I recently listened to a podcast in which Kalshi Co-Founder Luana Lopes Lara explained how her company has built a regulated prediction market – an exchange where you trade on real-world events.
The principle: would you pay 70p to win £1? That’s a 70% chance. Would you pay 15p? That’s a long shot.
Kalshi came to prominence when it started offering contracts on political outcomes (e.g., “Will Trump win the White House?”). And it got me thinking about UK politics, our NHS, and the latest show in town: the neighbourhood agenda.
No more vague promises. Just settleable contracts.
The neighbourhood health agenda isn’t new. It’s the latest version of an idea the NHS keeps returning to: organising care around people and places rather than institutions and contracts. The 2025/26 Neighbourhood Health Guidelines and the Medium Term Planning Framework represent the most comprehensive attempt to make this vision real in a generation.
But… we’ve been here before. GP Fundholding in the 1990s. Primary Care Groups. Primary Care Trusts. Clinical Commissioning Groups. Vanguards. PCNs. Each time, good ideas got undermined by the conditions they were implemented in.
So I want to ask a deliberately uncomfortable question: if you had to bet real money on the outcome, what would the odds be?
But there is a flaw in my analogy, but it’s also where it gets interesting.
A prediction market contract needs a binary outcome (yes/no), a specific settlement date, an objective measure that can be verified, and no ambiguity about what “winning” means.
The neighbourhood agenda has none of these.
And that’s not just a limitation of my analogy. I think that’s the actual problem.
We Can’t Agree on What Success Looks Like
Think about it. What would the contract even be?
“Neighbourhoods will deliver integrated care by [date]” — but what counts as integrated? Who decides? The Fuller Stocktake described ‘teams of teams’ but there’s no threshold that distinguishes coordination from integration.
“Financial flows will shift from hospital to community” — by how much? Measured how? The 10 Year Health Plan says the share of hospital spending ‘will fall’ but doesn’t specify a number or a deadline.
“90% same-day access for clinically urgent patients” — okay, this is measurable. But it’s an access metric, not a transformation metric. You can hit that number without any actual integration.
This is why the same reforms keep being declared both successes and failures, depending on who’s telling the story. GP Fundholding was abolished without a robust evaluation. PCTs were dismantled before anyone agreed whether they’d worked. The Darzi Review described the 2012 reforms as ‘a calamity without international precedent’ while others defended them as necessary modernisation.
The absence of a settleable contract isn’t incidental — I think it’s structural, and it allows political parties to claim both progress and failure while nothing fundamentally changes.
What History Actually Shows Us
My MBA dissertation, “A critical evaluation of the impact of the changing roles, responsibilities and new ways of working required by GPs in light of the NHS Five Year Forward View (2014)”, was completed in 2016. What struck me then – and still strikes me now – is that research spanning over decades reveals a striking pattern. The challenges we’re identifying in primary care reform today mirror those documented in 1988, 1998, and 2016.
Studies by Pettigrew, McKee and Ferlie (1988), research on Scotland’s ‘Designed to Care’ policy (1998), and my own primary research with GPs (2016) all identified the same barriers:
• Increasing workload and growing patient demands
• Recruitment challenges and workforce planning difficulties
• Fragmented care across organisational boundaries
• Tension between continuity and access
• Lack of leadership support and resources
• Difficulty communicating across professional boundaries
The recurrence of identical challenges suggests the problems are structural, not just implementation failures. If the same barriers appear regardless of the specific policy vehicle, the issues lie in the underlying system architecture.
The Scorecard: What’s Worked and What Hasn’t
The Five Structural Contradictions
When I examine what’s being asked against what’s actually in place, five fundamental contradictions emerge.
1. Transformation Without Transformation Funding
The Ask: Standardise, scale and rigorously evaluate six complex components simultaneously — “the most ambitious plan the NHS has published in a generation.”
The Reality: The 3% transformation reserve comes “over time” — not now. Meanwhile, £2.2 billion deficit support is being withdrawn from 2026/27. This mirrors Vanguards exactly: £200 million created innovation that couldn’t be sustained when funding ended.
2. Local Flexibility Within Centrally Defined Metrics
The Ask: Guidelines are “deliberately short and permissive.” Tailor approaches to local needs.
The Reality: Performance measured through public league tables with nationally defined metrics: 90% same-day access, 2% productivity, financial balance, RTT targets. Same tension as QOF — consistency at the cost of local responsiveness.
3. Integration Without Integrated Funding
The Ask: Deliver “joined-up care” across GP, community, mental health, social care, and voluntary sector.
The Reality: Money flows through multiple streams with different accountability requirements. GP contracts nationally negotiated. Community services block-contracted. Social care sits with local authorities under entirely different pressures. Darzi was explicit: “Financial flows must lock in this change irreversibly, or it will not happen.”
4. Hospital-to-Community Shift Without Corresponding Resource Shift
The Ask: The share of hospital expenditure will fall.
The Reality: The framework acknowledges “despite previous pledges, hospital-based funding has risen.” The mechanism depends on acute demand already having reduced — a chicken-and-egg problem. Every reform since the 1990s has promised this shift. Every time, acute providers protected their funding because they remain the default for unmet need.
5. Workforce Transformation Within Workforce Crisis
The Ask: “A flexible workforce working within and for local communities” — multidisciplinary teams spanning organisations.
The Reality: GP numbers falling. Burnout high. Retention challenging. Yet the framework requires 30% reduction in agency use while expecting workforce to “decouple growth from service delivery growth.” My research from 2016 identified workforce planning as a core GP concern. Scotland’s 1998 “Designed to Care” policy documented the same challenges. Still unresolved.
If We Were Designing Settleable Contracts
If the neighbourhood agenda were to be subjected to genuine accountability – the kind that comes from people putting real money on outcomes – what would we measure?
Here are six contracts that would tell us whether this reform is succeeding or following the historical pattern.
Contract 1: The Money Test
“Primary and community care spending will exceed 25% of total NHS revenue expenditure by March 2029”
This is the only test that truly matters. Currently, primary care is around 8-9%, community services around 5-6%. If that ratio doesn’t shift meaningfully, nothing else changes. The 10 Year Health Plan says hospital spending share ‘will fall’ but gives no number. Pick a number. Publish it. Settle against it. Implied probability: 20-25p
Contract 2: The Survival Test
“The term ‘Integrated Neighbourhood Team’ will still be used in official NHS planning guidance in January 2030”
This sounds cynical, but it’s actually profound. PCGs lasted 2 years. PCTs lasted 12. CCGs lasted 9. If the neighbourhood model is still the organising unit in 5 years — not replaced by something else – that alone would break the pattern. Implied probability: 45-50p
Contract 3: The Continuity Test
“The percentage of GP consultations with the patient’s usual GP will be higher in 2028 than in 2024”
Continuity of care has the strongest evidence base for improving outcomes. It’s already measured. It’s been declining for a decade.
If neighbourhood teams actually restore relational care, this number goes up. If they just add coordination layers without changing the transactional model, it stays flat or falls. Implied probability: 25-30p
Contract 4: The Hospital Admission Test
“Emergency admissions for ambulatory care sensitive conditions per 100,000 population will fall by 10% between 2025 and 2029”
These are admissions that good primary and community care should prevent — diabetes complications, COPD exacerbations, urinary infections in the elderly. It directly measures whether neighbourhood care is intercepting demand before it reaches hospital. Implied probability: 30-35p
Contract 5: The Workforce Test
“The number of full-time equivalent GPs in England will be higher in September 2028 than in September 2025”
You cannot deliver neighbourhood care without GPs. Numbers have been falling. Every workforce plan has failed to reverse this. If GP numbers actually grow, something fundamental has changed. If they keep falling, the model collapses under its own weight. Implied probability: 20-25p
Contract 6: The Authority Test
“By 2028, at least 10 ICBs will have delegated pooled budgets of £10m+ to neighbourhood level with authority to commission across organisational boundaries”
This tests whether neighbourhoods get real power or just coordination responsibility. The number is deliberately modest — 10 out of 42 — because even that would be unprecedented. Implied probability: 15-20p
The Uncomfortable Truth
If you made system leaders bet real money on any of these contracts, I think most would quietly decline. Because the moment you define the contract, you expose the gap between aspiration and structural reality.
What Would Actually Need to Change
The neighbourhood health agenda isn’t destined to fail. The vision is sound, the evidence base is robust, and there are things that are genuinely different this time: consistent language across all 42 ICSs, better data infrastructure, a statutory framework, and explicit focus on health inequalities.
But for this to succeed at scale, the following would need to change:
1. Protected transformation funding: Ring-fenced resources for neighbourhood development that cannot be absorbed into deficit recovery.
2. Real financial integration: Pooled budgets at the neighbourhood level with authority to commission across organisational boundaries.
3. Upfront community investment: Resources shifted to primary and community care before acute demand reduces.
4. Locally determined success measures: National standards for outcomes, but local flexibility in defining what success looks like.
5. Realistic timescales: Acknowledgement that cultural change takes 5-10 years, not 3-year planning cycles.
6. Settleable accountability: Clear, measurable, time-bound commitments that allow genuine assessment of success or failure.
So, Where Does That Leave Us?
The current guidance doesn’t make success impossible. Exceptional leadership in exceptional circumstances can overcome structural barriers. Some neighbourhoods will flourish, demonstrating what integrated care can achieve. But the evidence from history is clear: when the same structural conditions are present, the same outcomes tend to follow.
Unless the fundamental contradictions are addressed – transformation with resources, flexibility with accountability, integration with integrated funding – neighbourhood health risks becoming the latest chapter in a recurring story of good ideas undermined by implementation conditions.
I’ve proposed six contracts. What would you add or change and if you had to bet your money, what would you put on?
About the Author
Tara Humphrey is the founder and CEO of THC Primary Care, a healthcare consultancy that has supported over 300 healthcare networks and organisations to enhance their leadership and management performance. Her 2016 MBA dissertation, “A critical evaluation of the impact of the changing roles, responsibilities and new ways of working required by GPs in light of the NHS Five Year Forward View (2014)”, identified structural barriers to primary care reform that remain evident in current policy. This analysis draws on that primary research alongside documentary analysis of NHS policy from 1988 to 2025.
Sources
NHS England (2025) Neighbourhood Health Guidelines 2025/26
NHS England (2025) Medium Term Planning Framework 2026/27 to 2028/29
DHSC (2025) Fit for the Future: A 10 Year Health Plan for England
Darzi, A. (2024) Independent Investigation of the NHS in England
Fuller, C. (2022) Next Steps for Integrating Primary Care: Fuller Stocktake Report
Pettigrew, A., McKee, L. & Ferlie, E. (1988) Understanding Change in the NHS, Public Administration 66(3)
Goldie, J. & Sheffield, D. (2001) Designed to Care: the evolving organisational role of primary care. Health Bulletin 59(1):40-48
Humphrey, T. (2016) A critical evaluation of the impact of the changing roles, responsibilities and new ways of working required by GPs in light of the NHS Five Year Forward View. MBA Dissertation, Canterbury Christ Church University
Smith RD, Wilton P. (1998) General practice fundholding: progress to date. Br J Gen Pract 48(430):1253-1257
Le Grand J, Mays N, Mulligan JA. (1998) Learning from the NHS Internal Market. King’s Fund
Kay, A. (2002) The abolition of the GP fundholding scheme: a lesson in evidence-based policy making. Br J Gen Pract 52(475):141-144
Sandvik H, et al. (2025) Personal GP continuity improves healthcare outcomes in primary care populations: a systematic review. Br
