Integrated care across neighbourhoods requires more than goodwill and shared vision. While strong relationships remain essential, the economic and structural realities that shape collaboration often determine what's actually possible.
This tension between goodwill and structural reality, shapes much of what's possible in neighbourhood working. Leaders who understand the economic and structural forces at play are better positioned to build sustainable integration.
The hidden weight of economics
Integration requires aligning systems which are evolving their approach to supporting patients, bringing them closer together than ever before. And while we wait for the new neighbourhood contracts to be released, the current situation looks like:
Complex funding arrangements: PCNs operate within multiple contract frameworks—the Network Contract DES alongside individual practices managing GMS contracts (including QOF). PCN targets exist within specific parameters, and ARRS funding has restrictions around how networks can use these resources. Acute trusts operate under their own funding models, with certain aspects potentially shaped by Payment by Results. These different funding streams and contractual obligations create complexity when trying to align collaborative efforts across organisational boundaries.
Workforce and financial pressures: Even with aligned intentions, practical constraints shape what's possible. GP shortages, competition for nursing staff, and recruitment challenges for ARRS roles can prevent well-intentioned plans from materializing. Many providers operate on tight margins where rising estates costs or increased locum reliance can shift priorities overnight, destabilising collaborative commitments.
Competing political priorities: NHS England, Integrated Care Boards, local authorities, and acute trusts are all influenced by internal and external political forces that drive certain positions. These forces—which all parties involved may not necessarily understand or be fully aware of—can shift priorities and create new expectations that local leaders must navigate while managing existing partnerships built under different assumptions.
These forces are powerful enough to undermine even the strongest relationships when the underlying economics work against collaboration.
What leaders need to understand
The most effective PCN leaders combine relational skills with what might be called ‘economic literacy’—understanding how funding flows, contractual arrangements, and organisational pressures shape their partners' decisions.
This doesn't mean every leader needs detailed financial expertise, but it does mean asking the right questions.
When proposing new integrated services: How will this be funded, and do the incentives encourage all partners to participate fully?
When building secondary care partnerships: Are we working within a payment model that rewards activity or one that encourages prevention and integration?
When planning neighbourhood initiatives: Are we being realistic about organisational capacity and financial sustainability across all partners?
These questions demonstrate understanding that collaboration depends on more than clinical alignment—it requires economic coherence.
Moving beyond initial objections
Progress requires moving past the instinctive ‘this won't work’ response to have honest conversations about money. While these discussions can be sensitive, they are essential for understanding where money currently flows, how it could potentially be redistributed differently, and whether such redistribution is financially viable.
This means all parties involved need to work together to map the financial mechanics and explore what's genuinely possible rather than making assumptions about financial barriers. Only through this kind of detailed financial examination can partnerships move from theoretical collaboration to practical, sustainable integration.
Building economic literacy strengthens relationships
For PCN leaders navigating neighbourhood integration, success requires balancing relational leadership with structural understanding. This means first understanding the economic factors affecting the practices within their PCN, and then building knowledge of the broader context. This involves:
Understanding the broader context—not just for your organisation, but for partners across the system. When ICB structures change or funding streams shift, knowing how this affects collaborative partners helps maintain momentum despite structural uncertainty.
Developing influence and negotiation skills that recognise collaboration often requires aligning incentives, not just building trust. The most sustainable partnerships are those where economic interests support rather than undermine shared goals.
Being realistic about barriers rather than attributing every challenge to relationship issues. Sometimes progress stalls because funding flows or workforce shortages create genuine constraints that no amount of goodwill can overcome.
Continuing to learn as contexts evolve. The one thing we can all agree on is that change will always be the constant. Recent NHS England changes, emerging neighbourhood health frameworks, and shifting ICB priorities all create new structural realities, making it important to continually learn and evolve.
Tara Humphrey is CEO of THC Primary Care, which provides interim management training to PCN leaders and has supported more than 300 PCNs.