Who Owns Neighbourhood Health?

In this article, Matt Carter and Andrew Laird argue that neighbourhood health requires mature place partnerships and community-based leadership – not NHS provider or local authority dominance.

The context: ICBs in flux…

From April 2026, Integrated Care Boards (ICBs) will increasingly operate as strategic commissioners rather than operational managers of change and transformation. Their primary role will be to set direction, allocate resources and hold systems to account for outcomes. This marks a significant shift in how health systems are governed and where leadership for change actually sits.

For several years, the policy narrative around Integrated Care Systems (ICSs) has emphasised collaboration and partnership. Yet the emerging commissioning model makes something clearer - if ICBs are stepping back from operational leadership, then the practical delivery of neighbourhood health must be led elsewhere.

There is no nationally imposed answer to the question of who should actually lead neighbourhood health. At a place level, a variety of NHS providers, GP collaboratives of various types, even councils could all put their hands up and make the case that they are the obvious ones to lead... so who actually could or should lead it?

Strategic Commissioning and the Leadership Gap

Under the new arrangements, ICBs will focus on system strategy, outcomes and financial stewardship. ICSs remain the partnership framework connecting the NHS, local government and the voluntary sector, but the operational centre of gravity will move closer to communities.

This shift creates both opportunity and risk.

On the one hand prevention, integrated community care, and tackling the wider determinants of health only works when shaped locally. The closer decision-making sits to communities, the more likely services are to reflect real population need. We think everyone accepts this.

On the other hand, many places (by which we mean the combination of the partners which exist in each place geography) are not currently structurally configured to lead this agenda. In numerous ICS geographies there is no single accountable officer for health outcomes at Place level, and budgets are often fragmented across organisations.

Neighbourhood health, however, requires precisely the opposite: aligned resources, consistent priorities and coordinated behaviour across organisations.

This is where the leadership challenge emerges. As the system moves to strategic commissioning, leadership at Place shifts from managing services to convening partnerships.

The Mutual Ventures team have been making this exact argument in our work specifically with councils where the danger is that as budgets tighten, councils retreat to simply being a provider of last resort rather than an active convenor of place. See here - The Preconditions for Radical Place Leadership.

Authority Without Control

The defining feature of Place leadership is that it rarely comes with formal authority.

Local authorities do not control NHS provider organisations. NHS trusts do not govern primary care networks. Voluntary organisations operate with their own mandates and funding arrangements. Yet neighbourhood health requires all of them to move in the same direction.

This means Place leadership must operate through influence rather than hierarchy.

In practical terms, that means aligning incentives, building trust and creating shared accountability around outcomes rather than organisational performance. It requires leaders who can convene the system, hold difficult conversations about priorities and maintain collective focus on population outcomes.

In other words, leadership becomes relational.

This echoes the principles of Radical Place Leadership which our team have been discussing over the past couple of years - leadership rooted in collaboration, community legitimacy and shared purpose rather than institutional control.

The Provider Question

One of the most interesting dynamics emerging from the shift to strategic commissioning is the role of NHS providers.

Acute and community providers bring considerable strengths to system leadership. They possess executive capacity, financial management expertise, established governance structures and clinical credibility. They also hold significant data on population health and service utilisation.

In systems where Place governance is weak or informal, it is entirely rational that provider organisations could step forward to fill the leadership gap.

But there is a potential downside.

Neighbourhood health is not simply a clinical integration project. It is equally about the other critical elements of a healthy and fulfilling life such as housing, employment, not being lonely, and having support within a community. If leadership sits predominantly within provider organisations, there is a risk that neighbourhood health becomes framed primarily through a clinical lens. We have seen this happen before – organisations will always tend to focus on the things they are ultimately held accountable for. Provider Boards are not always configured to lead politically complex, community-focused agendas. Their governance structures, incentives and cultures are often centred on service delivery and performance metrics rather than broader social outcomes.

In a recent episode of the Radical Reformers podcast, Zina Etheridge, former Chief Exec of North East London ICB made the point that an NHS provider Chief Executive is much more likely to get the sack for failing to deliver on nationally set targets (e.g. A&E performance) than for failing to delivery on neighbourhood health. You can listen to the episode here - Supporting Communities to Thrive and Succeed with Zina Etheridge.

The challenge, therefore, is not whether providers should play a role - they clearly must - but how their leadership sits alongside local government, primary care and wider community organisations.

The Maturity of Place Partnerships

Ultimately, the question of who “owns” neighbourhood health depends less on policy design and more on the maturity of Place partnerships.

Where Place governance is informal, under-resourced and financially fragmented, the vacuum will inevitably be filled by the organisations with the strongest capacity, typically NHS providers.

Where Place governance is outcomes-focused, politically anchored and supported by aligned or pooled budgets, leadership becomes shared. In these contexts, NHS providers remain crucial partners but operate as part of a broader collective rather than as the dominant voice.

This distinction matters because neighbourhood health is fundamentally a system endeavour. It requires clinical integration, certainly, but also democratic accountability, community engagement and attention to the wider determinants of health.

No single organisation can deliver that alone.

Radical Place Leadership in Practice

The idea of Radical Place Leadership becomes particularly relevant here. If authority is dispersed across organisations, leadership must be constructed through relationships.

Three capabilities become especially important:

First, convening power - Place leaders must bring together organisations with different incentives and accountabilities. This involves creating forums where strategic priorities can be debated openly and where collective decisions are possible.

Second, financial alignment - Without some form of aligned budgeting, partnership working remains rhetorical. Strategic commissioning at ICB level needs to be matched by financial arrangements that support neighbourhood priorities.

Third, community legitimacy - Neighbourhood health ultimately exists to improve the lives of local people. Place leadership therefore requires strong connections to communities, voluntary organisations and elected representatives.

These capabilities do not sit naturally within any single institution. They must be developed collectively.

Ownership Is Relational, Not Structural

The shift toward strategic commissioning should not be framed as a debate between centralisation and localisation. A more useful lens is subsidiarity i.e. decisions taken at the lowest appropriate level within a shared outcomes framework.

In this model, ICBs provide system strategy, manage financial risk and ensure accountability for outcomes. Place partnerships translate that strategy into locally designed interventions that respond to neighbourhood need.

For this to work, delegation arrangements must be transparent and incentives aligned. Most importantly, Place leaders must be capable of shaping commissioning decisions rather than simply implementing them.

The success of neighbourhood health will therefore hinge less on organisational structures and more on leadership behaviours.

If Place partnerships remain fragile, neighbourhood health risks becoming another well-intentioned aspiration within integrated care.

But if Place leaders embrace a relational model - aligning organisations around shared outcomes, strengthening governance and embedding community voice, then the shift to strategic commissioning could provide the clarity and scale needed to sustain real change.

In that sense, the future of neighbourhood health does not belong to any single organisation.

It belongs to the quality of leadership at “Place”.

We’d love to start conversations with people who recognise some of these challenges and would like to explore what neighbourhood health could and should mean in their place. Drop Matt a line at Matt.carter@mutualventures.co.uk – we look forward to hearing from you.  

Matt Carter, Principal Consultant, Mutual Ventures

Andrew Laird, CEO Mutual Ventures