The UK government's 10 Year Health Plan commits to shifting care from hospitals into primary and community settings. As The King's Fund notes, this vision of moving care from hospital to community has "been echoed by successive governments" - yet the fundamental challenge remains: how do you actually sequence this shift?
Here's the impossible logic we're asking system leaders to navigate: you cannot shift demand to primary care until you've built the capacity to handle it. But you cannot build that capacity without shifting resources away from secondary care. Yet you cannot shift resources away from secondary care while it's still managing that demand. Add to this the fact that even when you do manage to shift demand away from secondary care, hospitals operate with high fixed costs and interdependent services, making it difficult to realise immediate financial benefits from reduced demand.
Here's how this typically plays out: an ICB identifies funding to invest in community diagnostics and GP capacity. The business case is solid - shift a proportion of outpatient activity, reduce A&E attendances, better outcomes.
But then the reality hits: the acute trust, facing its own deficit, contests the resource shift. The money is theoretically "new" investment, but in practice it means their block contract won't grow as expected. Meanwhile, GPs look at the proposed investment and say "this gives us equipment and some staff, but not enough to absorb the thousands of additional patients you're planning to divert from hospital in year one."
They're both right.
The system ends up splitting the difference - smaller investment, slower shift. Which means neither sector gets what it needs. The hospital remains under pressure. Primary care takes on more with insufficient resource. And the cycle continues.
The King's Fund is clear that we need "restructuring financial architecture, rebalancing the metrics and accountability, workforce redesign... and enabling locally driven, co-produced change." What they don't tell you is in what order.
Because sequencing is everything. Move too fast and you destabilise secondary care before alternatives exist. Move too slowly and you never achieve the shift, just add complexity to primary care without reducing hospital pressure.
Most systems are trying to do it all simultaneously - investing in community capacity while managing acute pressures while redesigning pathways while training new workforce models. The result? Fragmented change that doesn't add up to transformation.
So here's my question for system and practice leaders: what's actually working for you on sequencing? Have you found a way through this that doesn't leave both sectors under-supported? Or is everyone just managing the tension as best they can?
Because until we solve the sequencing problem, the 10 Year Plan remains exactly what The King's Fund called it - a welcome vision that faces the ultimate test of delivery.
