Delivering the system’s core objective: the left shift

Moving the money to earlier, more cost-effective interventions should improve allocative efficiency, boosting productivity to help address the NHS financial challenges (alongside ongoing efforts to improve technical efficiency). This will require “hardwiring of financial flows”

through three levers:

 

1. Payment mechanisms: A payment mechanism – adopted in the NHS Payment Scheme from April 2026 – which incentivises earlier, proactive intervention. This is likely either an outcome-based contract or capitated contract, where providers keep any savings from allocative efficiency. 
2. Gain/loss share mechanism: All providers along a care pathway must have an aligned financial incentive to deliver care earlier and avoid downstream admissions, ensuring acute providers are not financially penalised for doing so. This will likely be through a lead/integrated care provider or partnership, which sub-contracts services. 
3. Measurement: If the objective is to move money into primary and community-based care, we must know whether it is being achieved. This will require a metric which is monitored locally and nationally and enables intervention when necessary. 

 

Rather than promoting one delivery model, the centre should create strong incentives for systems and providers to develop a credible collaboration and accountability model that suits their local legacy and assets. The centre should require business plans and medium-term financial plans backed up by clinical plans defining care transformation (in particular around elective care). Monitoring progress in delivering the left shift will allow the efficacy of different models to be assessed and, if necessary, adapted.
 

Different delivery models

Integration and transformation are being delivered differently across systems. As each ICS is different, enforcement of a uniform approach to delivering the left shift would not work and risks creating unnecessary expense, significant disruption and delaying delivery. To deliver reform, practical, responsive and inclusive governance arrangements are needed to solidify partnership working as the expected standard at the heart of commissioning and delivering quality care. 

Clinical leadership will be key to delivering transformation, as will building consensus between clinical and managerial staff. Appropriate local arrangements should evolve from a robust understanding of system context and commitment to shared principles, generating a partnership structure that is greater than the sum of its parts and maximises the strengths of each unique organisation or contributor. There is a precedent for different approaches to this, as outlined below.

The focus of any delivery model should be on delivering a person-centered and outcome-focused approach. Local leaders should be empowered to elevate where things are best delivered at scale and held accountable for the outcomes they achieve – not for developing a particular structure. 

Within every model, partnership at place level – at a population size of around 250,000-500,000 – will be critical to moving towards more integrated, person-centred care and optimising the use of collective resources. Since the integration white paper and Thriving Places guidance, place partnerships have been the expected delivery model in England. [26],[27] Systems such as Cambridgeshire and Peterborough have a vertical model in which the ICB contracts with each place, potentially delegating commissioning responsibilities and/or financial allocations and a provider or provider collaborative is usually the designated ‘lead’ for integrating care. Leeds is another example of a place-based approach, where budgets are pooled across NHS bodies and local authorities. At this more local geography, commissioning can be integrated with co-terminous local authorities and proactive care can be planned around populations.

In other systems, particularly smaller systems such as Gloucestershire, where there are just two providers, there is a distributed model of leadership. This model may become less common with ICSs becoming larger and fewer in number. [28]

In other systems, the budget is delegated to a lead provider which then sub-commissions services to be delivered at place or neighbourhood level. For example, in Birmingham and Northumbria, a provider is designated to lead the commissioning of services, with delivery devolved to local neighbourhoods. In other systems, like Hertfordshire and West Essex ICS, the primary care at-scale provider is the lead provider of an integrated urgent treatment centre, which they deliver as part of a collaborative with other community, acute and out-of-hospital providers.

These provider collaborative or lead provider models may form the basis of an accountable care organisation (ACO) type approach – a provider with delegated responsibility for improving the health of a particular population cohort and planning the most cost-effective care interventions to that end. Through sub-contracting services, this approach ensures multiple providers across a care pathway have aligned incentives, sharing financial benefit from better managing demand and preventing more costly downstream interventions.  

ACOs have precedence in other countries, including Spain, Germany and the USA, and despite proposing the idea in 2014, the Health and Care Act 2022 effectively moved England towards accountable care systems in the form of ICBs. [29]

However, the current approach does not align incentives across providers. The latest NHS operational planning guidance signaled a move towards lead providers being given responsibility for planning and transformation of local services for a defined population cohort, stepping in the ACO direction. [30] This would require devolving knowledge and skills to provider organisations. NHS England indicated that this may extend to delivering strategic commissioning directly (through delegation arrangements and provider collaboratives), but that an accountable care model would only be explored in the most mature systems. [31] It is therefore a delivery model that is unlikely to take precedence for at least a decade. 

The below model illustrates three emerging ‘delivery models’ for achieving the left shift through place-based collaboration. These are archetypes which are presented to offer clarity. They and not mutually exclusive (for example, place could effectively be a lead provider) and are not intended as a definitive description of the future direction of travel.