NHS Alliance response to proposed multi-neighbourhood provider and single neighbourhood provider contracting models

This document provides an overview on the NHS Alliance’s (NHSA) response to the consultation on proposed multi-neighbourhood provider (MNP) and single neighbourhood provider (SNP) contracting models to support neighbourhood health services.

For questions relating to our response, please contact Jack Sansum.

The NHS Alliance welcomes the opportunity to respond to the proposed contracting models to support implementation of neighbourhood health. Our response is informed by engagement across our whole membership and provides: 

•    an overview of our position
•    responses under each of consultation theme
•    a summary of areas that require further clarification 
•    A summary of the views of each of our member networks.

• We strongly support the ambition of a neighbourhood health service and the shift towards integrated, preventative and community-based care and population health contracting.
• However, from all sections of our membership, there has been a consistent theme that, where neighbourhood health is already being commissioned and delivered, there needs to be greater clarity as to the added value these contracts will bring. Our members see value in a clear theory of change being published alongside an implementation roadmap before contracts are rolled out at scale.
• There is strong support for local flexibility in how neighbourhood arrangements are implemented, recognising the considerable variation in maturity, geography, provider landscapes and existing partnership arrangements across England.
• National guidance should provide sufficient clarity and consistency while allowing systems and neighbourhoods the flexibility to adapt contractual models to local circumstances and relationships. Our members’ feedback reflects a desire for greater clarity on the expectations and flexibilities within which local leaders are empowered, rather than a request for a prescribed model.
• MNP arrangements attract broad support where they coordinate partners, build on and consolidate existing arrangements and enable place-based delivery. Lead provider models may be appropriate in some circumstances but need proportionate safeguards and a clear commitment to system partnership.
• Further clarity is needed on the proposed SNP arrangements. This includes the relationship between the SNP, primary care networks and the PCN Direct Enhanced Service (DES), as well as subcontracting and accountability within MNP arrangements, and how to avoid fragmentation of care. There is potential for the SNP to build on existing partnerships and pathways, create a multi-year contracting vehicle and promote shared accountability for population outcomes across partners.
• The proposals must simplify commissioning, contracting and accountability, avoiding additional layers of governance, assurance and procurement burdens.
• Successful implementation of the contracts will require a managed period of transition that reflects the different starting points. Support will be needed in areas including workforce planning and design, organisational development and interoperable datasets. Whole-system collaboration is also critical, with local government, social care, VCSE organisations and communities as key partners. 

Feedback from across our membership is clear that neighbourhood health will not be delivered by contractual mechanisms alone. Contracts are enablers of neighbourhood working, not the primary driver of change. 

We therefore believe that decisions on whether, and how, to implement SNP/MNP contracting arrangements should be assessed against a set of core tests. These apply both in further development of the SNP/MNP contracts and through implementation:

Will the contracts:

• Improve outcomes, experience and access for local people and communities?
• Strengthen relationships and collaboration across neighbourhood and place-based partnerships?
• Support prevention and earlier intervention, and reduce health inequalities?
• Enable resources, decision-making and accountability to move closer to communities?
• Simplify commissioning, governance and accountability arrangements rather than adding complexity?
• Protect and build on successful local partnerships while allowing flexibility for different local contexts?

1. The strategic purpose of neighbourhood contracting

We support neighbourhood contracts where they solve a clearly defined local problem and deliver demonstrable additional value for patients, communities and partners. 

Neighbourhood contracts should not be viewed as an end in themselves. Decisions on whether to adopt MNP or SNP arrangements should be driven locally by a clear understanding of the problem they are intended to solve, the additional value they are expected to create, and why existing arrangements are insufficient to achieve the desired outcomes.

Reflecting on both the proposals and the wider direction of policy, our members are of the view that the MNP and SNP contracts would be strengthened by a clearer theory of change setting out how contractual reform (and the shift to population health contracting models) will improve outcomes, accelerate integration and support a shift in resources towards prevention and community-based care. 

A clearer articulation of the intended benefits is also necessary to determine how the success of MNP and SNP arrangements should ultimately be assessed. Contracts should be viewed as enablers of neighbourhood working rather than the primary driver of change. While effective contract management will remain important, our members have been clear that, as reflected in our core tests, success should ultimately be assessed against a focused outcomes framework that measures improvements in population health, reduction in inequalities, progress on prevention and the strength of cross-system collaboration.

There is broad agreement across our members that the NHS Standard Contract, with a planned ‘Neighbourhood Schedule’, is a pragmatic basis for MNP arrangements: an established and well tested framework that can consolidate existing arrangements. But the Schedule must remain proportionate and must not become a nationally prescribed model.

We suggest referring to a Neighbourhood Schedule rather than an MNP Contract throughout the final guidance where the intent is to supplement the existing NHS Standard Contract rather than create a separate contractual vehicle. This would better reflect the proposed architecture, reduce potential confusion for commissioners and providers, and reinforce the principle that neighbourhood working should build on, rather than replace, established contractual frameworks.

Similarly, referring to the SNP as a Single Neighbourhood Contract more accurately reflects its purpose as opposed to a new organisational form.

2.  Local flexibility and contract design 

We support the direction of policy travel for a neighbourhood health service, as set out in the Neighbourhood Health Framework, Towards Population Health Delivery Models, Neighbourhood Health Centre Guidance, and the recently published Rewiring the State.

We have been consistent in our messaging: national policy should define minimum expectations, safeguards and outcomes; commissioners should determine footprints, delivery models and pace. The diversity of local contexts, existing partnerships and levels of neighbourhood maturity means that a single national model will not be appropriate or effective in all areas, nor will there be the same level of MNP contracting in each system.

Our members recognise that many of the questions that have been raised in our response are not solely matters for national policy. While national guidance has a role in defining the overall framework, many of the detailed decisions regarding governance, accountability, partnership arrangements and delivery models will need to be agreed locally between commissioners, providers and wider partners.

Different areas will want to retain the flexibility to develop arrangements that are most appropriate for their circumstances. We currently see the widest immediate potential in the MNP Coordination Model (Option 1), that enables existing contracts to stay in place where they are fit for purpose and reflect new models of care. This approach is most consistent with the principle that contractual reform should build on existing strengths rather than requiring structural change that may not be necessary.

Lead provider arrangements may be advantageous in some circumstances, particularly where there is a clear local rationale and strong provider relationships. Such arrangements will require transparent governance, appropriate risk allocation and protection against single provider dominance. 

SNP arrangements require further consideration. They should only proceed where there is a clear local case for change, sufficient support from general practice and an agreed relationship with wider neighbourhood partners. If the proposed arrangements proceed there remains confusion as to the relationship between the PCN DES (and its subsequent variation) and the SNP contract, as well as the future of PCNs and the impact on other primary care contracts, such as GMS and community pharmacy. There is concern that in the transition to an SNP contract, this could lead to sustainability issues within general practice. 

3. Partnership, integration and neighbourhood leadership 

Neighbourhood health must be broader than the NHS, with partnership working at its core – bringing together the NHS, local government, social care, VCSE organisations and local communities around shared outcomes. Neighbourhood arrangements should therefore strengthen partnership working rather than create NHS-led structures that operate separately from existing place-based partnerships. 

Contract holders should be expected to demonstrate behaviours that support effective partnership working, including shared decision-making, transparent resource allocation, community participation and meaningful involvement for local government, social care, wider primary care and VCSE partners. Community voices should in turn shape priorities, governance and evaluation and not be confined to consultation after decisions are taken. 

The success of neighbourhood arrangements is likely to depend as much on leadership and relationships as on contractual mechanisms. Neighbourhood leadership should be collective rather than organisational, bringing together partners around shared outcomes while avoiding the concentration of power or accountability within a single institution.

We have developed a set of behaviours and ways of working for local partners to consider as they develop neighbourhood models:

• Coordination and subsidiarity – the MNP contract holder exists to make the neighbourhood system work and devolves decisions, resource and delivery to the most local level that can hold them.
• Fair and equitable treatment of partners – all partners should be involved in design. This includes a fair approach with sub-contractors and not favouring the MNP holder’s own organisational interests.
• Transparent and accountable – the MNP contract holder should be accountable to the commissioner and regulators for delivery of contractual obligations, with governance arrangements that support transparency and effective partnership working. Data, population intelligence and resource flows should be shared openly across partners, with proportionate mechanisms for collaboration and dispute resolution. Accountability for the contract should be clear and aligned to the partnership model adopted. While responsibility for improving population outcomes should be shared across the neighbourhood partnership, governance arrangements must clearly define who is accountable, to whom, and for which aspects of delivery, performance, and statutory responsibility.
• Resource follows responsibility – and supports the frontline. However, as part of the transition to a neighbourhood health service, the new contracting arrangements should not destabilise current provision and access to care. 
• Organise around population – the focus should be to a defined population and a set of outcomes (prevention, integration, reducing inequalities), rather than to institutional boundaries or activity. Invest in trust and shared decision-making and embedding community and patient voice in priority-setting, governance and evaluation.
• Proportionality, local adaptation and continuous learning – working in a test-and-learn way, adapting to local maturity, and supporting less mature neighbourhoods to develop.

The MNP has the opportunity to coordinate rather than displace existing place-based structures. It should strengthen collaboration and accountability at neighbourhood level while building on established place-based structures and relationships. NHS England should provide clarity through the second phase of the consultation on the respective roles of place-based partnerships and provider collaboratives, so that duplication or conflicting accountabilities are avoided. Where existing governance arrangements are effective, the MNP should operate through them rather than create additional standalone structures.

There is also a need to provide clarity on the relationship between the MNP and SNP arrangements and emerging integrated health organisation contracts (IHOs). In particular, members would benefit from a clearer explanation of the distinct purpose of each model, how they are intended to interact, and the respective responsibilities they will hold within the wider neighbourhood health architecture.

4.  Governance, accountability and risk 

Our members are clear that MNP and SNP arrangements should be underpinned by clear governance and accountability frameworks while avoiding unnecessary prescription or administrative burden. Governance arrangements should support collaboration, transparency and shared ownership of outcomes rather than creating additional layers of oversight. National policy should set minimum expectations and safeguards, with local partnerships determining how these are incorporated into existing governance arrangements.

At a minimum, arrangements should provide clarity on accountability for delivery and outcomes within the contractual scope, decision-making responsibilities, the management of conflicts of interest, transparent resource allocation, risk and reward sharing, dispute resolution and processes for entry, exit and failure. 

Members are keen that the Provider Selection Regime (PSR) does not disrupt existing collaborations or destabilise mature partnerships. NHS England should provide greater clarity on when competitive processes are necessary, and to what extent valuable existing partnerships and collaboration will be taken into account.

Contractual arrangements should provide sufficient stability to support workforce planning, service transformation and the development of partnership working. Contract duration should therefore be sufficient to enable workforce investment, trust and transformation, with proportionate review points rather than recurrent bidding. 

5. Implementation, capacity and enablers for success

The successful implementation of neighbourhood contracting arrangements will depend as much on capability, capacity and support as on the contractual mechanisms themselves. 

Smaller providers and VCSE organisations face material barriers, including limited bidding capacity, legal costs, cash flow, liability exposure and disproportionate assurance requirements.

Commissioners should be supported to use accessible processes, consortium and alliance approaches, proportionate thresholds and prompt-payment arrangements. 

Implementation should be phased, with providers and commissioners supported to have the capacity and capability required for success. Enablers for broader neighbourhood transformation include programme and change capacity, organisational development, legal and contracting support, workforce transition arrangements, digital interoperability, data-sharing infrastructure and analytical capability. Data expectations at this stage should be realistic and should enable improvement without excluding smaller partners. 

At the same time, areas with mature arrangements already in place should be given the flexibility to continue developing existing approaches to neighbourhood working, without being required to adopt a new contractual model where it does not add demonstrable value. 

The consultation has highlighted several areas where further clarity, detail and assurance will be required before neighbourhood contracting arrangements can be implemented with confidence. Across our membership, these issues were consistently identified as critical to successful implementation and achieving the intended benefits of neighbourhood health.

1. The purpose and added value of neighbourhood contracts

Members are seeking a clearer articulation of the purpose of neighbourhood contracts and the role they are intended to play in delivering neighbourhood health. In particular, there is need for greater clarity on:

• The theory of change underpinning these models, including how they are expected to accelerate progress towards neighbourhood health and improve outcomes for patients and communities.
• The additional value they will provide compared with existing neighbourhood and place-based approaches, particularly in areas that have already established strong collaborative models.
• Whether neighbourhood contracts are intended primarily as a mechanism to accelerate development in areas where neighbourhood arrangements are less mature, and how implementation will avoid disrupting or slowing progress in areas where mature arrangements are already delivering benefits.
• How the contracting approach will reduce complexity and enable more integrated working, rather than creating additional layers of governance, administration or uncertainty for providers and commissioners.

2. Relationship between neighbourhoods, place and systems

The strongest theme across networks was the need for greater clarity on how these arrangements fit within the wider operating model and what the intended end state looks like. 

Key questions remain about:

• How SNPs, MNPs and emerging IHO contracts are intended to work together. With IHO contracts still under development, the future relationship between these models remains unclear.
• How new contractual arrangements will integrate with existing governance and decision-making structures without creating duplication or conflicting accountabilities.
• The future of PCNs and the PCN DES in the context of an SNP contract.
• The involvement of wider primary care – community pharmacy, dentistry, optometry and audiology – which has an important role in neighbourhood health.

3. Governance, accountability and risk

Members consistently raised concerns regarding:

• How accountability will be distributed between commissioners, providers and the organisations holding and delivering MNP and SNP contracts, and where ultimate responsibility will sit for service delivery, performance and outcomes.
• How financial, operational and performance risks will be shared between contract partners, including how organisations will be protected from risks that sit outside their direct control.
• How success will be measured, what performance expectations providers will be held to, and how neighbourhood-level oversight will align with existing assurance and regulatory arrangements.
• Whether contracts will be of sufficient duration to support long-term investment, transformation and partnership development, while providing stability in a changing policy environment.
• How contractual disputes, underperformance or partner withdrawal will be managed, including the arrangements for failure, exit and maintaining continuity of care. 

4. Resources, workforce and infrastructure

A consistent concern was whether the resources, workforce and infrastructure required to support neighbourhood working will be in place. Members highlighted the risk that additional responsibilities could be transferred to neighbourhood partnerships and providers without the investment needed to deliver them effectively.

Key questions include:

• How organisations will be supported to manage the transition to new contractual and delivery models, including programme management capacity, organisational development, workforce, legal expertise and change management resource.
• How digital interoperability and data sharing will enable integrated working across neighbourhood partners.
• What implementation and transformation capacity will be available to support contract design, implementation and ongoing delivery, in the context of ongoing workforce reductions.

5. Procurement and partnership working

Members raised concerns about the potential unintended consequences of procurement processes. Clarification is required on:

• How the Provider Selection Regime will apply to SNP and MNP contracts.
• In what circumstances competitive procurement processes will be required.
• How existing neighbourhood and place-based partnerships will be protected from disruption.
• How procurement requirements will support, rather than hinder, the development of long-term relationships between partners.
• How smaller providers, VCSE organisations and primary care partners will be able to participate on an equitable basis.
• How contracting arrangements will avoid creating barriers to innovation, collaboration and local flexibility.

6. Maintaining a cross-sector model

Members consistently emphasised that neighbourhood health must remain a genuinely cross-sector endeavour rather than becoming NHS-led or NHS-centric. Further clarity is needed on:

• What role local government, social care and other public services will play within neighbourhood arrangements.
• How housing, employment and wider determinants of health will be reflected in neighbourhood delivery models.
• How VCSE organisations will be involved in decision-making, service delivery and leadership arrangements.
• How community voices will shape neighbourhood priorities, governance and accountability.
• How neighbourhood contracts will encourage collaboration across sectors rather than reinforcing organisational silos.
• How success will be measured in a way that reflects shared outcomes across partners, rather than NHS performance metrics alone.

1. Publish a clear theory of change and implementation roadmap before contracts are rolled out at scale.
2. Establish common national principles, outcomes and minimum safeguards, while enabling local determination of geography, governance, service model and pace of implementation.
3. Position the MNP (neighbourhood) Schedule initially as coordinating and enabling mechanisms that build on existing partnerships. Lead provider models may be appropriate in some circumstances but need proportionate safeguards and a clear commitment to system partnership.
4. Clarify the purpose and relationship between SNPs, PCNs and MNPs before implementation.
5. Provide practical implementation support, including workforce, organisational development, legal, digital and data capability.
6. Clarify Provider Selection Regime application and establish proportionate routes for primary care, VCSE and smaller providers.
7. Require meaningful involvement of communities and cross-sector partners in governance, decision-making, priority-setting, resource allocation and evaluation.
8. Ensure there is ongoing review and continuous improvement of new contractual models to ensure that they are meeting the needs of patients. 

ICB Network

ICB leaders view neighbourhood contracts as a potentially valuable mechanism for strengthening strategic commissioning and delivering integrated neighbourhood services. However, they require assurance that the proposals will simplify rather than increase commissioning, procurement and accountability complexity.

Key messages 

• MNPs could strengthen strategic commissioning, particularly where they support integrated, outcomes-focused delivery at place level. Most ICB leaders would aim for a single MNP covering each place, using the MNP option to commission neighbourhood services at scale. However, the form and role of that MNP should reflect local circumstances and should not automatically require consolidation of existing provider arrangements.
• Greater clarity is needed on how neighbourhood contracts fit within wider system reforms, including IHOs, advanced foundation trusts, place partnerships and local government reform.
• The Provider Selection Regime represents the most significant concern, with uncertainty around procurement routes, accountability and provider challenge.
• Contracts alone will not deliver neighbourhood health, with shared outcomes, data sharing and partnership development is equally important.

Implementation capacity within systems is constrained, requiring a phased and supported approach.

What ICB leaders are asking for 

• Clear guidance on PSR and procurement arrangements, including a central risk assessment developed with ICBs.
• National clarity on how neighbourhood contracts align with wider reforms.
• Proportionate governance and accountability frameworks.
• Phased implementation supported by national development support.  

Primary Care Network  

Primary care leaders strongly support neighbourhood working but emphasise that successful delivery depends on protecting the sustainability of general practice, providing certainty regarding PCNs and ensuring wider primary care are fully involved.

Key messages 

• Neighbourhood health should involve the whole of primary care, including community pharmacy, dentistry and optometry alongside general practice.
• Any new responsibilities must be matched by resource, workforce and infrastructure support.
• Greater clarity is required on the future role of PCNs, PCN DES (and its subsequent variation) and the relationship with the SNP contract.
• Any changes to the roles of PCNs should be developed with general practice and wider primary care.
• GP at-scale providers should be given equal consideration to other eligible providers to hold MNP contracts.
• Neighbourhood geographies should reflect population need rather than organisational boundaries alone.

What primary care leaders are asking for 

• Clarity on the future of PCNs and the DES.
• Protection of core general practice sustainability.
• Equal involvement of wider primary care partners (community pharmacy, dentistry, optometry and audiology) as well as public health, local government and VCSE partners.
• Resource transfer alongside service transfer.
• Assurance that GP providers will be treated equally when awarding MNP contracts (schedule).
• Approval that the MNP contract holder should follow a similar process to the National Neighbourhood Health Implementation Programme application process, requiring agreement by all chief executives (or equivalent) and PCN clinical directors in each constituent organisation in a place.

Acute and Ambulance Network

Acute and ambulance leaders are broadly supportive of neighbourhood contracting approaches where they build on existing NHS arrangements, maintain local flexibility and support stronger integration across providers.

Key messages 

• The NHS Standard Contract should remain the primary starting point for implementation. Existing partnerships should form the foundation for neighbourhood delivery.
• National guidance should be permissive rather than prescriptive, allowing systems to determine local models.
• Governance and accountability arrangements require greater clarity, particularly regarding MNP-SNP relationships and financial risk.
• Contracts alone will not deliver neighbourhood health without investment in community alternatives and prevention.

What acute and ambulance leaders are asking for 

• Retain flexibility through multiple delivery models, given mixed views on the lead provider model and concern it could be seen as organisational takeover.
• Clarify governance and procurement requirements.
• Support participation from smaller and VCSE providers.
• Invest in community-based alternatives to hospital care.   

Mental Health Network 

Mental health providers support the ambitions of neighbourhood health but are cautious about contractual changes that could weaken existing provider collaboratives, diminish mental health investment or separate mental and physical health pathways.

Key messages 

• Mental health must be embedded within whole-person neighbourhood care.
• Provider collaboratives and mature partnerships should be protected and built upon.
• Mental health investment requires explicit safeguards (equivalent to the Mental Health Investment Standard) and transparent funding arrangements, with clear monitoring of outcomes for people with severe mental illness.
• Neighbourhood health must address wider determinants of health, including housing, social care and community support.
• Procurement processes should not favour organisational scale over expertise, relationships and local credibility.

What mental health leaders are asking for

• Mental health providers recognised as core neighbourhood partners.
• Protection of mental health funding and specialist pathways.
• Support for provider collaboratives and established partnerships.
• Greater clarity on governance, accountability and PSR implications. 
   

Community Network

Community providers broadly support the proposals and see neighbourhood contracts as potentially useful mechanisms for enabling collaboration and integration. However, they emphasise that contractual reform must support, not replace, neighbourhood transformation.

Key messages 

• Contracts should enable transformation rather than become the focus of transformation. Local flexibility is essential to reflect different populations, geographies and partnership arrangements.
• Neighbourhood models should actively support the shift of care, resource and decision-making into communities.
• Governance arrangements should be clear but proportionate.
• VCSE organisations, children and young people, and underserved communities must remain central to neighbourhood delivery. 

 What community providers are asking for 

• A locally permissive implementation framework. 
• Meaningful resource transfer into community services. 
• Protection of existing partnerships and neighbourhood arrangements.
• Proportionate governance and procurement requirements.