The Embedded Left Shift Support Programme Explained
A board safe, subcontracted approach to releasing acute capacity without destabilising hospitals
The problem we’re actually trying to solve
Across the NHS, there is growing consensus that some care currently delivered in acute settings does not require an acute environment. However, despite policy intent, many left shift initiatives stall or fail once they reach Trust Board level.
The reason is usually not clinical, it’s almost always financial, operational or political.
At Board level, “left shift” is often instinctively heard as loss of activity, loss of income and an increased risk.
That reaction is understandable, but it is usually based on a misunderstanding of what is actually being lost.
The key reframe: this is not “de-funding”
What is typically being left shifted is not high value, complex acute work. It is usually low complexity, high volume outpatient or diagnostic activity delivered at or below marginal cost, consuming scarce consultant time, clinic rooms and admin capacity. It’s often loss making once true overheads are applied.
The uncomfortable truth (rarely stated explicitly in Board papers) is turnover does not equal profit. Profit does not equal cashflow.
When the right activity is left shifted loss making turnover is reduced and constrained clinical capacity is released.
Staff can be redeployed into complex elective work, income generating procedures, RTT backlog recovery and specialist pathways Trusts actively want to protect.
This is not de-funding. It is capacity reallocation. Boards that grasp this distinction tend to move from defensive to curious very quickly.
Why subcontracting is the stabilising mechanism (not the risk)
The safest way to enable left shift, politically and operationally, is not to commission activity directly away from the Trust. It is to use subcontracting with clear boundaries.
In well designed models the Trust retains the prime contract, while delivery is subcontracted to a GP provider organisation, a community partner or a blended delivery model.
Governance, escalation and quality remain linked to secondary care while the Trust controls inclusion and exclusion criteria, hand back triggers and clinical oversight.
This gives the Trust assurance, visibility and control, while giving primary or community providers delivery autonomy, commercial viability and credibility with commissioners.
From a Board perspective, subcontracting feels like risk management, not loss.
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Choosing the right work to left shift
Successful left shift programmes are selective, not expansive. Simply creating more enhanced services rarely solves the problem and often creates new ones.
Activity should meet five tests:
Test 1 – It does not require an acute environment (even if historically delivered there).
Test 2 – It is protocol driven and stable (not first-presentation uncertainty or unresolved diagnostic complexity).
Test 3 – It is consuming scarce acute capacity (outpatients, diagnostics, routine procedures).
Test 4 – A rapid access route back into secondary care can be maintained for complex cases
Test 5 – It carries sufficient tariff or block value (to be commercially viable outside hospital settings).
This is why services such as dermatology triage, ENT GPwSI activity, insulin and GLP-1 initiation, women’s health procedures and diagnostics like Holter ECG repeatedly emerge as strong candidates.
They sit in the “wrong place, wrong cost base”, not because they are low value, but because they create waiting list pressure for Trusts, access bottlenecks for GPs and delay and duplication for patients
That intersection is the sweet spot.
The incentive problem and how it’s solved
Trusts will not willingly give up activity unless incentives are aligned, formally or informally.
In practice, the incentives that work are:
- Capacity relief against RTT, diagnostics or clinic backlogs.
- Workforce relief (not workforce loss).
- Subcontract income without delivery overhead.
- Redeployment of consultants into higher value activity.
- Improved system reputation for access, flow and performance.
The mistake many systems make is trying to sell left shift as “efficiency”. The language that lands is flow, focus, and sustainability.
Avoiding competition and fragmentation
The most mature systems are moving away from GP vs community and community vs acute and toward blended delivery models, where the pathway is owned collectively and delivery is split by competence, cost base and workforce availability.
This ensures patients move seamlessly through care, not organisational boundaries.
GP provider organisations can be positioned as delivery vehicles, not rivals, hosting activity on behalf of acute Trusts, community services and place based collaboratives.
This is exactly the type of structure Boards find reassuring.
Introducing Embedded Left Shift
Embedded Left Shift is my consultation programme for hospitals. If a hospital wants to explore left shift I will bring them a framework to test what is suitable to make that move.
Once agreed we create the framework to shift the work, from a case for change, to a business case, to a hospital subcontract, all while helping them engage with the right stakeholders.
Rather than presenting a long menu of services, this approach is deliberately strategic:
1. Lead with principles, not projects
Right care. Right place. Right cost base.
2. Go deep on two or three exemplar pathways
Typically one diagnostic. One outpatient specialty. One procedural pathway.
Holter ECG is often an ideal low-risk starting point; simple, scalable and easily subcontracted, and can act as a proof point for wider left shift without destabilising existing services.
3. Be explicit about what the Trust keeps.
Complex work. Clinical oversight. Contract primacy.
And be equally explicit about what this is not, de-funding, fragmentation or GP workload dumping.
This keeps the conversation strategic rather than transactional.
What Embedded Left Shift actually offers
Embedded Left Shift is a structured, repeatable programme, not a one off piece of advice. It typically supports systems through an initial board safe sense check, development of a credible case for change and selective business case build where ideas are robust enough to proceed.
Not every idea progresses and that discipline is a strength.
Completed business cases developed for other organisations cannot be shared. They were commissioned, paid for and designed for specific local contexts.
What Embedded Left Shift provides is the structure, the logic, the framing and the discipline to help systems develop their own robust, credible cases for change, followed by the business case.
At www.scottmckenzieconsultancy.com, I work directly inside the NHS, supporting provider collaboratives, commissioners and system leaders to implement real change. I then help pharma, medtech and device companies interpret what’s happening, so they can engage the right stakeholders, align with NHS priorities and get their innovations embedded into care pathways.
With more than 20 years working within the NHS and Pharma, medtech and devices companies, I bring a unique dual perspective, now captured in my book, Embedded: How Pharma, MedTech, and Device Companies Can Get Their Products into NHS Pathways and Stay There, which distils everything I’ve learned into a practical playbook.
Tickets now on sale: The inaugural Embedded Seminar – London on September 30. If you’re trying to win work in the NHS, knowing the policy direction isn’t enough. You need to understand how decisions are really made, what creates confidence at Board level and what causes things to stall. This seminar brings that into the open. A small, focused group working through real examples of what gets through, what doesn’t, and how to position your work so it stands up under scrutiny. If you want to move beyond access conversations and into something that actually converts, this is where that shift starts.