Are neighbourhood health, digital and prevention starting to disappear into the familiar Bermuda Triangle of NHS reform, along with the promises to improve performance?
Key Takeaways
- NHS reforms rarely get cancelled. They slowly disappear, squeezed between three competing demands: performance, finances and implementing change.
- The triangle isn’t balanced. Performance and finances are enforced every day; change pays off later, for someone else, so it usually loses.
- With no dedicated new money for neighbourhood health, change has to come from making better decisions about what we already have.
- The same trade-offs play out at every level, from boards to individual neighbourhood projects.
- Escaping the triangle means being honest about trade-offs, funding the transition, protecting the capacity to change and making local decisions openly.
Table of Contents
Introduction
If you’re working on neighbourhood health right now, you’ve probably been told two things. This is the future of the NHS. And there’s no new money to make it happen.
This unfortunately seems to be history repeating itself. The NHS has a remarkable ability to make reforms disappear. Not overnight. They usually vanish slowly into the fog, never to be seen again.
We’ve seen this same pattern repeat in plan after plan, for decades.
The NHS 10 Year Health Plan recognised this problem and promised to ‘break with the past’ and ‘take a new course to change’.
So far it has followed a very familiar course. A big announcement. A deluge of policies. A lot of NHS organisations get re-disorganised. The data starts to improve (this could just be the Hawthorne Effect: where things improve just because people know they will be judge on them.), then things go back to the familiar slide. Gradually the changes all get a bit confused and lost.
Which is where we appear to be now. As reported across a number of article in the HSJ almost all of the government’s performance targets for the NHS look set to be missed.
Despite promising pilots and pockets of progress, there’s still no clear, credible plan, particularly for staff and funding, for how neighbourhood health, digitally enabled care and prevention will be implemented at scale. (Read a summary of the Neighbourhood Health Framework here) The plans are drifting off course, with little effort to steer them back.
We know how this story goes. The NHS gradually slides back towards crisis. The public gets angry. The government panics and starts chucking cash at the NHS (especially with an election coming). Things improve slightly, at great cost, and everyone demands that something MUST BE DONE. And yet again we’re told the NHS must “reform or die”.
And lo and behold, a new plan is created and the NHS is given a new life. Despite showing remarkable similarities to the old one, nobody asks what happened to the last plan. Where exactly did it disappear to?
I’m not arguing that the NHS is not under threat. Only that there is a profound inadequacy and futility in leaders shouting at a system that employs around 1.5 million people, and sits within a complicated wider system of care, to change or else. And then just hoping it happens. It is ‘performance’ management in all the wrong ways.
Lord Darzi’s report laid bare that we have been here so many times before, and yet the reality has often gone in a different direction than intended. Indeed only recently we have heard how hospitals are taking an even larger share of the pie and community services are even less well funded (Health Foundation).
So the question isn’t whether neighbourhood health is the right direction. It’s how we make change happen when there’s no dedicated new money to pay for it. That can’t be done with more demands, more policies and wishful thinking. It has to come from making sensible decisions about how we use what we already have. And that means changing how we think about those decisions in the first place.
I have seen this implementation failure up close several times myself. But I think I can add to this by pointing out not just that this happens, but why? When we encounter a problem, we tend to look for cause and effect. But when we recognise a recurring pattern, we need to look at the relationships and conditions that keep producing it. The NHS keeps getting lost in the same Bermuda Triangle of reform.
Earlier this year I wrote about how neighbourhood health risks being sucked back into the whirlpool of the existing system. The triangle explains why that pull is so strong, and how we might navigate it.
So what is this Bermuda Triangle and how do we escape the fate of NHS plans being another policy Mary Celeste (All policy but no one on board any more!)?
The Three Great Demands on the NHS: Performance, Finances and Change
At the corners of the triangle sit three demands every NHS leader will recognise.
Performance. Restore waiting times, improve access, maintain quality, hit the targets.
Finances. Balance the books, deliver efficiencies, cut expenditure, fight inflation.
Implementing change. Neighbourhood health, new technology, a shift towards prevention and communities, a fundamentally different NHS.
All while providing essential care every single day.
None of these is unreasonable. Indeed most commissioners and providers will have plans to do all three. The problem is they typically treat each one in isolation, when what really matters is how they relate to one another.
Most project managers will recognise the shape. We call it the iron triangle: time, cost and scope. They sit in a triangle because they pull against each other. Change one and the others have to move with it. You can do things cheaper, but you’ll need to reduce the scope or quality, or take longer. Want it faster? You need more resources or you do less. It is very rare that you get something for nothing.
I’ve simply translated the triangle into an NHS management context. Better performance usually needs more capacity and investment from somewhere. Financial ‘recovery’ usually means less of something, and the quickest way to save money is to stop paying for someone or something. Change needs investment, attention and time. Trying to do more, do better or do something different without investment is a real battle. The very concept of capitalism is based on the fundamental idea that you have to invest to get more.
(Whilst we are at it, efficiency, reducing the cost per unit, is NOT the same as productivity, increasing output per unit of input. Indeed Jevons’ paradox means that when things become more efficient, total costs can increase. So all our efforts to make hospitals more efficient may actually increase the amount we spend on hospitals (quicker operations can mean more operations!)
Can Technology Make the NHS Cheaper and More Efficient?
But what about technology, I hear you ask? Surely we can just roll out a platform and do more for less? The problem is the constraint is rarely the technology itself. It’s the human factors. Getting people to know about it, choose to use it and use it effectively all take time, effort and money. So implementing the technology change puts us straight back in the triangle. And these days you don’t buy technology, you rent it. It’s an ongoing running cost, which often puts it in direct competition with staff costs. Writing all these things as goals in a plan or a policy doesn’t help us escape the reality of the trade-offs.
(I’d love to make it the law that every time someone says the NHS is going to do more of something, they have to say what the NHS is going to do less of to make it happen. Because that is the reality on the ground. And then maybe, just maybe, people will ask whether and how it is possible first.)
The Business Case Tradeoff.
Business cases should be where these trade-offs get faced. In practice, they’re often where they get hidden. I’ve spent years on both sides of the table, writing them and deciding on them, and the pattern is familiar. Cases for change are expected to show cashable savings, quickly, to the organisation paying for them. But the benefits of prevention and neighbourhood health usually arrive years later, and often in someone else’s budget: the classic wrong pocket problem. So the case gets written to pass the test rather than to tell the truth. Double running costs get squeezed out, productivity gains get assumed and benefits get stretched to fit the timescale. The case is approved, the savings often don’t appear, and the next case for change is met with even more scepticism. Meanwhile, nobody has to write a business case for keeping things the way they are. I’ve written before about this built in bias towards the status quo.
The Case For Productivity
The Health Foundation’s NHS Productivity Commission has just reached a similar conclusion from a different direction. Its report, Breaking the cycle, argues that the NHS doesn’t lack talent or ideas. What holds it back is short-term planning, fragmented accountability and an operating environment so complex that sustained improvement becomes almost impossible. Its recommendations are sensible: stable long-term planning, fewer reporting requirements, investment in management and improvement capability, and more authority devolved to local systems. But they are mostly about creating the right conditions nationally. If decisions really are going to be devolved, local leaders will also need a practical way of making them. Every decision about how to use what we already have still involves trading off performance, finances and change. That’s where the triangle comes in.
The Power Imbalance at the Heart of NHS Reform
The triangle looks balanced. But the power behind each corner isn’t. Miss a performance target and you’ll hear about it within weeks.
Overspend and you’ll be at the bottom of the NHS Oversight Framework league table, putting your organisation’s leaders’ jobs on the line.
Whereas if you fall behind on implementing change, you’ll usually just be asked to submit a new plan. Meanwhile setting up a small pilot is given the same weight as changing the whole system… but without the accompanying risks and problems.
So two corners are given weight by power. The third pays off in the future, often for someone else. So when they come into conflict, change is usually the one that loses. It’s the same evolutionary trap that consumed NHS England: anything that doesn’t fit short-term targets gets selected out.
Why NHS Reforms Get Lost on the Journey
That imbalance typically sends reforms down one of two paths.
- Adrift in the middle. The organisation doesn’t recognise or accept that these demands are in tension. So it keeps changing direction as it tries to reduce costs, improve performance and implement change all at the same time. The reforms get lost in the middle of the triangle and never really go anywhere.
- 2. Following only the visible paths. This is the more pragmatic route. The organisation focuses on the visible priorities of today, cutting costs and hitting short-term targets. This is actually encouraged by the NHS Oversight Framework, which puts organisations under significant pressure on finances and short-term targets. The capacity to implement change is the sacrifice. The benefits of change are invisible now and may take years to arrive, so why not put it off until next year?
This is a reasonable and pragmatic approach, and arguably the course plotted nationally at the moment. The problem is that change is always postponed, and without it the situation is inevitably going to get worse.
We’ve seen this in the NHS so often before. The Five Year Forward View and its vanguards. Sustainability and transformation plans that became partnerships, then integrated care systems. A Long Term Plan that was quietly forgotten.An elective recovery plan relaunched with much the same ideas, while waiting lists kept growing. Each one disappearing into the murk. Not through a lack of effort, but because we never addressed the tension at its heart.
The Human Cost: Prevention and Community Services Lose Out
And this is not without cost. The people who pay the price are not sat in the boardrooms. The reforms that lose out most are usually the ones meant for people with the least voice. Prevention. Community services. The neighbourhoods with the worst outcomes. Nobody gets called to account when a prevention programme quietly disappears. The cost shows up years later, in lives that didn’t need to go the way they did. Indeed our current precarious position is precisely because of years of putting off change and prevention. Yet we are making exactly the same mistakes today and expecting a different outcome.
The Instruments Stop Responding: NHS England, ICBs and the Missing Machinery
The legends of the Bermuda Triangle are full of pilots whose compasses spin and whose instruments stop making sense.
That’s not a bad description of the NHS right now. Just as with previous plans, we reorganise our navigation tools before we reorganise anything else.
We have a 10 Year Health Plan, a Medium Term Planning Framework, an Oversight Framework and emerging outcomes measures. Plenty of documents describing the destination. We are running out of new names for plans describing the same destination. Very few explain and plot the journey, and none at all tell providers and decision makers how to make the trade-offs.
Meanwhile the machinery is being taken apart around us. The abolition of NHS England is now just months away. ICBs are being left in limbo, with their mergers on hold while they’re told to align with local authorities, which are themselves stuck in their own reorganisation. Providers are under enormous pressure to balance their books, which leaves them with no real capacity to take on change.
An ICB is meant to shift resources towards population health management while it’s still working out its own boundaries and who will be left to do the work. A hospital is meant to build alternatives to admission while cutting costs and paying for everything it already runs. A community provider is meant to take on more, without the workforce or investment to match.
Ministers can still set targets, demand action and replace leaders. The controls still move. The instructions still go out. But the machinery connecting national decisions to local action is being dismantled, and in most places we haven’t yet built the local capacity and skills to take ownership.
And now the targets are slipping, the instinct is to push harder. More targets. More assurance. More performance management. Four years ago I wrote about this and called it the Planning Stress Cycle, because I’d seen it so often. History is simply repeating itself. The effort to rescue a struggling plan consumes the very capacity needed to deliver it. More pressure on the two enforced corners only squeezes the third harder.
The Psychological Trap of NHS Reform
None of this is intentional. Indeed the NHS and ministers repeatedly say they DON’T want this to happen. But all that uncertainty and pressure creates a sense of threat, and threat changes how people and organisations behave. That’s how the triangle gets inside our heads.
Imagine you’re running a provider.
You’ve been told to improve performance, deliver major savings and transform services. Your people are stretched. Demand isn’t falling. Half of what you need depends on an ICB that’s reorganising again.
So you focus on what you can control. Vacancies held. Investment paused. Equipment maintenance postponed. More people squeezed into smaller spaces. Promotions stopped and staff performance managed to make sure you’re getting the most out of them.
Something else happens too. The organisation goes into a siege mentality, with people fighting to keep hold of what they have. Organisations under threat close in on themselves (threat rigidity theory), which undermines collaborative working. People stop taking risks. Conversations with partners get shorter and more guarded. People agree to things and then don’t actually do them, which will be familiar to many of us working in the NHS. And organisations start competing for staff and resources. I’ve explored how threat drives the spiral of control in more depth here.
Experienced people leave. Relationships fray. The knowledge of how things actually get done walks out of the door. Lord Darzi’s report is explicit about this in relation to the Lansley reforms: “The result of the disruption was a permanent loss of capability from the NHS.” All the staff cuts being made across the system to balance the books risk undermining the NHS’s ability to deliver even its future promises.
The transformation programme is still there. Today there’s a financial problem. Tomorrow there’s a performance problem. It won’t be long before we’re hearing about winter pressures. And so the cycle continues.
This Bermuda Triangle is so hard to see because so much of it exists in our heads. Our confusion, our uncertainty, our unwillingness to make difficult decisions. Wanting new things but being unwilling to let go of the old world.
The Triangle Applies At Every Level from Commissioners and Providers to Neighbourhoods
This isn’t just a problem for boards and chief executives. The same trade-offs play out in every neighbourhood team, every project and every partnership. A team setting up a frailty MDT is trading clinical time today for fewer crises tomorrow. A VCFSE partner taking on social prescribing referrals is trading its own capacity for someone else’s outcomes. A digital project is trading upfront effort and ongoing costs for benefits that may land years later in another budget. If we only think about the triangle at organisational level, we’ll keep missing the hundreds of small decisions where change actually quietly disappears.
How do we Stop NHS Reforms Disappearing?
I’m not arguing against performance standards or financial discipline. The NHS needs both. But if change keeps losing because it’s the only corner that lacks political power, it needs protecting just as seriously as the other two. Indeed it actually needs greater weight, to stop the system sapping the energy of change with the psychological comfort blanket of cost saving and productivity drives.
That starts with being honest about the trade-offs. If we want neighbourhood health, prevention and digitally enabled care, we have to say what will slow down or stop to make room for them. A plan that promises all three corners at once, without saying what gives, isn’t really a plan.
It means funding the transition, not just the pilot. New models of care need existing services to keep running while they’re established. If nobody pays for that overlap, the pilot stays a pilot.
It means business cases that show the trade-offs across all three corners: what it will cost, what will slow down or stop, and who will benefit, even when it isn’t the organisation paying.
It means protecting the capacity to change. Before cutting a team or role, understand what it actually does, which problems it quietly solves and which relationships it holds together. Otherwise the costs just reappear somewhere else.
It means building local capability before the national machinery is taken apart, not after. Otherwise there’s nobody left at the controls. This isn’t about national bodies micromanaging local decisions; that’s part of what got us into this mess. National should set the boundaries and get out of the way, while local partners make the trade-offs openly.
And it means being explicit when change is delayed. Delay is sometimes the right call. Disappearance isn’t. If something is paused, say so, say why, and say what would need to change to move forward, so the issue can be escalated to someone who can act on it.
We Don’t Live in an Iron World
There is one more important thing to say. We don’t live in an iron world. As I’ve argued before, healthcare is a system, not a set of parts to be optimised.
The iron triangle’s great weakness is that it’s self-referential. It tells you whether an organisation is internally coherent. It doesn’t tell you whether it’s doing any good. An organisation can be working extremely well on its own terms and still be completely out of touch with the people it exists to serve.
That’s when the real costs become clear. Cuts that undermine the future. Performance that becomes performative, cutting corners on the hard tasks and excluding the hard to help and the hard to treat. Change that creates far more disruption than the benefits it brings.
I’m not saying this out of idealism, but from years of putting change into practice. When we understand and work with the flows of people, places and opportunities around us, change stops being an ever more expensive battle to impose our will on the world.
To navigate out of the triangle, we need a north star: a clear sense of who the change is for and what difference it should make to their lives. Without it, every decision gets made on the strength of whichever corner is shouting loudest that week.
Conclusion
Costs, performance and change all matter, but only to the extent they make a difference to the people outside the boardroom. Any reform has to be coherent with what the organisation does now, what it intends to do in future and how it will sustain itself. But above all, it has to make sense in the world it is meant to serve.
Navigating The Triangle Together
The NHS doesn’t need a new plan. It needs better ways of making decisions with what it already has. If you’re working on neighbourhood health and recognise these trade-offs, you’re not on your own.
The Neighbourhood Health Academy is a free community of people working through exactly these challenges, sharing what’s working and what isn’t. Come and join us.
If you’d like help applying the triangle to your own decisions, whether that’s a business case, a partnership or a neighbourhood project, book a free 30-minute conversation. No fees, no commitment.
And look out for my next piece, where I’ll set out a practical way to spot when change is starting to disappear, and what to do about it before it’s gone.
Further Reading
- The Neighbourhood Health Framework: How can we escape the whirlpool? Why neighbourhood health keeps getting pulled back into the old system.
- The Bureaucratic Planning Stress Cycle Why the response to failing plans so often makes things worse.
- NHS England’s Darwinian trap How short-term survival selected against prevention, community and long-term investment.
- The powerful NHS budgeting lie Why “it’s not in the budget” stops change, and why the NHS needs smarter use of money rather than more of it.
- The spiral of control and power The psychology that pulls managers back towards control under pressure.
- Don’t write business cases that assume the world is flat What a neighbourhood health business case now has to do.
- Breaking the cycle, the Health Foundation’s NHS Productivity Commission report.