Week 1 of 10
The three shifts and twenty years of promises
The neighbourhood health service is the current attempt at a shift that policy has promised since 2006, and the honest place to start is with why the earlier attempts did not hold.
Three shifts, and a plan that names them
Fit for the future, the 10 Year Health Plan published in July 2025, organises every proposal it makes around three shifts: from hospital to community, from analogue to digital, and from sickness to prevention (10 Year Health Plan, 2025). The plan is candid about its starting point. The NHS, it says, is "hospital-centric, detached from communities and organises its care into multiple, fragmented silos". On technology it concedes that "today the NHS is behind the technological curve". On prevention it wants to make "the healthy choice the easy choice".
That diagnosis is not in dispute here. What a plan cannot settle simply by stating it is the question a professional reader should put first: if these three shifts are so obviously right, why has the service not already made them? The argument of this week is that the shifts have been promised before, repeatedly, and that each earlier promise failed for the same reason. The ambition was never the problem. The delivery settlement was: no named owner, no protected money, no workforce plan, and no prior agreement about what would count as success before the money ran out.
The community shift has been promised since 2006
Our health, our care, our say, published in January 2006, promised "more services available closer to home and in the community" and set four goals, the first of which was "better prevention services with earlier intervention" (Our health, our care, our say, 2006). The same white paper promised to expand local care settings outside hospitals. That is the hospital-to-community shift, in 2006, in the language of its time.
The delivery record is documented by the policy documents that came after. The NHS Long Term Plan of 2019 recorded that following the 2004 GP contract "relative investment in primary care then fell for the rest of the decade", that "there is shortage of practice and district nurses", and that "patient satisfaction with access to primary care has declined" (The NHS Long Term Plan, 2019). Its remedy was a funding guarantee: spending on primary medical and community health services would be at least 4.5 billion pounds higher within five years, the first time such funding was guaranteed to grow faster than the rising NHS budget overall.
The 10 Year Health Plan returns to the same commitment with a different mechanism, promising that "the share of expenditure on hospital care will fall", and adding a deadline that earlier versions lacked: this shift in investment is to be delivered "over the next 3 to 4 years" (10 Year Health Plan, 2025). Whether a spending share can be commanded, or only observed after the fact, is one of the unresolved questions.
The evidence on whether moving care out of hospital delivers what is claimed is more conditional than the policy language. Sibbald, McDonald and Roland reviewed 119 studies of four strategies for shifting specialist care into the community. Transferring services and changing referral behaviour reduced outpatient activity but "risked reducing quality", and cost savings "were offset by increases in overall service volume and loss of economies of scale" (Sibbald et al., 2007). Relocating specialists and joint working between primary and acute care improved access without harming quality, but "rarely reduced" outpatient activity and generally increased costs.
The largest recent attempt to test integration at scale was the Vanguard new care models programme, which ran from 2015 to 2018 and covered around 9 per cent of the population of England. Morciano and colleagues evaluated it with a difference-in-differences design and found that it slowed the rise in emergency admissions, "especially in care home sites and in the third and final year", but that "there was no significant reduction in bed-days" (Morciano et al., 2020). Coleman and colleagues, studying the programme's implementation, described the "pressures coming from what was initially perceived as a permissive policy approach of encouraging experimentation, whilst also requiring rapid learning, scale and spread" (Coleman et al., 2021).
The digital shift has a date that has already passed
The digital shift's first full statement is Equity and excellence, the white paper of 2010 that promised "an information revolution and greater choice and control" and made shared decision-making the norm, summarised in the phrase "no decision about me without me" (Equity and excellence, 2010).
Four years later Personalised health and care 2020 converted the ambition into dates: "All patient and care records will be digital, real-time and interoperable by 2020", with clinicians in primary, urgent and emergency care "operating without needing to use paper records" by 2018 (Personalised health and care 2020, 2014). The NHS Long Term Plan of 2019 restated the same destination, promising that "digitally-enabled primary and outpatient care will go mainstream across the NHS".
That the dates were not met is not a matter of external criticism. The current plan says so itself, twice. The 10 Year Health Plan states that the NHS is "behind the technological curve" and that it will "take the NHS from the 20th century technological laggard it is today". It then sets a new marker, that the NHS App is to be "a full front door to the entire NHS" by 2028 (10 Year Health Plan, 2025).
Why this keeps slipping is the subject of a later week, but its shape is already visible in Greenhalgh and colleagues' study of technology implementation, which followed six technology-supported programmes for up to three years and produced a framework for the non-adoption, abandonment and failure to scale of health and care technologies. Their conclusion is that success depends less on the technology than on the complexity of the condition, the people expected to adopt it, the organisation and the wider system in which it is placed (Greenhalgh et al., 2017). A national record deadline cannot reduce that complexity. It can only set a date by which the complexity is discovered.
Prevention: the shift whose benefits arrive after the budget
Healthy Lives, Healthy People, published in November 2010, described itself as "a radical shift in the way we tackle public health challenges" and moved public health functions and a ring-fenced grant to local government, on the argument that "one-size-fits-all solutions are no good when public health challenges vary from one neighbourhood to the next" (Healthy Lives, Healthy People, 2010). The Five Year Forward View of 2014 repeated the point with more force: the future health of millions of children and the sustainability of the NHS "all now depend on a radical upgrade in prevention and public health", and the Wanless warning of 2002 "has not been heeded" (Five Year Forward View, 2014).
The NHS Long Term Plan of 2019 funded specific prevention programmes, including a doubling of enrolment in the Type 2 diabetes prevention programme, and required every local area to set "specific measurable goals" for reducing inequalities (The NHS Long Term Plan, 2019). The 10 Year Health Plan makes prevention its third shift and frames it as a question of power: making the healthy choice the easy choice.
Two problems persist. The first is the distribution of benefit. Lorenc and colleagues reviewed systematic reviews of intervention-generated inequalities and found that "downstream" preventive measures, including media campaigns and workplace smoking bans, showed "some evidence of increasing inequalities", while upstream measures such as tobacco pricing showed evidence of reducing them (Lorenc et al., 2013). A neighbourhood prevention offer that is easiest to take up by the already advantaged will widen the gap it was meant to close. The second problem is time. Prevention's returns arrive over years and land on budgets other than the one that paid for them, and the 10 Year Health Plan concedes that "the NHS has avoided taking its responsibility seriously on secondary prevention".
Policy churn is the mechanism, not the background
Policy churn is not an unlucky environment in which good plans happen to fail. It is a mechanism of failure, and the evidence names it. Miller, Glasby and Dickinson reviewed a decade of English integrated care policy against reports from the audit office, parliamentary committees and the regulator, and concluded that "a hyperactive policy context is not helpful to developing and sustaining joint activity", that the decade produced "a layering of new policy on top of old policy", and that pilot schemes were "established but not maintained for sufficiently long to have an influence on mainstream services" (Miller, Glasby and Dickinson, 2021). Their verdict is that despite progress in a few local areas, "expected improvements were not achieved", emergency admissions continued to grow and health inequalities worsened.
Coleman and colleagues document the same mechanism inside a single programme. The Vanguards were caught between a permissive invitation to experiment and a simultaneous demand for "rapid learning, scale and spread" (Coleman et al., 2021). When a programme is required to prove and to spread at the same time, the evidence arrives after the decision has been made.
The King's Fund has made this the centre of its reading of the current plan. Its long read on public perceptions states that the three shifts "are not new ambitions" and that they "have proved stubbornly difficult to implement", with progress on all three "glacial, and in some cases is going in the opposite direction" (King's Fund, 2025). Its analysis of the published 10 Year Health Plan adds the sharper judgement, that the plan "echoes what NHS reform plans have been saying for much of the past 25 years", that it is in many ways "a greatest hits of many of the 2000s Labour plans", and that the test is whether this government can deliver what its predecessors could not.
What is different this time, and what would have to be true
Two things are genuinely different in 2026. The first is that the current policy concedes the failure in its own text rather than leaving it to historians. The Neighbourhood Health Framework, published in March 2026, states that "similar proposals have been set out over the last 15 years", that "over the last 10 years, the system has orientated more to hospitals, with significantly greater spend and investment in hospitals rather than in primary and community care", and that "the challenge is the ability of the system to make the change" (Neighbourhood Health Framework, 2026). A policy that names its predecessors' failure has removed the excuse of not knowing.
The second difference is the delivery vehicle. The framework does not ask local systems to invent a service model. It hands them a defined set of building blocks and asks them to agree "a series of minimum interventions in every community over the next 3 years", describing these as the "foundation upon which local priorities will be built". It then sets two stages: minimum basic requirements in 2026 to 2027, including neighbourhood footprints agreed around natural communities and plans for integrated neighbourhood teams focused on high priority cohorts, and a locally owned neighbourhood health plan from 2027 to 2028, agreed with the health and wellbeing board, within a period that runs to March 2029 (Neighbourhood Health Framework, 2026).
The framework also puts numbers on the offer. It commits to building and upgrading 250 new neighbourhood health centres, and the 10 Year Health Plan adds that neighbourhood health centres will be open at least 12 hours a day and 6 days a week, and that 95 per cent of people with complex needs will hold an agreed care plan by 2027 (Neighbourhood Health Framework, 2026; 10 Year Health Plan, 2025). It also requires that data-sharing arrangements be confirmed so that patients can be identified and results evaluated.
None of that answers the delivery question on its own. The framework is explicit that it is "light touch and flexible", refuses to prescribe a single model and leaves each system to choose its own footprint. The evidence set out above suggests three conditions that would have to hold. Money would have to move on a multi-year basis rather than as a share to be observed; the workforce would have to exist in primary and community settings, since Sibbald's review and the Long Term Plan's own account turn on capacity rather than on intent; and success would have to be defined before the money is spent, in terms that survive a change of leadership. Miller, Glasby and Dickinson make the last point directly: the greatest progress came when integrated care "focusses on tangible issues and when there is a clear understanding of how success will be measured".
The argument of this week is therefore not that the three shifts are wrong. It is that twenty years of promises are themselves the strongest available evidence base, and that they locate the risk in implementation rather than in design. The framework is the first version of the community shift to arrive with staged requirements, named organisational owners and a place in the commissioning cycle. Whether it holds will depend on whether the next four years look like the last twenty. A reader should hold the framework to that test, and begin by asking which of its requirements their own system has already agreed in public, and which have quietly been left to 2027.
The contested question
Whether the three shifts are a genuine change of direction or a relabelling of a long-standing set of ambitions that local systems have never been funded or organised to deliver.
Working across professions
Shared history as shared ground
Every profession in the room has been promised this shift before, and each one lost something different when it failed. Start the module by asking each participant to name what their own profession was asked to give up last time, and record the answers: the disagreement that follows is the working material for the rest of the module.
For your profession
Written for the groups City St George's trains. Read your own first, then the two nearest to you: the disagreements between them are the working material.
General practice and primary care (including physician associates)
Physician Associate Studies (Pre-Registration) MPAS
What changes for you. After the 2004 contract, relative investment in primary care fell for the rest of the decade, so general practice was asked to hold the community shift on a shrinking share and absorbed the resulting access pressure. In 2026/27 the ask returns in new language: agree the neighbourhood footprint and release GP and physician associate time into an integrated team.
The decision on your desk. Whether to sign the integrated team's case for 2026/27, which means naming which GP and physician associate sessions leave the practice list, or to keep the list protected and record that choice in the footprint return.
What goes wrong if this is done badly. If the footprint is agreed without released clinical time, the team meets on top of a full appointment book, the same few clinicians attend, and the community capacity the plan promised is never actually staffed.
Community nursing and district nursing
Public Health and Specialist Community Nursing MSc/PGDip
What changes for you. The Long Term Plan itself recorded a shortage of practice and district nurses, and Sibbald's review of 119 studies found that shifting services out of hospital risked reducing quality while savings were offset by extra volume. District nursing was asked to absorb the community shift on a falling workforce. In 2026/27 it is asked again, through the neighbourhood team.
The decision on your desk. Whether to staff the neighbourhood team's frailty caseload from the existing district nursing pool, accepting longer waits for housebound patients, or to set a safe caseload figure and escalate the gap in writing.
What goes wrong if this is done badly. If the caseload is set by the team's ambition rather than by district nurse numbers, unplanned visits and delayed discharges are absorbed silently, and lone working risk rises before anyone records a workforce shortfall.
Adult social care and social work
Partner profession: local authority adult social care
What changes for you. Healthy Lives, Healthy People handed local government public health functions and a ring-fenced grant in 2010. Integrated care policy then layered ambition on ambition while, as Miller, Glasby and Dickinson found, pilots were not maintained long enough to reach mainstream services. Adult social care was asked to hold the prevention end of the shift without settled funding, and in 2026/27 it is asked to pool the Better Care Fund.
The decision on your desk. Whether to commit pooled Better Care Fund money to the neighbourhood team's cohort and name the social care outcomes it buys, or to keep the budget separate until the team can show it reduces unmet need.
What goes wrong if this is done badly. If prevention is funded through a grant that later folds into general local authority funding, the social care staff doing joint work are an early saving, and the team loses the partner that connects it to housing and care.
Mental health nursing and mental health practice
Mental Health Nursing BSc (Hons)
What changes for you. The week's policy history barely names mental health. The 2006 white paper, the Long Term Plan and the 2026 framework all describe the community shift through physical and primary care, and the prevention evidence warns that downstream measures can widen the inequalities they target. Mental health was asked to accept a place outside the shift's main frame and to keep its caseload through each reorganisation.
The decision on your desk. Whether to put mental health into the neighbourhood team's high priority cohorts in the footprint return, or to accept remaining a core service that other teams refer into, which is what the silence currently assumes.
What goes wrong if this is done badly. If mental health stays a referral destination, people with severe mental illness sit outside the frailty and long term condition cohorts, and the group with the worst physical health outcomes is reached last by a service built to prevent admissions.
Physiotherapy
Physiotherapy BSc (Hons)
What changes for you. Sibbald's review found that relocating specialists and joint working improved access without harming quality, but rarely reduced outpatient activity and generally increased costs. Physiotherapy was therefore asked to move into the community while the hospital outpatient capacity it left behind was not released. In 2026/27 the same substitution question returns in the neighbourhood footprint.
The decision on your desk. Whether to commission physiotherapy as a neighbourhood rehabilitation and falls service for the frailty cohort, or to keep the outpatient waiting list as the referral route and add only the sessions the team can agree.
What goes wrong if this is done badly. If community physiotherapy is added without reshaping an outpatient pathway, the system pays twice for the same demand, and the falls and reablement work that would have prevented admissions stays behind a waiting list.
Public health and local government
Public Health MPH
What changes for you. Public health was moved to local government in 2010 on the argument that one size does not fit a neighbourhood, and the week's prevention evidence shows returns arriving over years and landing on budgets other than the one that paid. The 2026/27 asks fall on the health and wellbeing board that public health supports: footprint, team plan and data sharing.
The decision on your desk. Whether to draw the neighbourhood footprint around need using local authority data, or to accept the boundary drawn around registered GP lists, which is the easier footprint to agree and the weaker one for inequalities.
What goes wrong if this is done badly. If the footprint follows practice lists, the prevention offer reaches the already advantaged first, the gap widens as Lorenc's evidence predicts, and the ambition of the shift is met on paper while the neediest neighbourhoods are split across plans.
Pharmacy (pharmacists and pharmacy technicians)
Pharmacy MPharm (Hons) (awarded by Kingston University, delivered jointly with St George's, University of London)
What changes for you. The week's twenty-year policy history does not name pharmacy, and neither the 2006 white paper nor the digital and prevention strands put medicines review at the centre of the community shift. Community and primary care pharmacy was asked to serve the shift through repeat prescribing and discharge reconciliation rather than as a profession with a defined neighbourhood role. The 2026/27 data-sharing ask is where that absence stops being neutral.
The decision on your desk. Whether to take a seat in the neighbourhood team on the strength of structured medication review, or to stay a practice-based service that other team members refer to once polypharmacy has caused a problem.
What goes wrong if this is done badly. If medication review is left out of the team's defined function, care home residents accumulate prescribing without review, and the polypharmacy risk a frailty cohort concentrates is discovered at a crisis admission instead of being planned for.
Speech and language therapy
Speech and Language Therapy BSc (Hons) and MSc
What changes for you. Each earlier version of the community shift promised earlier intervention closer to home, and each time speech and language therapy was left to follow the patients without a settlement that named a post. The 2006 white paper set the goal, the 2019 plan guaranteed the community money, and the 2026 framework lists minimum interventions; none funded a therapist.
The decision on your desk. Whether to name speech and language therapy in the neighbourhood establishment now, and fund the post, or to accept the historic pattern in which the shift is agreed first and the therapist is counted, later, under children's services.
What goes wrong if this is done badly. If the shift is agreed without a named therapy post, adult dysphagia and post-stroke communication have no community home, and the aspiration admissions that earlier versions were meant to prevent keep arriving through the hospital door.
Critical commentary
Where this week is argued with
Full-text commentaries and critical analyses from peer-reviewed journals. The policy column tests the claim against what government actually commissioned. The practice column tests it against what staff can deliver. Read one from each before the contested question.
Policy-facing
Alderwick, H. (2025). Government's 10 year plan for the NHS in England. The BMJ, 390, r1396.
FULL TEXTEditorial arguing the plan's ambitions are right but its substance is thin: the promise to shift investment is vague, hospital power will not be dented, and the reforms add another round of redisorganisation. It agrees these promises are familiar, yet holds that integrated care can still improve access and satisfaction. It lands with the week's delivery scepticism.
Analysis of the commissioning and integration literature arguing that the shift needs formal commissioning structures at place level, trusted local commissioners, shared population data, and financial rules that reward collaboration. It notes that integrated care boards will be the default commissioners while delegation to place level has barely happened, so the problem lies in commissioning design, not ambition.
A commentary that disputes a premise this week rests on: that earlier failures yield transferable lessons. Using a Manchester cancer service reconfiguration, it argues success came from attending to local history, relationships and politics, and that generic change management cannot be transplanted. It lands partly against the week's assumption that the reasons past attempts collapsed are simply knowable.
Practice-facing
An editorial arguing the plan's 50,000 person neighbourhood is an urban construct that fits rural populations badly: sparse settlement and poor transport make centralised hubs reduce access and continuity, while digital substitutes risk worsening exclusion. It notes that NHS England's neighbourhood health guidance never uses the word rural. It lands against the plan's practice model.
An editorial introducing a special issue on engagement in integrated care. It argues that engagement must move beyond time-limited projects and tokenistic consultation towards sustained partnership with communities, and names project-focused culture and short funding cycles as obstacles. It backs the week by giving a practice-level reason why earlier integration efforts underdelivered.
An editorial on a review of 56 NICE guidelines that found only a fifth referenced multimorbidity and none included a section on adapting care for it, with generalists under-represented on panels. It argues single disease guidance weakens frontline care for people with several conditions, and backs the week's claim that community generalist care needs different tools.
Key sources
The White Paper that first put the community shift into formal government language, promising more services closer to home, expansion of care settings outside hospitals, and four goals led by earlier intervention and prevention. It also introduced practice-based commissioning and joint commissioning between primary care trusts and local authorities. It is the origin point for the twenty-year promise that this week interrogates.
The 2010 white paper that opened the digital phase of the shift, promising an information revolution, greater patient control over records and shared decision-making as the norm, captured in the phrase no decision about me without me. It also promised real terms increases in health spending in each year of that Parliament. Access is recorded as abstract because this reading covered the foreword, the executive summary and the chapter on the information revolution rather than all 61 pages.
The framework that converted the digital ambition into dates, committing to all patient and care records being digital, real-time and interoperable by 2020 and to paperless working in primary, urgent and emergency care by 2018. It also set data standards, universal NHS number adoption and interoperability roadmaps for commissioners and providers. It supplies the date against which the digital shift's delivery record can be measured.
The 2019 plan that committed to dissolving the historic divide between primary and community health services and guaranteed real terms growth for primary and community funding. It recorded that relative investment in primary care fell after the 2004 contract, that practice and district nurse shortages had emerged, and that patient satisfaction with access had declined. It is the immediate predecessor whose delivery record the 10 Year Health Plan has to answer.
The current plan, published in July 2025, which organises its proposals around the three shifts from hospital to community, analogue to digital and sickness to prevention. It concedes that the NHS is hospital-centric and behind the technological curve, and commits to a falling share of hospital expenditure, 250 new neighbourhood health centres open 12 hours a day and 6 days a week, and a full NHS App front door by 2028. It is the document whose claim to novelty this week tests.
The framework published in March 2026 that acts as the delivery vehicle for the community shift. It defines neighbourhood health, asks integrated care boards to implement minimum interventions in every community over the next three years, sets minimum basic requirements for 2026 to 2027 and locally owned neighbourhood health plans from 2027 to 2028. Its conclusion concedes that similar proposals have been set out over the last 15 years and that the system has orientated more to hospitals.
The King's Fund's analysis of the published plan, which concludes that it echoes what NHS reform plans have been saying for much of the past 25 years and is in many ways a greatest hits of the 2000s Labour plans. It finds more space given to describing the future than to explaining implementation, and treats the prevention shift as the least developed of the three. It supplies the second of the two King's Fund judgements used this week; the page returns 403 to an automated request and was read through a text extraction fetch.
A long read on public attitudes to the three shifts, built on Ipsos analysis of existing polling for The King's Fund. It states the first King's Fund judgement used this week, that the shifts are not new ambitions and have proved stubbornly difficult to implement, with progress on all three glacial or in some cases going backwards. It also sets out tensions within each shift, including public anxiety about reductions in local hospital services; the page returns 403 to an automated request and was read through a text extraction fetch.
A scoping review and qualitative synthesis of 119 studies covering four strategies for shifting specialist services from acute hospitals into the community. It found that transferring services and changing referral behaviour reduced outpatient activity but risked reducing quality, with savings offset by increased service volume and lost economies of scale, while relocating specialists and joint working improved access without reducing activity. It is the strongest single answer to the assumption that moving care out of hospital saves money.
A quasi-experimental difference-in-differences evaluation of the Vanguard new care models programme, which ran from 2015 to 2018 and covered around 9 per cent of the population of England. It found that the programme slowed the rise in emergency admissions, especially in care home sites and in the third and final year, but produced no significant reduction in bed-days. It sets a realistic upper bound on what an integrated neighbourhood model can be expected to deliver in its first years.
A qualitative study of how the Vanguard programme was implemented and early operated, read through Matland's ambiguity-conflict model of policy implementation. It shows that sites faced pressures from what was perceived as a permissive invitation to experiment alongside a simultaneous requirement for rapid learning, scale and spread, and argues that future programmes should spread principles for design rather than fixed products and templates. It explains why the largest recent test of the community shift could not produce a transferable model.
A critical commentary on English integrated care policy from 2010 to 2020, drawing on reviews by the audit office, parliamentary committees and the care regulator. It concludes that despite progress in a few local areas, expected improvements were not achieved, with emergency admissions still growing and health inequalities worsening, and names a hyperactive policy context, layering of new policy on old, and social care underfunding as causes. It is this week's central evidence on what policy churn does to delivery.
A rapid overview of systematic reviews of intervention-generated inequalities by socioeconomic status in high-income countries. It found some evidence that media campaigns and workplace smoking bans increased inequalities, while structural workplace interventions, provision of resources and fiscal measures such as tobacco pricing reduced them, which supports the view that downstream prevention widens gaps more than upstream action does. It is the evidence base for the risk that a neighbourhood prevention offer could widen the inequalities it was designed to close.
A hermeneutic systematic review combined with longitudinal case studies of six technology-supported health and social care programmes, each followed for up to three years, producing the NASSS framework. It argues that non-adoption, abandonment and failure to scale are driven by the complexity of the illness, the adopter system, the organisation and the wider system rather than by the technology itself. It explains why a single national record deadline cannot by itself deliver the digital shift.