One year on: Moving care closer to home means giving local systems the space to deliver

What has changed over the past year is the level of national commitment behind that ambition. The language of neighbourhood health now runs through almost every major policy document, with community-based care increasingly positioned as central to improving outcomes, reducing pressure in hospitals and delivering a more sustainable NHS.

This is without a doubt an increasingly positive direction of travel. Now, one year on, the conversation needs to move beyond why we should shift care into communities and focus instead on how we create the conditions for local systems to make it happen.

There have been encouraging examples of progress, with some services that were once firmly rooted in hospital settings beginning to move into primary and community care. Dermatology, including Teledermatology, as an example, has expanded significantly, allowing many patients to receive specialist advice without attending hospital, while similar approaches are now being developed across areas such as ophthalmology.

These changes demonstrate what is possible when clinical innovation, local leadership and digital capability come together. However, scaling this kind of transformation remains far harder than designing it.

For many integrated care boards, the past year has also been dominated by the imminent abolition of NHS England – alongside significant restructuring within ICBs themselves – inevitably absorbing leadership time and organisational capacity. At the same time, systems are expected to continue managing intense operational pressures, financial constraints and aspirational national performance expectations around elective care waiting lists and emergency care.

There is also a challenge around consistency. While neighbourhood health is now a common feature across national policy, different programmes often describe it in different ways. Whether considering cancer services, neighbourhood health pilots or wider commissioning guidance, the underlying ambition is broadly shared, but expectations of what neighbourhood delivery should actually look like can vary considerably.

For local systems trying to translate national policy into practical commissioning decisions, that variation can create uncertainty.

Every community faces different challenges. In some places, frailty may rightly become the priority. Elsewhere, reducing demand from high-intensity users of urgent and emergency care, improving mental health support or tackling health inequalities may deliver greater benefit. The strength of neighbourhood working is that it allows local systems to respond to the needs of their own populations.

Looking ahead, three things will be critical if the shift from hospital to community is to accelerate over the remainder of the 10 Year Health Plan.

First, local systems need the freedom to design solutions around their populations rather than deliver a nationally prescribed model. Innovation happens when commissioners, clinicians and communities are able to develop approaches that reflect local need, not simply implement centrally determined programmes. The ICB then has the task of ensuring equitable outcomes for the whole population.

Second, we need dedicated investment to support transformation. Too often, commissioners find themselves balancing the immediate pressures of financial recovery, waiting list targets and urgent care performance against longer-term ambitions for prevention and community services. Without protected funding for neighbourhood transformation, it is difficult to invest in new models of care – even where there is strong evidence they will improve outcomes and reduce demand over time. Whilst for patients, moving services into the community is the right move, the overheads and costs overall will be less costly when delivered on a larger basis, delivering economies of scale.

Finally, success needs to be measured differently. If systems continue to be judged primarily on acute activity and short-term operational performance (ICBs are currently managed on a Performance Oversight Framework based on 1 year only), it will always be harder to justify investment in prevention and community-based services when those benefits emerge over several years. The incentives need to align with the ambitions of the Plan.

One year on, there is little disagreement about the destination, but the delivery of the shift will be defined by whether we give local systems the capacity, flexibility and investment needed to turn that ambition into reality.