practice may be willing in principle. Industry may have a product or service that could help, but then the local operating model breaks down.
The money is unclear. The LES is underfunded. The workload sits in primary care, but the benefit is seen in secondary care. The ICB supports the idea strategically but cannot release funding, or the trust is under pressure to protect its own income.
That is where many good ideas stall.
What to watch / what this means in practice
Watch whether:
- ICBs become more consistent in funding locally commissioned services.
- Spirometry becomes a test case for prevention and diagnostics closer to home.
- LES funding improves or becomes an even bigger flashpoint in GP contract tensions.
- ICB financial control affects local providers, innovation and pathway redesign.
Practical implications
For NHS leaders. Local variation must be understood as a delivery risk, not just a commissioning choice.
For commissioners and ICBs. Services such as spirometry and LES funded pathways need realistic pricing, workload assessment and clear outcomes.
For commercial and system partners. Market access planning must be local. The key question is not just “is this policy aligned?” but “is this ICB willing and able to fund the pathway?”
Sources
Advice and Guidance still needs clarity on accountability, not just activity
Advice and Guidance continues to expose one of the biggest weaknesses in NHS pathway redesign.
The idea behind A&G remains sensible. Earlier specialist input should help avoid unnecessary referrals, improve decision making, support GPs and help patients receive advice sooner, but the latest reporting from Pulse and HSJ shows that regulators are now demanding greater clarity from NHS England on mandated Advice and Guidance.
The issue is no longer just whether A&G should exist. It is whether the governance, accountability and clinical responsibility around it are clear enough.
If A&G is genuinely used as collaborative specialist advice, it can support better pathways. If it becomes a referral management tool, it can create hidden workload, clinical uncertainty and frustration for both GPs and consultants.
The fact that both the CQC and GMC are reportedly seeking clarity suggests these concerns are now being taken seriously beyond general practice.
A&G sits right at the interface between primary and secondary care. That interface is already one of the most pressured parts of the NHS. Referral demand is high. Outpatient capacity is constrained. GPs are under pressure. Consultants are under pressure. Patients are often waiting too long. In that context, A&G can either improve flow or create further friction. The difference depends on whether it is designed around patient safety, clinical accountability and pathway clarity.
What’s being underestimated
- The clinical risk created by unclear accountability.
- The hidden workload generated by poorly designed A&G pathways.
- The difference between referral avoidance and pathway improvement.
- The impact on GP morale when A&G feels like referral deflection.
- The importance of regulator concern as a signal that this issue has moved beyond local frustration.
What I’m seeing on the ground
I continue to hear mixed views on A&G. Many clinicians support the principle. There are good examples where specialist advice helps GPs manage patients safely and avoids unnecessary outpatient appointments.
I also hear frustration when A&G feels like a mechanism for bouncing referrals back, creating extra work, or leaving GPs with ongoing risk but without the resources or authority to manage the patient.
The systems making progress tend to use A&G as part of pathway redesign, not as a standalone referral reduction tool.
What to watch / what this means in practice
Watch whether:
- NHS England responds to regulator concerns.
- A&G guidance becomes clearer on accountability, responsibility and patient safety.
- Systems continue using A&G as a referral management tool or redesign pathways around it.
- Commercial digital pathway tools are required to demonstrate governance and workload impact, not just activity reduction.
Practical implications
For NHS leaders. A&G needs to be treated as a clinical pathway tool, not simply a demand management mechanism.
For commissioners and ICBs. The test is whether A&G improves safety, flow and experience without creating hidden workload in primary care.
For commercial and system partners. Any solution supporting referral management or specialist advice must be able to demonstrate clear accountability, governance and workload benefit.
Sources
- CQC and GMC demand clarity from NHS England on mandated A&G
- Regulators demand answers on Advice and Guidance
Hospitals are showing improvement, but the financial and operating model remains fragile
The latest hospital stories show a system improving in some places while remaining under significant pressure overall.
The HSJ report that 21 trusts delivered a year’s elective recovery in a single month is striking ( I sense all may not be quite as it seems). It suggests that some organisations have been able to make rapid progress against waiting list pressures.
NHSE approval of the first six advanced foundation trusts also suggests a desire to identify and recognise high performing organisations with greater autonomy or capability.
At the same time, other HSJ stories point in the opposite direction. A top trust is reportedly struggling with tariff reform. Six trusts have exited the NHSE recovery regime but NHSE is also planning for a £1.5bn local deficit. The King’s Fund data on NHS trust deficits reinforces the wider financial context.
The Pulse report that Government has formally established an online hospital trust that GPs can refer to from next year adds another important dimension. The NHS is not only trying to recover existing hospital performance, it is also trying to create new models of hospital access and delivery.
Hospital performance is becoming more complex. The wider financial environment remains difficult, with tariff reform challenges and significant deficit planning across local systems. At the same time, new digital and online hospital models are being developed to support referral and access from general practice.
The hospital sector is being asked to do several things at once.
- It must recover elective performance.
- It must improve urgent and emergency care flow.
- It must support the shift to community and neighbourhood care.
- It must absorb tariff and payment reform.
- It must manage deficits.
- It must modernise outpatient and digital delivery.
- It must improve productivity.
That is a very difficult operating environment, and the risk is that headline performance improvement hides underlying fragility.
What’s being underestimated
- The financial fragility sitting underneath some performance improvement.
- The impact of tariff reform on trust behaviour.
- The difficulty of sustaining elective recovery while redesigning pathways.
- The significance of online hospital models for future referral and access routes.
- The tension between autonomy for high performing trusts and system wide financial pressure.
What I’m seeing on the ground
I continue to see hospitals interested in pathway redesign, outpatient transformation, admission avoidance, community delivery and digital models, but I also see how hard it is to redesign services while still managing backlog, finance, workforce and day to day operational pressure.
The most credible models are the ones that reduce friction across the whole pathway, rather than simply moving activity from one part of the system to another.
What to watch / what this means in practice
Watch whether:
- Rapid elective recovery can be sustained.
- Advanced foundation trust status changes behaviour and system relationships.
- Tariff reform creates new incentives or new instability.
- The online hospital trust model affects GP referrals and outpatient redesign.
- Local deficits constrain transformation and innovation.
Practical implications
For NHS leaders. Hospital improvement needs to be judged through sustainability, not just short-term activity gains.
For commissioners and ICBs. The challenge is to support recovery while redesigning pathways and maintaining financial control.
For commercial and system partners. The opportunity is in solutions that improve flow, reduce avoidable activity, support outpatient redesign and help hospitals manage financial and operational pressure.
Sources
- 21 trusts delivered year’s elective recovery in single month
- NHSE approves first six advanced FTs
- Top trust struggling with tariff reform
- Government formally establishes online hospital trust GPs can refer to from next year
- Six trusts exit NHSE recovery regime
- Revealed: NHSE planning for £1.5bn local deficit
- NHS trusts deficit
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General Practice is moving from frustration into organised resistance
General Practice remains one of the clearest indicators of whether NHS reform is operationally credible. The latest group of articles shows a profession moving beyond frustration and into more organised resistance.
GPonline reports that the BMA has set out next steps for ramping up Collective Action. Pulse reports that the BMA will oppose the Government replacing GMS negotiations with informal processes. There are also reports of GPs removing or ignoring medicines optimisation software as part of contract dispute escalation, further debate about why GPs take on unfunded LES work, and renewed discussion about replacing Carr-Hill with a model reflecting morbidity, deprivation and capacity.
Alongside this, GPonline reports on a BMA ballot for a Plan B semi-private contract, while Pulse reports DHSC opposition to GPs moving to a private model. At the same time, GPonline reports GPs are the fastest growing part of the NHS workforce, that Collective Action will be expensive for ICBs and that MPs have warned NHS England has overloaded GPs with access targets.
The Pulse opinion piece on general practice’s digital front door adds another layer; even where access is being digitised, patients and practices are still dealing with friction, complexity and poorly joined-up pathways.
At the same time, Government and NHS messaging continues to point to GP workforce growth and improved access. Both can be true of course. The workforce may be growing in some ways, while workload, complexity and dissatisfaction also increase.
This matters because if general practice becomes less willing to absorb unfunded work, less trusting of national policy and more organised in its resistance, that will affect the pace and shape of NHS reform.
It will also affect market access. Products and services that depend on primary care adoption will need to recognise that practices are increasingly selective about what they take on.
Many GPs support prevention, continuity, neighbourhood working and better patient pathways. What they are resisting is the continual expansion of responsibility without enough funding, workforce, autonomy or operational control.
What’s being underestimated
- The growing organisational confidence of general practice.
- The cost of Collective Action for ICBs and the wider system.
- The impact of unfunded LES work on trust and willingness to participate.
- The importance of funding formula reform.
- The risk that digital access tools increase pressure if they are not pathway designed.
- The significance of debate around semi-private or alternative contractual models.
What I’m seeing on the ground
I continue to see general practice leaders willing to innovate when the model is right.
Practices and PCNs will engage with new services when the funding is realistic, the workload is clear, the governance is safe and the pathway makes sense, but I also see a much lower tolerance for vague asks, unfunded work, poorly designed shared care, weak LES pricing and digital solutions that add work rather than remove it.
What to watch / what this means in practice
Watch whether
- Collective Action escalates and how ICBs respond.
- GMS negotiation processes become more formal, transparent and trusted.
- Medicines optimisation, LES work and access targets are used in the dispute.
- Carr-Hill reform becomes a major redistribution flashpoint.
- Talk of alternative models remains a negotiating tactic or becomes a serious strategic direction.
Practical implications
For NHS leaders. The wider reform agenda depends on rebuilding trust with general practice.
For commissioners and ICBs. The cost of underfunded or poorly designed asks is increasing. General practice is less likely to absorb work quietly.
For commercial and system partners. Primary care engagement must be built around workload reduction, realistic funding, clear governance and operational simplicity.
Sources
- BMA sets next steps for GPs to ramp Collective Action
- BMA to oppose Government replacing GMS negotiations with informal processes
- GPs to remove or ignore medicines optimisation software in contract dispute escalation
- Why do GPs take on unfunded LES work?
- Replace Carr-Hill with new model reflecting morbidity, deprivation and capacity, say experts
- BMA ballot GPs on Plan B semi-private contract
- DHSC opposes GPs moving to private model as BMA plans ballot
- GPs fastest growing part of NHS workforce, experts say
- GP Collective Action will be expensive for ICBs
- NHS England overloaded GPs with access targets, MPs warn
- General practice’s digital front door still has too many locks for patients
The wider reform agenda is still expanding, but delivery capacity remains the constraint
Two wider developments are worth noting.
The Nuffield Trust analysis of the new Health Bill provides important context for the next stage of NHS reform. The Bill is part of the wider attempt to reshape accountability, national structures and the operating framework of the NHS.
At the same time, Pulse reports that Pharmacy First is being expanded to include independent prescribing and to ease pressure on GPs. This fits clearly with the wider direction of travel around moving activity away from general practice where appropriate, making better use of community pharmacy and creating more routes for patients to access care.
Both developments make sense strategically but, again, the test will be operational.
Legislation can change structures and accountability, but it does not automatically create capacity. Pharmacy First can help ease pressure but only if the model is clinically safe, well understood by patients, properly funded, integrated with GP records and trusted by both pharmacists and practices.
That is the common thread across this edition.
The NHS is still trying to redesign the system around more local delivery, better access and more efficient use of workforce, but the question is whether the practical infrastructure is strong enough to support the ambition.
The Health Bill appears to be part of a broader structural reform agenda affecting NHS accountability and organisation.
Pharmacy First is being expanded, including independent prescribing, with the aim of easing pressure on general practice and improving access.
These are different developments, but they both point toward the same direction of broader redistribution of work across the system.
What’s being underestimated
- The operational work required to turn legislation into delivery.
- The integration challenge around Pharmacy First and general practice.
- The importance of shared records and communication.
- The risk of shifting work without reducing overall system complexity.
- The need to evaluate whether new access routes genuinely reduce GP pressure.
What I’m seeing on the ground
I continue to see support for wider use of pharmacy, community services and alternative delivery models, but I also see concern about fragmentation. Patients need simple routes through the system. Practices need confidence that work shifted elsewhere will not come back as additional coordination burden. Commissioners need assurance that new models deliver value rather than simply activity.
What to watch / what this means in practice
Watch whether:
- The Health Bill changes accountability in practice, not just on paper.
- Pharmacy First expansion reduces GP workload or creates new coordination demands.
- Independent prescribing is integrated into wider primary care pathways.
- Patients understand where to go and when.
- Industry engagement starts to follow new delivery routes into pharmacy, neighbourhood and community models.
Practical implications
For NHS leaders. Reform needs to be judged by whether it improves delivery, not just whether it changes structures.
For commissioners and ICBs. Pharmacy First and similar models need clear governance, record-sharing and workload impact assessment.
For commercial and system partners. The expanding role of pharmacy and community delivery creates opportunities, but only where offers support safe, integrated pathway delivery.
Sources
Summary
Across this edition, the common theme is that NHS reform is becoming much more local, practical and operational.
The Kent and Medway neighbourhood contract shows what neighbourhood health can look like when it starts to move beyond policy language and into a funded local operating model.
The important point is the model appears to recognise several of the things the wider NHS often underestimates, including the importance of GP leadership, contractual clarity, defined patient cohorts, investment, list based care and practical delivery confidence.
That makes it an important development to welcome but the other stories in this edition also show why this will not be straightforward. They show that the next phase of NHS reform will not be determined by national policy statements alone, it will be determined locally.
It will depend on whether systems can turn ambition into contracts, pathways, workforce models, funding flows and governance arrangements that people on the ground believe are deliverable.
For pharma, medtech and device companies, the opportunity is to understand how those ambitions are being translated locally, where the pressure points sit, who owns the pathway, who carries the workload, who funds the service and what problem the system is actually trying to solve.
Final Thought
If I step back from all the stories in this edition, the direction of travel feels clearer than ever.
The NHS still wants care closer to home. It still wants prevention. It still wants neighbourhood working. It still wants better access, stronger primary care, more efficient hospitals, wider use of pharmacy, more digital infrastructure and more consistent pathway management, but increasingly, the test is no longer whether people agree with those ambitions.
Most people do. The test is whether the operating model underneath them is credible. That is why Kent and Medway matters. It suggests one possible route forward, use existing PCN infrastructure where it makes sense, define the patient cohort, invest in the work, protect clinical leadership and create a contractual mechanism that gives practices enough confidence to participate.
That feels very different from simply asking general practice to absorb more responsibility because national policy says care should move closer to home.
The risk across the NHS is that the left shift becomes a phrase used to describe work moving from hospitals into primary and community care without the funding, workforce, governance or accountability moving with it. When that happens, it is not transformation. It is displacement.
For NHS leaders, the challenge is to make reform deliverable without destabilising the parts of the system already carrying the greatest pressure.
For ICBs, the task is to move from aspiration to operating model with clear funding, clear accountability, realistic workforce assumptions and honest conversations about variation.
For general practice, the current moment is both risky and important. The profession is under pressure, but it is also becoming clearer about what it can and cannot safely absorb.
For hospitals, recovery and redesign will only be sustainable if community and primary care alternatives are real, funded and reliable.
For pharma, medtech and device companies, the lesson is simple. The NHS is looking for practical help with delivery. That means understanding local context. It means designing offers that reduce workload, simplify pathways, support capacity, improve flow and make implementation easier. It means recognising that the same national policy can create very different market access realities in different ICBs.
The opportunity now is not to sell into the NHS as if it is one system moving neatly in one direction. It is to understand where the system is trying to move, where it is getting stuck, and how to help make the next step operationally possible.
That is what being embedded really means.
As ever, if you are seeing something different locally, or think I have misread the direction of travel, I am always open to challenge.
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Turn Strategy into Progress. Faster.
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.
He’s also the author of the groundbreaking book Embedded – a practical, insider’s guide to landing projects with the NHS and making them stick.
His newly launched coaching and mentorship membership programme is built for results: combining NHS insider insight, proven engagement strategies and warm introductions to the people who hold the pen on purchasing decisions.