Acute, primary and community healthcare

Approximate read time: 25 minutes

The House of Lords is scheduled to debate the following motion on 25 June 2026:

Baroness Janke (Liberal Democrat) to move that this House takes note of the relationship between (1) acute, and (2) primary and community, healthcare services.

1. Background on current health service delivery

Established in 1948, the National Health Service (NHS) seeks to provide a comprehensive health service across the UK, free at the point of delivery and accessible to all based on clinical need rather than the ability to pay.^[1] The system became a primarily devolved area in 1999 and the devolved legislatures have responsibility for organisational control and funding of NHS systems, the provision of health services and the prevention, treatment and alleviation of disease, illness, injury, disability and mental disorder in their respective countries.^[2]

Across the UK a large majority of funding comes from general taxation. The NHS also receives additional funding from sources such as prescription charges, charges for NHS dental treatment and hospital car parking charges.^[3] Different countries in the UK now have different structures for NHS services and have also made different decisions about priorities and sources of income. For example, prescription charges have been abolished in all UK countries apart from England and rates of charges for NHS dental treatment vary by country.

The NHS in England is allocated a specific budget by the UK government, while Scotland, Northern Ireland and Wales receive a general block grant for public spending in all policy areas.

This briefing deals predominantly with the NHS in England where expenditure in 2024/25 was £202.9bn.^[4] Of this figure £191bn was current spending and £11.9bn was capital expenditure.^[5]

1.1 Current structure of the NHS in England

In England, the Department of Health and Social Care (DHSC) is responsible for overall health policy. A non-departmental public body, NHS England, is currently responsible for overseeing the day-to-day running of the NHS in England, including through budgeting, planning and delivering the commissioning of healthcare services. However, the government’s Health Bill currently before Parliament would abolish NHS England and transfer its functions into the DHSC or the wider system.^[6]

Below NHS England there are 42 integrated care systems (ICSs). Established by the Health and Care Act 2022, ICSs are responsible for planning local services to improve health and reduce health inequalities.^[7] They replaced clinical commissioning groups, which were abolished under the 2022 act, and are comprised of two linked bodies:

• an integrated care board (ICB): NHS organisations responsible for controlling most health care resources to improve health and care for their local population, planning local services and commissioning care from providers
• an integrated care partnership (ICP): a looser collaboration of NHS, local government and other agencies, such as housing or social care providers, responsible for developing an ‘integrated care strategy’ to guide local decisions—including the decisions of the ICB^[8]

ICSs vary considerably in size and structure.^[9] In addition, a complex mix of organisations and structures can work below an ICS. For example, within ICSs, services are organised at a more local level through ‘place-based partnerships’, while primary care networks are groups of GP practices. Other NHS service providers and groups of NHS trusts also work closely together in ‘provider collaboratives’ or alliances.^[10]

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England and inspects organisations such as hospitals, community services, dentists, GP services and mental health services.^[11] It also has a statutory duty to assess ICSs.^[12]

The House of Commons Library briefing ‘The structure of the NHS in England’ (10 July 2023) provides more detail about the current organisation of the NHS in England and the way in which it has been reformed since its inception. Another briefing, ‘Health Bill 2026–27’ (27 May 2026), provides information on how the Health Bill will affect health service structures.

1.2 NHS funding and expenditure

The majority of funding for health services in England is transferred from the budget of DHSC to NHS England, with some funding allocated to other DHSC agencies such as the National Institute for Health and Care Excellence and the CQC.^[13]

NHS England allocates most of its budget to ICBs, which then commission healthcare services. NHS England also carries out direct commissioning of certain services such as specialised services, and centrally funds other programmes, such as vaccination services.^[14]

Funding for the providers of NHS healthcare services can be broadly broken down into the following categories:^[15]

• Acute care: provides medical or surgical investigations, diagnosis and treatment for physical illness, condition, injury or disease. Acute healthcare providers can admit patients on a day case basis, including at short notice or in an emergency. In addition, providers can see people on an outpatient basis. Services can include surgical operations, consultations, accident and emergency, maternity and pathology.
• Specialised services: includes treatments such as those provided to patients with rare cancers, genetic disorders or complex medical and surgical conditions. These services are not available in every local hospital because they need to be delivered by specialist teams. In total, there are 150 specialised services covering areas such as renal dialysis and secure mental health services.
• Core mental health services: includes community mental health teams, crisis teams, perinatal care, children and young people’s services, and in-patient units.
• Community services: includes services such as community nursing teams, community palliative care, specialist long-term condition services such as services for people with diabetes, heart failure or neurological conditions, and child health services such as health visiting and school nursing.
• Primary medical care: general practice, dental practices, optometrists and community pharmacies.
• Continuing care: a package of care for people who are assessed as having a ‘primary health need’, that is, ongoing significant physical and/or mental health needs. Support can be at home or in a care home. Assessments of eligibility are made by ICBs.

Table 1 below shows the amount of NHS expenditure on these different categories of healthcare in 2024/25 and compares it, in real-terms 2024/25 prices, to the amount spent in 2015/16.

Table 1. Breakdown of NHS spending (£bn: real-terms 2024/25 prices)

* Prescribing and delegated pharmacy/ophthalmology/primary and secondary dental all sit within the ‘Other’ category.

(House of Commons. ‘Written question: NHS: Finance (117398)’, 25 March 2026)

Spending on acute care in 2024/25 was £74.7bn, approximately 43% of the total spent. This contrasted with £14.5bn on primary care and £13.8bn on community services. While community mental health services only made up around 9% of spending (£15.5bn), it saw the largest percentage increase in real terms with a 58% increase.^[16]

2. Government policy

Successive governments and policymakers have proposed a greater amount of healthcare provision taking place in the community, rather than in acute settings. The King’s Fund notes:

When trying to envision the future of the health and care system in England, the difficult question to answer is not ‘What do we do?’—the vision for care has been outlined by multiple governments in countless policy documents—but ‘How do we actually make it happen?’.^[17]

Reform of the NHS was one of the Labour Party’s five missions “to rebuild Britain”.^[18] In its 2024 general election manifesto, Labour said it would “build an NHS fit for the future that is there when people need it”.^[19] Among the commitments relating to health, the manifesto emphasised care delivered in local communities, dubbed a ‘neighbourhood health service’.^[20] For example, the manifesto made a number of commitments regarding primary care:

We will train thousands more GPs, guarantee a face-to-face appointment for all those who want one and deliver a modern appointment booking system to end the 8am scramble. We will bring back the family doctor by incentivising GPs to see the same patient, so ongoing or complex conditions are dealt with effectively.^[21]

In July 2024, following the general election, Wes Streeting, the then health secretary, commissioned Lord Darzi of Denham, a professor of surgery and former junior health minister, to carry out an independent investigation into the NHS in England. In particular, the review focused on assessing patient access to healthcare, the quality of healthcare being provided and the overall performance of the health system.^[22] The government said, among other purposes, the investigation would “ensure that a new 10 year plan for health focuses on these challenges”.^[23]

In October 2024 the government launched ‘Change NHS’, which it described as “the biggest ever conversation on the future of the NHS”.^[24] This included national surveys, public deliberative events and approximately 2mn visits to the change.nhs.uk website.^[25]

Lord Darzi’s ‘Independent investigation of the National Health Service in England’ was published in September 2024. In a summary letter accompanying the report, he argued that the NHS was “in serious trouble” with public satisfaction at its lowest ever level.^[26] Lord Darzi pointed to high waiting lists for community services and mental health services, people struggling to see their GP and problems with acute care. However, he also argued that the state of the NHS was “not due entirely to what has happened within the health service”. He said “the health of the nation has deteriorated”, with a surge in multiple long-term conditions and increasing mental health needs, and highlighted how this had impacted NHS performance.

Discussing the relationship between acute care and other healthcare providers, Lord Darzi argued that too much money was being spent in hospitals, and too little in the community:

Since at least 2006, and arguably for much longer, successive governments have promised to shift care away from hospitals and into the community. In practice, the reverse has happened. Both hospital expenditure and hospital staffing numbers have grown faster than the other parts of the NHS, while numbers in some of the key out-of-hospital components have declined. Between 2006 and 2022, the share of the NHS budget spent on hospitals increased from 47% to 58%. This distribution is perpetually reinforced: performance standards are focused on hospitals, not on primary care, community services or mental health. Single-year budgets necessarily reinforce the status quo—and when things go wrong the knee-jerk response from ministers has been to throw more money at hospitals where the pressure is most apparent as waiting areas fill up and ambulances queue outside.^[27]

Lord Darzi highlighted several major themes for the 10 year health plan which his report had identified. These included calls to:^[28]

• shift care closer to home and lock in this change “irreversibly” by hardwiring financial flows
• simplify and innovate care delivery for a neighbourhood NHS, including embracing new multidisciplinary models of care that bring together primary, community and mental health services
• tilt towards technology to unlock productivity, particularly for the hundreds of thousands of NHS staff working outside hospitals who need the benefits of digital systems
• reform to make the structure deliver, through more work to clarify roles and accountabilities and ensure the right balance of management resources in different parts of the structure

Responding to the report, Mr Streeting said it showed:

The NHS is broken, but it is not beaten. Together with the 1.5 million people working in the health service, this government will turn our NHS around, get it back on its feet, and make it fit for the future.^[29]

2.1 Fit for the future: 10 year health plan for England

In July 2025, the government published its 10 year health plan entitled ‘Fit for the future: 10 year health plan for England’. It said this would:

Reinvent the NHS through 3 radical shifts—hospital to community, analogue to digital and sickness to prevention. These will be the core components of our new care model.^[30]

The plan stated that the NHS was “hospital-centric, detached from communities and organises its care into multiple, fragmented siloes”. It called for the NHS to shift to provide continuous, accessible and integrated care, stating:

The neighbourhood health service is our alternative. It will bring care into local communities, convene professionals into patient-centred teams and end fragmentation. In doing so, it will revitalise access to general practice and enable hospitals to focus on providing world class specialist care to those who need it […] At its core, the neighbourhood health service will embody our new preventative principle that care should happen as locally as it can: digitally by default, in a patient’s home if possible, in a neighbourhood health centre when needed, in a hospital if necessary.^[31]

The government outlined a number of actions which it said would make this possible, including:^[32]

• shifting the pattern of health spending, with a smaller share of expenditure on hospital care and proportionally greater investment in out-of-hospital care to happen in the next three to four years
• training “thousands more” GPs and building online advice into the NHS app
• ensuring people with complex needs have an agreed care plan by 2027
• increasing the number of people offered a personal health budget, with an aim to make this a universal offer to all who would benefit by 2035
• establishing a neighbourhood health centre in every community, beginning with places where healthy life expectancy is lowest
• increasing the role of community pharmacies in the management of long-term conditions and linking them to the single patient record
• improving access to NHS dentistry, improving children’s oral health and increasing the number of NHS dentists

The plan also included a number of other proposals. For example, an increase in digital services, with an expanded role for the NHS app and a new single patient record. The government said that science and technology would be key to the reinvention of the NHS.^[33] It said “harnessing the digital revolution” would:

• ensure rapid access for those in generally good health
• free up physical access for those with the most complex needs
• help ensure the NHS’s financial sustainability for future generations^[34]

In addition, the plan contained a number of proposals to make structural changes to the NHS, such as decreasing the number of regulators and changing the structure and responsibilities of ICBs.^[35]

2.2 Neighbourhood health framework

On 17 March 2026, the government published the ‘Neighbourhood health framework’ (NHF). The framework details the aims of neighbourhood health and how these will be achieved. It builds upon on the 10 year health plan for England, the ‘Neighbourhood health guidelines 2025/26’ and the ‘Medium term planning framework’.^[36] In the ministerial foreword to the plan, Minister of State for Care Stephen Kinnock commented:

This framework is designed to support ICBs and local authorities, including health and wellbeing boards (HWBs) and their local voluntary, community and social enterprise organisations (VCSEs) and wider system partners to deliver the vision that the 10 year health plan offers, the truly modern service that people, communities and staff are crying out for. As we work together to make neighbourhood health a reality across the country, we will regularly update this framework to reflect the learning from communities up and down the country.^[37]

The NHF reiterated the government’s aims for neighbourhood health, namely:^[38]

• improve people’s health and care outcomes, reduce health inequalities and help them stay well at home
• organise services around the person with more convenient, personalised joined-up care
• reduce pressure on more acute services—including hospitals and care homes
• cut waste and duplication
• help the NHS deliver against core targets

The framework included details of how the success of neighbourhood health would be measured and how it could be delivered. It called on the NHS and local authorities to transform how they work together, and with wider partners, to improve planning and outcomes.^[39] The plan set out immediate changes to be made in the 2026/27 financial year and longer-term reform to happen from April 2027 to March 2029.

In a House of Commons debate on community hospitals, held on 16 June 2026, the government said it planned to “deliver 250 neighbourhood health centres, with 120 of them opening by 2030”. It also said its medium-term planning framework had:

For the first time […] set a target for systems to reduce long waits for community health services. By 2028/29, at least 80% of activity delivered by community health services should take place within 18 weeks, bringing those services in line with targets for elective care.^[40]

3. Reaction to the government’s reforms

3.1 Think tanks, medical bodies and charities

The King’s Fund has previously called for a refocusing of the healthcare system to primary and secondary care in order to make the system “effective and sustainable”. It has said that despite successive governments supporting this aim the “vision is very far from being achieved”.^[41] It proposed several actions to achieve a “wholesale shift”, including:

• clarity that a change of focus aims to deliver improved care and outcomes, rather than deliver short-term cost savings
• aligning policies such as investment, workforce, financial architecture and performance management policies to deliver the vision and a long-term focus^[42]

Senior Fellow at the King’s Fund Anna Charles welcomed the publication of the NHF, arguing “the framework offers welcome clarity on early priorities and avoids an overly NHS centric lens”.^[43] However, she said that “questions remain about the longer-term direction of reform and how the different elements fit together”, noting that the local leaders tasked with delivering neighbourhood health “are overstretched and facing significant disruption through local reorganisations”. Beccy Baird, also a King’s Fund senior fellow, argued that the framework was “dominated by hospital-driven priorities” and as a result “still feels heavily shaped by secondary care performance pressures rather than the realities of delivering primary care at neighbourhood level”.

In 2026 the Health Foundation published research examining the development of integrated care systems.^[44] Based on qualitative research with senior leaders from the NHS, local government and other sectors, it found overall support for the broad goals of the government’s healthcare reforms, including the shift from hospital to community. However, the research reported varied interpretations by respondents of what the changes would mean in practice and major concerns about delivering them.^[45]

Writing for the Health Foundation and commenting on the proposals in the NHF, Nina Hemmings and Dr Luisa Pettigrew argued there was a “a gulf between the state of community services today and the ambitions in the framework”.^[46] The new single and multi-neighbourhood provider contracts and integrated health organisation (IHO) contracts proposed in the NHF could, they said, have “major implications for general practice”, with the potential for IHO contracts to cause a significant loss of autonomy for GPs.^[47]

Sarah Reed and Dr Becks Fisher at the Nuffield Trust described the NHF as an attempt to fill the gap in “credible delivery detail” which was present in the 10 year health plan.^[48] While welcoming the broader rationale about the benefits of neighbourhood delivery, they were critical of what they described as a lack of appreciation for the scale and breadth of ambition landing amid major system disruption, tight finances and limited delivery capacity. They also raised questions about the practicalities of shifting staff into neighbourhood services and queried who would be accountable for different targets and how performance would be measured.

The Nuffield Trust has previously highlighted the growing waiting lists for community care, arguing that introducing a waiting time for community services would increase political focus on the sector.^[49] It also called for a shift in resources, stating that increasing the number of staff working in community areas would be key to achieving a move from hospital care to the community:

The increasing number of people living with long-term conditions together with our ageing population mean that people are more likely to need support from community health services in the coming years. The government intends to shift more care into communities, but some existing community services are struggling to keep up with demand as things stand. Attention must be paid to how to improve access to these services while rolling out new initiatives from the 10 year health plan.^[50]

Commenting on the 10 year health plan for England, the British Medical Association (BMA) stated:

[…] while BMA members do not fundamentally disagree with principles of the ‘three shifts’ [hospital to community, analogue to digital and sickness to prevention], doctors are strongly opposed to much of the content of the plan and its proposed reforms.^[51]

It has said the plan “needs to be thoroughly revised” and failed to address the BMA’s priorities.^[52] The BMA has also commented on proposals in the NHF for the development of IHOs and integrated care organisations. It has raised concerns about the impact of the changes on the partnership model of general practice, claiming that the NHF “fails to fully address or clarify the future of important elements of the existing structure of general practice” and calling for a central role for doctors in the leadership and decision-making structures of any NHS model.^[53]

The Royal College of General Practitioners (RCGP) noted that while the RCGP has “consistently supported” the ambition to deliver more care in communities “many details still need to be worked through to ensure neighbourhood working is safe, sustainable and effective in practice”.^[54] It called for sustained investment in the GP workforce and premises and clear governance and contracting arrangements to reduce rather than add to complexity, duplication and inefficiency across the wider system.^[55]

The Royal College of Nursing called the proposals for a neighbourhood health service in the 10 year health plan in England “a bold vision”. It noted that “moving care away from overcrowded hospitals is urgent and necessary” but argued that “it will prove impossible whilst this part of the healthcare workforce is so depleted and undervalued”.^[56]

The government’s press release launching the 10 year health plan for England contained a number of supportive comments from representatives of several health bodies and charities.^[57] Chief Executive of NHS England Sir James Mackey described the neighbourhood health service as “a huge opportunity for us to transform how we deliver care over the next decade—starting right on people’s doorsteps”. While Matthew Taylor, chief executive of the NHS Confederation, said that bringing care closer to people’s homes was “the right direction for both improving outcomes and alleviating pressure on hospitals”.^[58]

3.2 Political commentary

Responding to proposals in the 10 year health plan for England, Edward Argar, the then shadow health secretary, said the long-term goals of the plan were correct and built upon work of previous Conservative governments, noting:

The desire to shift care from hospital to community, to better use technology and to move to prevention is not new at all, but it remains vital […] But the plan, while welcome, is still sketchy on some of the details of delivery.^[59]

More recently, Shadow Health Secretary Stuart Andrew “cautiously welcomed” neighbourhood health centres,^[60] but queried how the plans would be paid for, stating:

Will the government simply move resources around or will there be genuinely innovative new ways [of] working, joining up services and improving the patient care experience? I hope that it is the latter, because shuffling the deck chairs into new buildings will not deliver the benefits that patients deserve.^[61]

Liberal Democrat health spokesperson Helen Morgan said her party supported the government’s vision of “shift[ing] the NHS to a community-focused, preventive service”.^[62] However, she was critical of the lack of reference to social care, saying: “solving the crisis in social care is a huge part of moving care out of hospital and into the community”. She also queried how neighbourhood health centres would interact with general practitioners.^[63]

The House of Commons Health and Social Care Committee has examined the importance of areas such as workforce and the NHS estate in delivering neighbourhood health. Chair of the committee Layla Moran (Liberal Democrat MP for Oxford West and Abingdon) noted:

There is broad support for the principle of shifting NHS services back to neighbourhoods, but this move could flounder if chronic problems aren’t tackled.^[64]

The committee has called for the NHS workforce plan, which was expected in spring 2026, to include “concrete” proposals to address these challenges and make the community a more attractive place for staff to work and build a career.^[65]

4. Read more

• King’s Fund, ‘Neighbourhood health framework: Clarity, gaps and what comes next’, 1 April 2026; and ‘What is neighbourhood health?’, 2 April 2026
• House of Commons Library, ‘General practice in England’, 28 April 2026; ‘Community hospitals’, 10 June 2026; and ‘The 10 year health plan for England’, 17 October 2025
• Nuffield Trust, ‘How will waiting times in community health services affect the shift towards neighbourhood health?’, 16 October 2025; and ‘Bringing care closer to home: Three questions that need answering’, 3 December 2024

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