The Neighbourhood Health Framework:
The NHS Neighbourhood Health Framework was quietly slipped out the back door of the NHS on 17th March. Whilst having a Framework on how to deliver neighbourhood health is helpful, unfortunately there have been many attempts to deliver Neighbourhood Health over the years, all of which have been sucked back into the NHS whirlpool and broken apart.
The goal of the framework is to create a platfrom around which the NHS can shape neighbourhood health. The aim is to allign the NHS along a single path of travel, manage expectations and show how it will be assessed.
The central argument of this article is simple: how do we accelerate delivery of these plans and avoid getting pulled back into the old ways of doing things? Momentum is vital. As Lord Darzi’s report made clear, previous attempts to ‘shift the NHS left’ have in fact resulted in a shift right, with the existing system gaining ever more resources.
“Despite longstanding ambitions to move care closer to home, activity has in practice become increasingly concentrated in hospitals.”
Darzi Review, 2024
Table of Contents
The Whirlpool Effect
The existing system acts like a whirlpool, constantly reinforcing itself and drawing resources inward, feeding bureaucratic processes and pulling ever more activity into hospitals, which now consume 58% of all NHS resources. Previous attempts to move resources and staff into community settings all begin with excitement, but drain themselves before they can escape the pull.
To succeed, any new initiative needs to achieve escape velocity from the current system. As history has shown, without that momentum, we will look back in a few years and find ourselves calling for yet another new plan.
Everyday Pressures Are the Whirlpool
It is easy to blame individuals for creating the whirlpool, to see it as a stubborn refusal to change. In some cases that may be true. But the reality, as evidenced by UCL research, is that there is a widespread desire to change. The problem is that people are constantly dragged into the daily grind of short-term pressures: fixing crises, keeping services running, reducing waiting times, managing staff gaps. This relentless firefighting creates the whirlpool, and systematically prioritises short-term fixes over long-term investment in community prevention and digital transformation.
The Whirlpool Is Also Bureaucracy
Don’t believe what the newspapers or misguided politicians say: bureaucracy is not people, it is a process. You don’t sack people and make bureaucracy disappear. Bureaucracy grows from entirely understandable impulses: the desire to get things right, to be fair, to spend money wisely, to ensure safety. We are all afraid of failure, afraid of being blamed, afraid of losing control. That fear is where bureaucracy takes root and grows. I’ve written about how and why it plagues healthcare management in this article: The Spiral of Control and Power.
The Framework Needs to Help Us Escape
For Neighbourhood Health to succeed, we must escape the ongoing pull of the whirlpool. That means using the new Framework not as a document to be achieved in every detail, since that path leads to running out of resources before anything meaningful is done, but as a compass for direction. What is proposed is a massive societal change with no defined boundaries. We need to take the elements of the framework and use them to adapt and build quickly, learning as we go rather than getting bogged down in impossible plans. The quicker we start, the more momentum we build.
The Accelerators of Change
A Clear Sense of Direction
The best part of the Framework is that it provides genuine clarity of intent. If we are to escape the whirlpool, people need to be pulling in the same direction. This document does a strong job of removing ambiguity around what Neighbourhood Health is trying to achieve, differentiating between national and local goals and explaining how they connect. Used as leaders’ intent rather than a compliance checklist, it can be a powerful tool for change.
Local Goals & Objectives
Bringing together local authorities, outcome commissioning, social care and wider reform is an essential step toward joint action at place level. Local professionals and communities must feel they have a genuine say in what happens. Local people also need to feel the neighbourhood health service is actually for them. If we want trust, our services have to reflect and respond to their needs.
Crucially, conversations need to focus not just on what should happen in the future, but on what is practical and possible right now. This allows us to learn what works and move fast. Even well-founded projects can be delayed for months by the challenge of finding staff, equipment and facilities. At the same time, things can often move much faster when you simply ask people what is possible.
Pathways
The NHS tends to look at pathways as a series of transactions, matching demand and capacity and processing people as fast as possible. (Kings Fund) But this often just pushes problems from one part of the system to another: increase diagnosis, and people wait longer for treatment. We need to look at pathways in their entirety, which means getting people together across organisational boundaries to understand what is really happening and, most importantly, where intervention will make the biggest difference.
Multi-Neighbourhood Providers
Multi-Neighbourhood Providers have the potential to be the real foundations of Neighbourhood Health, providing infrastructure, support and coordination across roughly 250,000 people, often aligning with ‘place’ or local council geographies. This makes collaboration far more practical. If well designed and properly supported, these can become the natural centre point for collaboration between organisations, and the host of the infrastructure and technology needed to turn neighbourhoods into a joined-up system of care.
The Decelerators in the Framework
NHS Goals
NHS goals are well intentioned and could, in principle, deliver meaningful improvements. The problem is not what the goals are: It is in how they work and get implemented. There is ample research that shows that when goals become targets, they distort behaviour, prioritising what is measurable over what matters to people. This pulls focus inward, toward processes and organisational priorities, at the expense of locally grounded, relational approaches. And when we start from our own pain points, we keep making the same decisions: the hospital needs a new scanner, or another consultant, and drip by drip resources flow back to the familiar.
“The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.”
Campbell’s Law
The evidence backs this up. When metrics are tied to targets, systems frequently generate perverse incentives, gaming behaviours such as excluding or redirecting people who negatively affect organisational performance. Challenging goals can drive organisations into conflict rather than cooperation.
Single Neighbourhood Provider Contracts
The wording in this section appears to have shifted from previous documents on neighbourhood health a collaborative, multi-provider approach to a purely contractual model of primary care reform. (It is looking increasingly likely that Primary Care Networks being expected to become Single Neighbourhood Providers) This risks creating unnecessary conflict and controversy, particularly given there is no additional funding, and GPs are private businesses for whom these contracts directly affect financial viability.
If Neighbourhood Health is funded through activity, it simply replicates the old problems. If it is funded through changing outc1omes, that becomes a business risk many GPs will be unwilling to carry. Certainly it is incredibly hard to fairly balance risk and rewards for changing outcomes in areas of deprivation vs affluent areas, especially when many factors have nothing to do with GPs ‘performance’.
The likely result is conflict between primary care and ICBs over activity and payments, and the effective squeezing out of non-primary care providers. To be direct: you cannot ask for collaboration and simultaneously create adversarial contractual relationships. To escape the whirlpool, we have to win together.
Multi-Neighbourhood Provider Contracts
The MNP contracts are both a potential strength and a real risk. To make this role work, these organisations need genuine agency, power, and funding they can allocate themselves. The danger is that they end up caught in the crossfire between primary and secondary care, the NHS and councils, patient need and NHS targets, given all the responsibility and none of the power.
Equally significant is the fact that these organisations largely don’t exist yet. The system will have to make very hard choices about what to sacrifice in order to create them. Under-resourcing these foundations would be a critical mistake. MNPs are the engines of Neighbourhood Health, and engines need power to function.
“Don’t tell me where your priorities are. Show me where you spend your money, and I’ll tell you what they are.”
James W. Frick
Funding of Neighbourhood Health
There is no new funding for Neighbourhood Health. There is a compelling argument that the NHS has been better funded since Covid and failed to move the dial on population health metrics is not wrong, but the money is already fully committed. We do absolutely need to move the funding to areas that will have a bigger impact on population outcomes. But moving it requires closing hospital services and cutting staff, decisions that are politically almost impossible. The drag on the existing system in redirecting funding to Neighbourhood Health will be enormous, and as we have seen with ICBs, restructuring costs money and takes time before any savings materialise.
The Funding Gap Will Increase Inequalities
This deserves to be said plainly. In 2024/25, 69% of acute trusts (82 organisations) were in deficit, and acute trusts account for 75% of all trust spending. (Kings Fund) Without additional funding, areas with significant deficits have almost no capacity to start building neighbourhoods. Areas with a surplus can race ahead. This is not just grossly unfair; it is politically unsustainable. It will widen the postcode lottery and, in all likelihood, deepen health inequalities.
Staffing of Neighbourhood Health
A recent UCL’s Health of the Health System Index concluded that workforce pressure is the defining constraint on system health. The Framework acknowledges, somewhat grudgingly, that some new staff may be needed, but it is clear that most will have to come from existing organisations. This is a serious problem. Moving staff will make many organisations’ existing pressures worse, not better.
Consider the scale: each hospital serves, on average, 10 neighbourhoods. Instead of one clinic in one hospital, the same staff may now need to operate across 10 different locations, with all the travel, logistics, equipment and support that entails. Many of the most skilled and specialised staff will not want, or be able, to do that. In rural areas especially, the practicalities of staffing may turn out to be the single biggest barrier to delivery. This cannot be left as a problem to solve later or at the end of the process. Neighbourhood Health may have to pull people out of the whirlpool to move forward, and that may be the hardest challenge of all.
The Whirlpool Within The Neighbourhood Health Framework
The Implementation Plan
The next steps section of the Framework is, frankly, rubbish. From April this year, a further year of planning begins. Then from April 2027 to March 2029, the plan is to spend two more years “confirming plans.” That is five years of planning, with very little commitment to actually doing anything. The fact is that the bigger plans are the less likely they are to work. (HBR)
“Everyone has a plan until they get punched in the face”
Mike Tyson
We have known about the shift to neighbourhoods since before the last election. An entire year was supposed to be spent planning for implementation this April. Instead, we get more planning. This is bureaucracy in full flow: don’t act unless it has been quadruple-checked and approved. It feels like an attempt to defer the staffing and funding challenges rather than confront them. But the challenge is now. The future of the NHS is at risk now. Some planning is necessary, but it must be necessary and sufficient. Endless approval processes will kill momentum, and if momentum dies, the whirlpool wins. When we spend too much time planning or making them too big the more that science is against us.
Neighbourhood Health Risks Becoming a Bureaucratic Swamp
Take a step back and consider what this Framework actually creates: Neighbourhood Health layered on top of all existing provider contracts and processes, with national goals, local goals, outcomes commissioning, population targeting, IHO, MNP and SNP contracts, sub-contracts, digital contracts, new pathways for frailty and elective care, all with no new funding and limited staff.
Each of those layers will generate new data collection, reporting requirements, data sharing agreements, performance management processes and governance structures, before a single piece of care is delivered differently. Nearly a third of NHS staff already report feeling burnt out, and two thirds say staffing levels prevent them from doing their jobs properly (NHS Staff Survey). It is very hard to see how people will find the capacity for all of this.
Integrated Health Organisations
The IHO model risks becoming “One Hospital to Rule Them All.” The incentives for a Trust to seek IHO status, such as financial control, strategic dominance and organisational security, are precisely the dynamics the Framework is trying to reduce. Concentrating funding and decision-making power in a single organisation creates a deep structural bias in the system that will be very difficult to reverse. And the NHS has committed to scaling this model everywhere, before there is any evidence it works. Whatever integrity individual IHOs might demonstrate, the structural incentives point in the wrong direction, and those incentives tend to win over time.
That said, there is a potential escape route. Not all Trusts are hospitals; around 35% are community, mental health or ambulance services. There is also potential for SNPs and MNPs to take on a Trust-like role in future. In the right hands, the IHO model could accelerate the shifts rather than undermine them. But the risks are substantial and the benefits uncertain. At the very least, this should be delayed until there is clearer evidence it serves local populations rather than institutional interests.
Escaping the Whirlpool: Finding a New Path With The Neighbourhood Health Framework
The Whirlpool Is Our Own Creation
More often than not, the whirlpool is something we have created ourselves. It is the default state of our healthcare system, the embodiment of how we think about the NHS. When most people picture the NHS, they picture a hospital. It is, in practice, the National Hospital Service. To change the system, we first have to change that mental model. Few people know what a neighbourhood health service is, but everyone knows what a hospital is. When people feel threatened or confused, they retreat to what they know. To escape the whirlpool, we need to help as many people as possible think and feel differently about what the NHS can be.
To Go Faster, We Have to Go Slower
With so much change happening at once, trying to do everything simultaneously is full of risk. Overwhelmed people default to old habits. We need to start with practice: get things working well on the ground, build confidence in what works, then develop the infrastructure to support and scale it. This means being genuinely pragmatic, focusing on what matters most to staff and patients, and letting go of the organisational Game of Thrones. Build momentum in the things that are moving, and don’t let the things that aren’t moving consume all your energy.
Neighbourhood Health Needs to Be the Lighthouse
The reason hospitals and bureaucracies tend to win is that they offer a familiar sense of safety and security. To counter that, we need to show that neighbourhoods work, not somewhere abstract, but somewhere local and visible, where people can see and experience it for themselves. We need to create stability, guide people through the changes, and above all, make clear why the changes matter. If we want Neighbourhood Health to arrive, we need to be the lighthouse in the storm.
Point Your Boats in the Right Direction
It sounds obvious, but we often don’t do it. Our targets and goals too frequently point back toward the system, hospital admissions for instance, rather than toward what we’re actually trying to achieve: keeping people healthy. It’s a subtle reframe, but it profoundly shapes what we pay attention to and what we do. Without vigilance, contracts, reports and requirements will quietly turn our boats back toward the whirlpool before we’ve noticed.
Keep Your Load Light
There is always a drive in healthcare to over-engineer everything. But if we want to move fast, we need to think with agility, focusing only on what is needed right now and building up over time. Hire a room for a short period rather than setting up full clinics with rotas, IT systems and contracts from day one. The lighter we are at the start, the harder it is for the system to say no.
Work as a Multi-Disciplinary Team
The advantage of working across organisations is that each brings something different to the table. If you have a gap, find someone who can help fill it. A diverse group of people has far more collective capability than any single organisation. But that only works if we genuinely appreciate what others bring and pull toward shared goals. If everyone is pulling in different directions, the whirlpool will always win.
Momentum of Change Matters
The whirlpool is powerful, but it is slow and demoralising. It acts as an energy vampire, constantly creating new requirements and obstacles, draining the life from change. To keep moving forward, you need to keep the people around you inspired and motivated. Look constantly for new allies, new approaches, new ways forward. Rather than one big project waiting for permission, run ten smaller ones. Put your energy into the things that are moving fastest. Don’t let the things that aren’t working pull you backwards.
Conclusion: The Moment Is Now
The NHS Neighbourhood Health Framework represents both a genuine opportunity and a familiar danger. The opportunity is real: a clear direction of travel, a growing consensus that the current system is unsustainable, and communities across the country ready and willing to be part of something different. The danger is equally real, that this becomes yet another well-intentioned document consumed by the very whirlpool it was designed to escape.
The history of NHS reform is littered with bold ambitions that quietly dissolved under the weight of daily pressures, bureaucratic inertia, and the gravitational pull of hospital-centred thinking. There is no reason to believe this time will be different, unless we make it different.
That means resisting the temptation to plan endlessly before acting. It means giving Multi-Neighbourhood Providers genuine power, not just responsibility. It means measuring what matters to people, not what is convenient to count. It means funding the foundations, not just the ambition. And above all, it means building momentum now, in real places, with real people, before the whirlpool reasserts itself.
Neighbourhood Health will not be won in a policy document or a boardroom. It will be won street by street, surgery by surgery, in the small victories that show people a different kind of NHS is possible. One that comes to them, knows them, and keeps them well.
The lighthouse cannot guide anyone if it is never lit. It is time to light it.
Learn More At The Neighbourhood Health Academy
One of the biggest challenges is that everyone sees something We are holding a meeting of the Neighbourhood Health Academy to discuss different perspectives on the Neighbourhood Health Framework and how to navigated the tension and put it into practice.
Sign up the Neighbourhood Health Academy Here: www.NeighbourhoodHealthAcademy.org.
