In Views

Follow this topic

Bookmark

Record learning outcomes

Moving care is not the same as reducing the need for care, as Trevor Gore explains…

The NHS neighbourhood health framework has arrived with plenty of fanfare and its ambition is clear. Move care "out of hospitals and into neighbourhoods", bring services closer to home, improve integration and reduce pressure on acute care.

On the surface, it's hard to disagree with. Community-based care is generally more convenient, more accessible, and often more cost-effective than hospital-based care.

As someone who has spent much of my career championing self-care, prevention, and the role of community pharmacy, I should be celebrating. Yet, reading the framework, I found myself asking a simple question, are we focusing on the wrong problem?

The framework talks a lot about shifting care from one setting to another, from hospitals to neighbourhoods, secondary care to primary care, and acute settings to community settings.

But moving care isn't the same as reducing the need for care. In behavioural economics terms, we are concentrating on the supply side of the equation while paying less attention to the demand side. But moving demand isn't the same as preventing demand.

The underlying assumption seems to be that if we relocate services, we'll reduce pressure on hospitals. Maybe. But what if we simply end up with community services and hospitals both carrying the same burden?

After all, people don't suddenly become healthier because the consultation happens in a different building. Many of the conditions filling hospital beds today didn't start there.

They began weeks, months or even years earlier with uncontrolled hypertension becoming a stroke, poorly managed diabetes becomes an admission, a lingering chest infection becomes pneumonia and a missed opportunity for intervention becomes a hospital attendance.

The challenge isn't simply where care happens, but rather when care happens. The greatest savings are often generated not by relocating treatment, but by preventing deterioration.

One of the recurring frustrations in healthcare policy is that it often assumes people behave rationally, but behavioural economics tells us otherwise.

People procrastinate, they ignore symptoms, they underestimate risks. Basically, they choose the easiest option available.

A patient with rising blood pressure rarely wakes up thinking ‘I should proactively seek preventive care today’. Many patients only enter the system when symptoms become impossible to ignore and at that point, the NHS is already playing catch-up.

The framework rightly talks about proactive care but the practical mechanisms for changing behaviour often feel underdeveloped. If we genuinely want to reduce hospital demand, we need to make earlier action the easiest action, and that's a behavioural challenge as much as a clinical one.

Is community pharmacy the missed opportunity? The framework does mention pharmacy but largely as an access point, and that feels like a missed opportunity to me.

Community pharmacy is arguably the most underused behavioural intervention platform in the NHS, because every day, millions of people walk through pharmacy doors without appointments, referrals or waiting lists.

No other part of the health system enjoys that combination of accessibility, convenience, and trust. Yet we continue to think of pharmacies primarily as places where services happen and not where prevention happens.

Imagine pharmacies functioning as prevention hubs, identifying risks before symptoms emerge. Detection centres finding hypertension, atrial fibrillation, and diabetes earlier. 

Behaviour-change platforms supporting healthier habits through small, repeated interventions. Nudge centres using reminders, prompts and defaults to encourage action.

Low-friction front doors that make seeking help easier than delaying. The behavioural science is clear that minor changes, delivered consistently at moments when people are already engaged, can have disproportionate effects.

Pharmacies interact with patients repeatedly over time, and that's exactly where behaviour change tends to work best.

Reading the framework, I was struck by how much attention is devoted to organisational design, with possibly another set of acronyms to follow.

Integrated neighbourhood teams, provider models, governance arrangement, and commissioning structures are all in there, but structures don't change behaviour by themselves, and healthcare has a long history of reorganising boxes on organisational charts and expecting different outcomes.

Behavioural economics teaches us that outcomes are often shaped less by organisational diagrams and more by the tiny frictions, defaults and incentives that influence everyday decisions.

The question shouldn't simply be, "How do we move care into neighbourhoods?" but should also be, "How do we help people act earlier?" and these are not the same thing. 

The phrase "neighbourhood first" captures an important ambition but perhaps we need to go one step further: Neighbourhood first. Hospital last.

Not because care has been physically relocated, but because intervention happened early enough that hospital care was never required.

And that's where the biggest prize sits, because if we genuinely want a sustainable NHS, success will not be measured by how much activity we transfer from hospitals into communities.

It will be measured by how much activity never needs to happen at all, and community pharmacy has a critical role to play in that future.

Not simply as a destination for transferred care, but as a proactive, behavioural, prevention-focused part of the system that helps stop problems escalating in the first place.

Because the ultimate goal shouldn't be moving care, but rather it should be reducing the need for it.

Trevor Gore is the founder of Maestro Consulting, a Self-Care Forum trustee and associate director at the Institute for Collaborative Working.