Embedded Bulletin | Edition 20 – The NHS is moving from structural reform to behavioural reform
In this edition of the Embedded Bulletin, I look at how the NHS is beginning to move beyond structural reform and into a more operational phase focused on shaping behaviour.
The overall direction remains familiar, with neighbourhood care, prevention, partnership working and the “three shifts” still firmly in place. But the way the system is trying to deliver them is starting to change.
Increasingly, this is being driven through funding flows, contractual pressure and clearer expectations around delivery.
I explore how developments such as the proposed Carr-Hill review, ongoing GP contract tensions and the continued push for neighbourhood models are starting to influence real world decision making, particularly around financial stability, workforce capacity and organisational risk.
Across the system, there is still broad support for the direction of travel, but there is also growing realism about what it takes to implement these changes without destabilising services already under pressure.
The result is a shift toward a more cautious, delivery focused NHS, where progress depends less on structural ambition and more on whether pathways, funding and accountability can be made to work in practice.
For quick access, click the links below to access the topics of interest:
Neighbourhood agenda gets real
Open warning from Integrated Care Boards (ICBs)
Advice and Guidance tension between NHS England and General Practice
Quality and Outcomes Framework (QOF) evolves
Hospitals struggle to balance transformation with day-to-day pressure
General Practice – is more responsibility sustainable?
What’s New In The World Of NHS Market Access
The NHS is starting to shape behaviour through contracts, funding mechanisms and neighbourhood expectations
Taken together, the latest discussions around the Carr-Hill formula review, GP Collective Action, neighbourhood health and the “three shifts” agenda all point in the same direction. The centre increasingly understands that changing the NHS is not just about publishing strategy. It is about changing incentives, financial flows and operational expectations. That is a significant shift. Because for years, the NHS has often relied on policy ambition sitting alongside existing structures. What we are now starting to see is a more active attempt to redesign the conditions in which organisations operate.
What’s actually happening
There are three overlapping developments here. First, the government is signalling that reform of the Carr-Hill formula could arrive from April 2027. On paper, this is about fairness and redistribution. In practice, it raises very real concerns about destabilisation, particularly for practices already operating close to the financial edge.
Second, negotiations between the BMA and DHSC continue against the backdrop of possible GP Collective Action. That matters because it reflects how strained the relationship between national expectation and frontline delivery capacity has become.
Third, the neighbourhood agenda continues to move forward, with growing emphasis on partnership, integration and the “three shifts”:
- Hospital to community.
- Analogue to digital.
- Treatment to prevention.
None of that is new conceptually, what is changing is the attempt to operationalise it.
Why it matters in practice
This matters because the NHS is now entering a phase where structural reform starts colliding with delivery reality.
Neighbourhood health sounds coherent at policy level. So does shifting care closer to home. So does reducing variation in funding. But operationally, these changes affect workforce stability, financial viability, organisational behaviour, clinical confidence and local relationships. And those things move much more slowly than policy documents do. That is why the tone across the system currently feels more cautious than transformational.
People broadly understand the direction of travel. The uncertainty sits around how it is implemented without destabilising the parts of the system already carrying the greatest pressure.
What’s being misunderstood
There is still a tendency to assume that neighbourhood working is primarily a structural or organisational exercise. In reality, it is a behavioural and financial one. The real challenge is not whether organisations can sit inside the same framework. It is whether:
- Money flows align with activity
- Risk is shared realistically
- Governance is clear
- Capacity exists to absorb shifted demand
- Organisations trust each other enough to genuinely redesign pathways
Without those things, neighbourhoods risk becoming another layer placed on top of existing pressure rather than a redesign of care itself. The same applies to Carr-Hill reform. Redistribution may make sense strategically, but systems do not absorb financial shock evenly.
What I’m seeing on the ground
Across the systems I’m working in, there is still strong support for the overall direction of travel. Most leaders understand that more care must move upstream, that hospitals and General Practice cannot continue absorbing demand indefinitely, that prevention and continuity matter and that General Practice remains central to system stability. But there is also growing realism about the operational complexity involved.
What I’m increasingly hearing is less how do we transform, more how do we stabilise enough parts of the system to make transformation possible? I’m noticing greater caution around structural change, increasing focus on stabilisation before transformation and more honest conversations about workforce, capacity and delivery risk.
What’s being underestimated
- How financially sensitive General Practice now is to redistribution and contract reform.
- The amount of operational redesign required to make neighbourhoods function properly.
- The importance of trust, governance and pathway ownership in partnership working.
What to watch / what this means in practice
- Whether Carr-Hill reform creates redistribution without destabilisation.
- How neighbourhood models translate from framework into operational reality.
- Whether partnership working genuinely changes pathway delivery or remains largely structural.
Practical implications
For NHS leaders. The challenge is no longer agreeing the direction. It is sequencing change in a way the system can realistically absorb.
For commissioners and ICBs. Neighbourhood models will only work if financial flows, accountability and operational responsibility align properly.
For commercial and system partners. The NHS is increasingly looking for organisations that reduce operational friction, not add to it. Partnership language alone is no longer enough.
Sources
Government plan to overhaul Carr-Hill formula in April 2027 risks destabilising practices
BMA hails progress in talks with DHSC as GP collective action deadline nears
Unpacking the neighbourhood health framework: the good, the bad and the puzzling
From policy to practice: Partnership as an enabler of the NHS three shifts (£Paywalled)
Embedded Conversations Podcast – Real discussions about what’s shaping the NHS
In the latest episode of Embedded Conversations, Scott is joined by Samantha Bramley, a leadership coach and facilitator. Samantha breaks down her core framework – leadership driven by heart, defined by clarity and powered by mental fitness – and explains how these elements come together to create alignment and long-term success.
Neighbourhood agenda gets real
The neighbourhood agenda continues to move from abstract policy language into operational planning. NHS England has now confirmed neighbourhood health centres are expected to include on-site general practice, while local leaders continue trying to understand how these models will work in practice.
What still feels unresolved is the relationship between neighbourhood ambition and the practical realities of estate, workforce, contracts and governance. There remains a risk that neighbourhoods become discussed as buildings rather than pathways.
I continue to see strong interest locally in closer integration and multidisciplinary working. But I also see growing nervousness from general practice about being drawn into structures where responsibility moves faster than funding, workforce or operational clarity.
The most interesting shift is that neighbourhoods are now increasingly being framed as delivery infrastructure rather than optional transformation.
What’s being underestimated
- The scale of operational redesign required to make neighbourhoods work.
- The estate and workforce implications of co-location.
- The importance of preserving clinical autonomy while integrating services.
What I’m seeing
- Growing pressure for GP involvement in neighbourhood leadership.
- More focus on physical hubs and access points.
- Continued uncertainty about contracts, governance and delivery responsibilities.
What to watch / what this means in practice
- Whether neighbourhood centres become pathway redesign vehicles or simply new estates projects.
- How quickly local systems can align funding and governance.
- The extent to which general practice remains willing to participate without clearer operational protections.
Sources
Neighbourhood centres expected to include on-site general practice
NHS England – Neighbourhood Health Centres
GP Online - LMCs say NHS England left GPs out of plans to develop neighbourhoods
Open warning from Integrated Care Boards (ICBs)
A recurring theme across systems at the moment is workload transfer into primary care without corresponding resource movement. Several ICBs are now openly warning about the patient safety implications of inappropriate workload transfer.
At the same time, NHS England has published updated annual assessment guidance for ICBs, reinforcing the increasing focus on accountability, performance oversight and delivery assurance.
This matters because the NHS is continuing to tighten oversight while simultaneously asking systems to redesign care under financial pressure.
I increasingly see ICBs caught between national expectations, provider pressures and workforce reality. Many still support the direction of travel but there is growing realism about the limits of what can be absorbed operationally.
What’s being underestimated
- The cumulative impact of workload transfer into general practice.
- The operational burden placed on ICBs through performance oversight.
- The extent to which financial pressure is shaping commissioning behaviour.
What I’m seeing
- More explicit conversations about patient safety risk.
- Greater scrutiny of pathway ownership and accountability.
- Increasing pressure on ICB leadership teams to demonstrate control.
What to watch / what this means in practice
- Whether systems can redesign pathways without destabilising frontline services.
- How ICB assessment frameworks influence local decision making.
- The balance between national oversight and local flexibility.
Sources
Inappropriate workload transfer to primary care poses crucial risk for patients
GPs warn of underfunding as primary care share lags behind NHS growth
NHS England – Annual assessment of integrated care boards guidance
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Advice and Guidance tension between NHS England and General Practice
Advice and Guidance continues to generate significant tension between NHS England and general practice.
The original ambition behind A&G was understandable. Used properly, it has the potential to improve patient outcomes earlier, reduce unnecessary referrals, avoid wasted time and effort in general practice from patients chasing up outpatient referral and support more pathway based care. I still believe that.
But what I increasingly see is concern that operational targets are starting to distort the original purpose. GPs are becoming worried about referral deflection, additional unfunded workload and clinical accountability.
NHS England appears to be softening some of the original targets and messaging, which probably reflects growing recognition that implementation matters as much as ambition.
What’s being underestimated
- The additional workload generated through poorly designed A&G processes.
- The impact of repeated referral bounce backs on workforce morale.
- The importance of clinical accountability and governance clarity.
What I’m seeing
- More pushback from GPs and representative bodies.
- Growing debate about referral ownership and liability.
- Recognition that pathway redesign matters more than digital process alone.
What to watch / what this means in practice
- Whether A&G evolves into a genuinely collaborative clinical model.
- How systems fund and resource the additional operational workload.
- Whether patient experience improves or deteriorates through implementation.
Sources
Advice and Guidance “ping pong” fueling GP retention crisis
GPs advised to demand consultant GMC number when referral turned into A&G
GPs query referrals turned into Advice and Guidance
NHSE rows back on controversial target (£Paywalled)
NHS rules out national target to cut GP referrals through A&G
Quality and Outcomes Framework (QOF) evolves
QOF quietly continues to evolve in the background while much of the focus remains on access and contract reform.
The interesting point for me is that QOF increasingly reflects a wider NHS trend; trying to standardise prevention, monitoring and population management while systems are simultaneously under operational strain.
That creates a tension between quality ambition and delivery capacity.
What’s being underestimated
- The operational workload linked to increasingly complex indicators.
- The relationship between prevention metrics and workforce capacity.
- The degree to which practices are already operating at delivery limits.
What I’m seeing
- More selective prioritisation by practices.
- Increasing focus on financially meaningful indicators.
- Greater concern about administrative burden.
What to watch / what this means in practice
- Whether QOF continues to expand or becomes more targeted.
- How prevention priorities survive financial pressure.
- The extent to which practices can sustain quality improvement alongside rising demand.
Sources
Hospitals struggle to balance transformation with day to day pressure
Hospitals remain under extraordinary operational pressure despite some improvement against headline targets. March was reportedly the busiest month ever for A&E departments, while HSJ continues to report concerns around performance, corridor care, administration failures and wider operational resilience.
At the same time, there is increasing discussion about alternative delivery models, including hospital at home pathways and technology enabled outpatient redesign. The challenge is that many hospitals are trying to transform while simultaneously managing day to day operational overload.
What’s being underestimated
- The fragility sitting underneath headline performance improvements.
- The scale of workforce fatigue and operational pressure.
- The administrative burden created through fragmented pathways.
What I’m seeing
- Greater focus on reducing avoidable admissions.
- Increased interest in technology enabled outpatient redesign.
- Continued tension between operational recovery and transformation capacity.
What to watch / what this means in practice
- Whether hospital avoidance models genuinely scale.
- How corridor care and urgent care pressure evolve next winter.
- The extent to which digital redesign can release meaningful capacity.
Sources
Hospital care at home could save NHS hundreds of millions
March busiest month ever for A&Es
NHS a cat’s whisker from hitting headline targets (£Paywalled)
General Practice – is more responsibility sustainable?
General practice continues to sit at the centre of almost every NHS operational conversation.
Online consultations continue to rise sharply, Collective Action discussions remain active and concerns about funding, estates and workforce sustainability continue to grow.
At the same time, national messaging increasingly highlights rising GP workforce numbers and improved access.
Both things can be true simultaneously. Activity is rising. Pressure is rising. Expectations are rising.
What I increasingly see is a profession trying to absorb more operational responsibility while still debating whether the underlying model remains sustainable long term.
What’s being underestimated
- The cumulative impact of rising digital demand.
- The estate pressures linked to population growth.
- The operational consequences of continual workload expansion.
What I’m seeing
- Increased fatigue around access expectations.
- More debate about the future shape of NHS general practice.
- Continued tension between workforce growth statistics and lived frontline experience.
What to watch / what this means in practice
- Whether Collective Action escalates again.
- How access targets influence clinical prioritisation.
- The degree to which practices continue absorbing additional workload.
Sources
GP pay rise recommendation analysis
Could GPs really “do a dentist”?
Call for GP guarantee amid housing growth
Preparations underway for return of GP Collective Action
Online consultations rise steeply
GP workforce at 10-year high claims government
LMC conference to vote on taking GPs outside NHS
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Mental Health – rising demand and complexity taking toll
Mental Health demand continues to rise, while systems remain under pressure to improve access, reduce delays and manage increasingly complex patient need. The most concerning signal for me is the continued reporting around mental health patients remaining in acute hospitals because appropriate onward care is unavailable.
That reflects a wider system issue. Mental health services are increasingly carrying both rising demand and rising complexity, often without equivalent expansion in operational capacity.
What’s being underestimated
- The impact of delayed discharge on both acute and mental health systems.
- The growing complexity of mental health demand.
- The operational consequences of constrained specialist capacity.
What I’m seeing
- Greater pressure on urgent mental health pathways.
- Increasing overlap between acute and mental health operational pressures.
- Continued concern about system resilience.
What to watch / what this means in practice
- Whether investment keeps pace with demand growth.
- How systems manage flow between acute and mental health settings.
- The degree to which neighbourhood models support earlier intervention.
Sources
Demand growth “genuine”, says NHSE director (£Paywalled)
Campaign urges government to prioritise mental health
Spiralling cost of mental health patients stuck in acute hospitals
Wider developing themes
Prevention, diagnostics closer to home, women’s health, medicines optimisation and population health delivery models.
What links many of these stories is the continuing push toward earlier intervention and more community-based delivery.
The challenge remains whether systems can operationalise these ambitions consistently while managing immediate financial and workforce pressure.
What’s being underestimated
- The delivery complexity behind prevention and population health models.
- The importance of targeted primary care investment.
- The operational barriers to scaling innovation.
What I’m seeing
- Continued movement towards diagnostics and care closer to home.
- Greater emphasis on prevention and risk stratification.
- Increasing interest in pharmacy and community based delivery models.
What to watch / what this means in practice
- Whether prevention investment survives financial constraint.
- How quickly community diagnostic and pharmacy models scale.
- The extent to which procurement behaviour genuinely shifts from “cheapest first” thinking.
Sources
Targeted primary care investment would make biggest difference
Quicker tests and scans closer to home
Summary
Across this edition, the common thread is not a lack of ambition. It is the growing tension between ambition and operational reality.
Neighbourhood models continue to evolve, but many of the practical questions around workforce, estates, governance and funding remain unresolved. Advice and Guidance is increasingly exposing the difference between pathway redesign and workload redistribution. Hospitals remain under sustained operational pressure despite some encouraging headline metrics, while general practice continues absorbing rising demand, digital workload and growing system expectation.
At the same time, systems are being asked to improve access, deliver prevention, redesign pathways, manage deficits and stabilise workforce morale, often simultaneously.
What feels increasingly clear is that the NHS is moving into a more delivery focused phase of reform. The language is becoming less about aspiration and more about operational control, accountability, flow and affordability. That changes how organisations engage with the system.
The NHS still wants innovation, transformation and partnership. But increasingly it wants them delivered in ways that reduce operational friction, improve pathway reliability and function within constrained financial envelopes.
Final Thought
If you step back from the individual stories this month, the wider direction becomes clearer.
The NHS is continuing to push care closer to home, expand neighbourhood delivery, increase pathway control and improve productivity. But it is trying to do so inside one of the most financially and operationally constrained environments the service has faced in years. That tension now sits underneath almost every conversation.
Where I continue to see progress, it is usually because somebody has focused relentlessly on practical delivery; clear pathways, defined responsibilities, workable funding flows and operational simplicity. Where I see friction, it is often because policy ambition has moved faster than workforce, contracts or implementation reality.
The next phase of NHS change will not be determined by strategy documents alone. It will be determined by whether systems can make redesigned pathways function consistently in practice, under pressure, at scale. For those working inside the NHS, that pressure is already very visible.
For those working alongside it, the challenge is becoming clearer too. The question is no longer simply whether something aligns with policy. Increasingly, it is whether it helps the system operate more safely, sustainably and predictably within constraint.
As ever, if you are seeing something different locally, or think I’ve misread the direction of travel, I am always open to challenge.
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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.
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.