Week 10 of 10
Making it stick
Every previous version of this shift failed at implementation rather than at design, so the last week is about governance, measurement and the specific things that make a service survive its second year.
The last week is about implementation, not design
The Neighbourhood Health Framework concedes the history. It 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", and that "the challenge is the ability of the system to make the change" (Neighbourhood Health Framework, 2026). The model is not unknown or untested. England has tried a version of it in nearly every decade since 2006 and kept the hospitals.
So what decides whether a neighbourhood service is still running in its second year? Three things that can be settled before money is spent: who is accountable for what, what is counted, and what keeps the work visible once the enthusiast who set it up has moved on. The framework is deliberately "light touch and flexible". That is a strength in design and a liability in delivery: it leaves all three questions to people with no spare capacity and no protected budget.
Who is accountable, and where the chain breaks
The neighbourhood health plan is "designed under the collective leadership of the HWB", agreed with health and wellbeing board partners, and incorporated by the integrated care board into its five-year strategic commissioning plan. Integrated care boards are "responsible for ensuring neighbourhood health is the default for NHS care provision in their population", and health and wellbeing boards "will need to set the geography" of a neighbourhood. The next steps letter asks both to confirm footprints, "organisational ownership of planned deliverables", and "which organisations are responsible for different elements of delivery" (NHS England, 2026).
Two limits sit inside that machinery, and the documents state both. The first is that a board can agree a plan without any partner's accountability moving: where health and wellbeing boards agree changes to public health or social care, "this does not alter the accountability or funding responsibilities of local authorities". The second is that the requirements are to disclose rather than to resolve. A plan can confirm organisational ownership and still name no person accountable for the frailty cohort. The National Audit Office found that arrangements to assess integrated care boards were developing, but that "it is less clear who will monitor whether integration between the NHS, local government, and others is working well, or what will happen if it is not" (National Audit Office, 2022).
The evidence on health and wellbeing boards is weaker than the framework assumes. Perkins and colleagues studied boards in five localities over three years, to 2017, and concluded that they had largely repeated the history of earlier health partnerships: unclear aims, ownership and accountability that partners did not share, and no significant effect on health outcomes (Perkins et al., 2020, Journal of Health Services Research and Policy).
The JSNA is the evidence base, and it is a weak instrument
The plan must "address local priorities and health inequalities set out in the local joint strategic needs assessment" and "set out how local objectives are informed by the JSNA" (Neighbourhood Health Framework, 2026; NHS England, 2026). That assessment is the formal evidence base for the largest shift in English health care for two decades.
Beenstock and colleagues analysed 47 health and wellbeing strategies and found that evidence was used most commonly to mean evidence of local need rather than evidence of effectiveness, that all but two strategies referred to their joint strategic needs assessment, and that the strategies were dominated by evidence of need (Beenstock et al., 2015, Journal of Public Health). The assessment tells you how much need there is. It does not tell you which intervention reduces it. Connolly and colleagues add a second weakness: of 142 local authorities with a current joint strategic needs assessment, 108 mentioned LGBTQ+ health at least once, but few considered diversity within those communities, and the assessments "do not adequately characterise the needs" of the populations concerned (Connolly et al., 2026, Perspectives in Public Health). A document strongest on need, silent on effect and uneven in whom it describes is a starting point, not a warrant.
Activity, outcomes and the architecture of the counting
The framework sets five national goals measured against a 2025 to 2026 baseline. Reduce non-elective admissions and bed days by 10 per cent for the frailty cohort by March 2029; see 90 per cent of clinically urgent patients on the same day by March 2027; reach 70 per cent of the referral to treatment standard by March 2027 and 92 per cent by March 2029; and give 95 per cent of people with complex needs an agreed care plan by 2027 (Neighbourhood Health Framework, 2026). Local aims and outcomes are set through the neighbourhood health plan itself, under the collective leadership of the health and wellbeing board. Several measures are still being developed, and the patient experience measures arrive in 2026 to 2027 with details "confirmed in due course".
Most of these are counts of service use. The framework's access measure makes the point most sharply, promising that "at least 78 per cent of community health service activity" will occur within 18 weeks by 2026 to 2027, rising to at least 80 per cent by 2028 to 2029. A service can reach 80 per cent activity within 18 weeks while the person with frailty still loses their independence, because activity counts contacts and outcomes count lives. Bevan and Hood described the mechanism when they analysed the English target regime as synecdoche, taking a part to stand for a whole, and documented the measurement problems and gaming that followed (Bevan and Hood, 2006, Public Administration). What is measured displaces what is not.
The money shows the same pattern. The National Audit Office found that 77 per cent of senior integrated care system staff said their system intended to invest in prevention, while only 31 per cent thought it had the capacity, and that 97 million pounds was allocated across all 42 integrated care boards for prevention against 2 billion pounds for elective care recovery (National Audit Office, 2022). Measurement follows money, and money follows the measured. In the 92 sustainability evaluations Braithwaite and colleagues reviewed, half used routinely collected organisational data such as length of stay and admissions (Braithwaite et al., 2020, BMJ Open).
What the earlier attempts actually found
The Vanguard programme ran from 2015 to 2018, testing five models in 50 local areas and covering around 9 per cent of the population of England. Morciano and colleagues found that it "slowed the rise in emergency admissions, especially in care home sites and in the third and final year", that "there was no significant reduction in bed-days", and that integrated care policies "should not be relied upon to make large reductions in hospital activity in the short-run" (Morciano et al., 2020, Health Policy). MacInnes and colleagues then asked why only one of the five models was scaled and spread. The causes were "a lack of direction near the end of the Vanguard programme, a lack of ongoing resources, and limited success in providing real-time monitoring and evaluation". They call it the scale and spread paradox, in which the localism that made implementation work also limited the spread (MacInnes et al., 2023, Journal of Health Services Research and Policy).
The pioneers produced a comparable result. Keeble and colleagues compared wave 1 pioneer areas with non-pioneer areas from a baseline of April 2010 to March 2013. Emergency admission rates rose by 1.93 per cent in pioneer areas against 4.84 per cent in non-pioneer areas by 2014/15, a statistically significant difference at p=0.0379. By 2015/16 the difference had narrowed and was not statistically significant at p=0.1879. It is "ambitious to expect unequivocal changes" from a single indirect indicator (Keeble et al., 2019, BMJ Open).
The evaluation also failed, in a way that matters for governance. Durand and colleagues tried to run a prospective quasi-experimental evaluation of community-based multidisciplinary teams and met four obstacles: commissioner specifications unrealistic about what could be delivered; difficulty recruiting study sites; ethics and governance processes that consumed time and data; and difficulty obtaining consent to link routine service use data. There was no clear incentive for local sites to take part (Durand et al., 2025, Journal of Health Services Research and Policy).
Evidence on current arrangements is provisional. Lalani and colleagues interviewed 60 system leaders across four integrated care systems: emphasis on population health, set against tension between quality assurance and improvement, with concern that a narrow focus on assurance would impede work on inequalities. Their conclusion is blunt: "It is unclear whether ICSs can achieve their ambition" (Lalani et al., 2024, Journal of Health Services Research and Policy). The National Audit Office found that 57 per cent of senior integrated care system staff expected it to take between three and ten years for their system to improve population health outcomes significantly (National Audit Office, 2022).
What makes a service survive its pilot
Funding continuity is the first condition. Neighbourhood health is to be funded "by rebalancing existing resources rather than relying on new funding", and the National Audit Office found that local priorities had "fewer mechanisms and no protected budget" behind them. The timetable is minimum basic requirements in 2026 to 2027, a locally owned plan from 2027 to 2028, and a period running to March 2029. Three budget years is enough for a pilot, not for a service to become routine. The second-year funding line, and whether it recurs, is the first thing to inspect.
The sustainability literature explains why the second year is where the evidence stops. Braithwaite and colleagues reviewed 92 evaluations and found that only 11, 12.0 per cent, reported evaluation after initial programme funding had ended; the largest group, 42.5 per cent, assessed programmes one to two years after implementation. Only 29.3 per cent of studies offered any definition of sustainability (Braithwaite et al., 2020, BMJ Open).
Zurynski and colleagues reviewed 124 studies of healthcare programme sustainability and mapped what sustains or ends a programme. The most commonly named single factors were leadership and support, in 49.2 per cent; training, support and supervision, in 43.5 per cent; and staffing and turnover, in 40.3 per cent. Only 29 studies, 23.4 per cent, covered a programme sustained for five years or more, and adaptability was the key facilitator in 8 of those 29, 27.6 per cent. Their caution: the "strident quest for sustainability of all implemented programs" is wrong when a programme is ineffective (Zurynski et al., 2023, Implementation Science).
Turnover is the third most reported factor in the sustainability evidence, so the practice task takes succession literally: write the succession plan for your own team, name the roles that would notice if the lead left in month nine, and name the three pieces of routine data that would show the service fading. The framework sets the test that plan has to pass, requiring systems to confirm plans for data-sharing arrangements for patient identification and evaluation, and asking the national implementation programme to "identify success criteria for the scaling of these new models" (Neighbourhood Health Framework, 2026; NHS England, 2026). A service whose success criteria do not yet exist, and whose data-sharing arrangements are not yet agreed, has no evidence of its own survival by default.
Tests to apply to any neighbourhood health plan
- Accountability: does it name the post or person accountable for each deliverable and for the high priority cohort, or only the organisations involved?
- Money in year two: which budget line pays in 2028 to 2029, is that money recurring, and what has stopped being funded to release it?
- Outcomes or activity: which measure would fall if the service stopped working well for people? If every measure counts contacts and days, nothing measures a person.
- Evidence and omission: what does the local joint strategic needs assessment measure, and which populations does it leave out?
- Succession: if the named lead leaves in month nine, which role notices, and which three routine data items show the service fading before it fails?
- Comparison: what is the counterfactual, and was it agreed before the money was spent?
The last test is the contested question this week must leave you able to answer: should the neighbourhood health service be evaluated as a set of local innovations or as a national programme with a common counterfactual? The evidence supports the second, with a qualification. Evaluating each place against itself repeats the pioneer experience, where local projects claimed success while the aggregate indicator barely moved. A national programme does not require identical local models: the Vanguard and pioneer evaluations applied common outcome measures to different local arrangements, which is what makes them usable. What it does require is what Durand and colleagues found missing in practice: data-sharing agreed in advance and research approvals proportionate to low-risk service evaluation. The qualification is MacInnes's paradox: a programme national in measurement must stay local in design, or it loses the adaptation the sustainability evidence identifies as the leading facilitator of survival. The practical answer is a small national core measure set, agreed before the money is spent, with each local model also evaluated as an implementation case and negative results published. Hold the second year, not the launch, as the test of whether this shift is different.
The contested question
Whether the neighbourhood health service should be evaluated as a set of local innovations or as a national programme with a common counterfactual.
Working across professions
Holding it together after the enthusiast
Neighbourhood services usually survive on one person's energy. Ask the group to write the succession plan for their own team, naming the roles that would notice if the lead left, and the three pieces of routine data that would show the service was fading. Then test it against a case where the lead leaves in month nine.
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)
Advanced Clinical Practice MSc
What changes for you. The week's metric set lands on the practice as access counts: 90 per cent of clinically urgent patients seen the same day by March 2027. The plan also has to confirm named accountability, and the framework insists on clinical leadership from general practitioners, so the lead GP role becomes a documented post with a succession plan and three routine data items rather than informal goodwill.
The decision on your desk. Whether the practice names one accountable clinician for the frailty cohort, with released sessions and a second named deputy, or keeps the neighbourhood role as unpaid interest held by whoever is keenest this year.
What goes wrong if this is done badly. If the role is unnamed and unfunded, the service is one resignation deep, the second year funding case has no owner, and the need described in the local joint strategic needs assessment is never converted into a funded plan.
Community nursing and district nursing
Public Health and Specialist Community Nursing MSc/PGDip
What changes for you. Community nursing carries the measure the week calls the trap: at least 78 per cent of community health service activity within 18 weeks by 2026 to 2027, rising to 80 per cent by 2028 to 2029. Staffing and turnover were the third most reported factor in the sustainability review, so the caseload arithmetic in the plan decides whether the team survives its second year.
The decision on your desk. Whether to accept the neighbourhood caseload with a protected supervision figure and named cover for absence, or to let the team absorb discharge demand until the second year review records turnover it cannot replace.
What goes wrong if this is done badly. If the plan counts contacts rather than the housebound people behind them, the service can reach 80 per cent within 18 weeks while frailty admissions stay flat, and the district nursing vacancy becomes the reason the outcome measures are never met.
Adult social care and social work
Partner profession: local authority adult social care
What changes for you. The framework states that a health and wellbeing board agreeing changes to public health or social care does not alter local authority accountability or funding. Social care therefore enters the plan as a partner whose own duties are untouched, and the Better Care Fund pooled funding confirmation is the point where a share of the plan's money, and its risk, becomes visible in a council budget.
The decision on your desk. Whether the council signs up to a pooled neighbourhood budget with one accountable co-ordinator for the shared cohort, or keeps separate budgets and confirms its contribution only at Better Care Fund minimums.
What goes wrong if this is done badly. If budgets stay separate, accountability for the cohort sits with whoever holds the risk rather than the money, and the plan can pass the disclosure test of naming organisations while no person can release a care package.
Mental health nursing and mental health practice
Mental Health Nursing BSc (Hons)
What changes for you. The framework's mental health offer rests on 24/7 neighbourhood mental health centres, distinct from integrated neighbourhood teams, and on pilots whose guidance arrives in autumn 2026 only after an independent evaluation. The week's evidence says the commissioning decision usually arrives before the evidence, so mental health practitioners should expect to be placed inside a model that is still being evaluated.
The decision on your desk. Whether to commit scarce practitioner time to a neighbourhood mental health model before the autumn 2026 evaluation is published, or to keep the existing community mental health base until the evidence lands.
What goes wrong if this is done badly. If the service is stood up on pilot enthusiasm alone, its second year is judged on metrics that say nothing about crisis continuity, and the sustainability evidence's commonest factors, leadership and staffing, decide its fate rather than its clinical case.
Speech and language therapy
Speech and Language Therapy BSc (Hons)
What changes for you. The framework's five goals measure admissions, bed days, waiting, clinical outcomes, care plans and staff experience. None names swallowing or communication. The evidence base for the local plan is a joint strategic needs assessment that is strongest on need and uneven in whom it describes, so dysphagia and communication need is the work most likely to be missing from the document that decides which posts are funded.
The decision on your desk. Whether to argue for a named therapy post inside the neighbourhood team on the strength of aspiration and communication risk, or to accept a referral route that no team member is trained to use safely.
What goes wrong if this is done badly. If the plan measures only frailty admissions and bed days, aspiration pneumonia appears as another admission and nobody can show whether a therapist would have prevented it, so the profession leaves the plan while remaining on the staff list.
Physiotherapy
Physiotherapy BSc (Hons)
What changes for you. The framework's first minimum requirement is a plan to cut non-elective admissions and bed days by increasing urgent, rehabilitation and reablement capacity, based on risk register analysis. Physiotherapy is where that capacity is delivered, and the week's counting problem applies at once: reablement is read through bed days and admissions, so the therapy that preserves independence is invisible unless routine data record it separately.
The decision on your desk. Whether to hold out for reablement outcome measures and routine collection of function at the start and end of a therapy episode, or to accept the framework's admission and bed day counts as the available evidence of value.
What goes wrong if this is done badly. If function is not in the routine data, an effective reablement service looks like a cost with no return, and the second year cut falls on the therapy that the plan's own minimum requirement depends on.
Public health and local government
Public Health MPH
What changes for you. The week puts the joint strategic needs assessment and the health and wellbeing board at the centre of the plan. The evidence is unflattering: boards studied over three years largely repeated earlier partnerships, and the strategies they produced used evidence of local need far more often than evidence of effectiveness. Directors of public health hold the evidence function and can insist that the plan states what works.
The decision on your desk. Whether to resource the joint strategic needs assessment and the plan's outcome measures properly, with analyst time and a published counterfactual, or to sign off a plan whose measures are the national activity counts already in the planning round.
What goes wrong if this is done badly. If the evidence base stays a document of need, the plan holds no test of effect, the board cannot answer the audit question about who monitors whether integration works, and the second year is judged on throughput the service never controlled.
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
The commentary reply argues that England's integrated care systems are a politically contingent model rather than a settled blueprint, since abolishing NHS England, halving integrated care board budgets and probable mergers have stripped the governance and capacity neighbourhood health needs. It lands against the week's confidence that governance can be fixed once and then sustained. Article type: commentary.
Critical commentary reviewing a decade of English integration policy through regulator, parliamentary and audit reports. It concludes that expected improvements were not achieved, that performance frameworks discouraged system working, and that layering initiative upon initiative confused rather than advanced the work. It lands against the week's hope that a better-designed national programme will finally stick. Article type: critical commentary.
Perspective arguing that multisector collaboration, the dominant partnership model behind place-based integration, is difficult to accomplish and only mitigates social harms rather than transforming the conditions that produce them, and that accountability is thereby diffused. It lands against the week's assumption that voluntary local partnership working can deliver population health gains. Article type: perspective.
Practice-facing
Editorial welcoming the ten year plan's neighbourhood vision while doubting it can be delivered, because funding, workforce capacity and accountability remain unresolved, general practice is at breaking point, and more roles do not always mean better care. It lands against treating implementation as a matter of governance and measurement alone. Article type: editorial.
Analysis of spread and scale-up evidence, arguing through implementation, complexity and social science logics that adoption depends on local adaptation, behaviour change and informal professional networks rather than blueprint roll-out. It reports that nearly half of successful scale-ups ignored the standard sequence. It lands against the week's search for one transferable delivery model. Article type: analysis.
Comment extending the PRISM and RE-AIM frameworks, arguing that interventions lose impact and are not sustained when they are not aligned to local context, and that co-creation with staff, patients and communities should run through planning, delivery and evaluation. It lands against designing a neighbourhood service centrally and dropping it into place. Article type: comment.
Key sources
The framework that sets the minimum interventions, the five national goals and the staged timetable for the neighbourhood health service in England. Read in full. Its concession that similar proposals have been set out over the last 15 years is the week's starting point, and its own metric list supplies the activity measures the week tests.
The letter to integrated care board and provider leaders that operationalises the framework, listing what must be confirmed in 2026 to 2027 and what a local neighbourhood health plan must contain from 2027 to 2028. Read in full. It is the source of the organisational ownership and data-sharing confirmations the week turns into a governance test.
Value for money study of the introduction of integrated care systems, of which the summary, key findings and conclusion were read. It supplies the finding that responsibility for monitoring whether integration is working is unclear, and the gap between the 77 per cent of senior staff whose system intended to invest in prevention and the 31 per cent who thought it had the capacity.
Difference-in-differences evaluation of the Vanguard new care models programme, which 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 final year, but produced no significant reduction in bed days, and it warns against expecting large short-run reductions in hospital activity.
Quasi-experimental evaluation comparing wave 1 pioneer areas with non-pioneer areas from a baseline of April 2010 to March 2013. Emergency admission rates rose by 1.93 per cent in pioneer areas against 4.84 per cent elsewhere to 2014/15, a statistically significant difference, but the difference was not significant by 2015/16. It is the week's main evidence for caution about single programme-level indicators.
Interview and documentary study of why only one of five Vanguard models was scaled and spread. It attributes the failure to a lack of direction near the end of the programme, a lack of ongoing resources and limited real-time monitoring and evaluation, and names the scale and spread paradox in which localism drove implementation and then limited the spread.
Account of four obstacles met in attempting a prospective quasi-experimental evaluation of community-based multidisciplinary teams: unrealistic commissioner specifications, difficulty recruiting sites, research ethics and governance processes, and obtaining consent to link routine data. It is the week's evidence that a common counterfactual is a governance problem before it is a statistical one.
Three year study of health and wellbeing boards in five English localities. It concludes that the boards largely repeated the pattern of earlier health partnerships, with unclear aims, ownership and accountability that partners did not share and no significant impact on health outcomes, and that boards need more executive power to make a difference.
Thematic content analysis of 47 health and wellbeing strategies from a sample of 50 of the 152 upper tier authorities. It found that evidence was used most commonly to mean evidence of local need rather than evidence of effectiveness, that all but two strategies referred to their joint strategic needs assessment, and that the strategies were dominated by evidence of need.
Review of current joint strategic needs assessments in the 142 local authorities in receipt of a public health grant. Of these, 108 mentioned LGBTQ+ health at least once, few considered diversity within those communities, and the paper concludes that English assessments do not adequately characterise the needs of local LGBTQ+ populations.
Study of quality management across four newly established integrated care systems, using interviews with 60 system leaders, observation of meetings and documents. It found emphasis on population health set against tension between quality assurance and improvement, and concluded that it is unclear whether integrated care systems can achieve their ambition.
Integrative review of 124 studies that mapped barriers to and facilitators of programme sustainability onto the Integrated Sustainability Framework. Read in full. Leadership and support, training and supervision, and staffing and turnover were the most reported factors; only 29 studies covered five years or more, and only 8 reported a discontinued programme.
Integrative review of 92 evaluations of healthcare improvement programmes. Read in full. Only 11 reported evaluation after initial programme funding had ended, the largest group assessed programmes one to two years after implementation, and only 29.3 per cent defined sustainability at all. Half used routinely collected organisational data as the outcome.
Analysis of the English target and terror regime of the 2000s, arguing that governance by targets rests on synecdoche, taking a part to stand for a whole, and on the assumption that problems of measurement and gaming do not matter. The week uses it for the mechanism by which activity measures displace outcome measures.