Closing the collaboration gap

For years, policy has emphasised the need for closer collaboration between local government and the NHS. From integrated care systems to neighbourhood health, the language of partnership is now well established. But a gap between policy and practice persists.

Closing that gap matters because of the difference collaboration can make to people’s lives. Hospitals and clinical services are critical, but the factors that shape health most profoundly lie elsewhere: housing, employment, social connection, air quality, education, safety and income.

The public do not share the distinctions that institutions hold dear. They do not experience life through organisational charts. They simply want services to work and to be treated with dignity.

If leaders are serious about prevention and tackling health inequalities, collaboration between the NHS and local government is not optional, it is foundational.

Why collaboration is difficult

Much of the disconnect between policy and practice is structural. At the moment, we have integration rhetoric layered on top of competitive, compliance-driven structures. That contradiction is why the gap persists.

Structural and cultural differences between the NHS and local government are also a factor.

Local government operates within a democratic framework. Elected members face direct accountability to their communities. The NHS, by contrast, is largely managed through national structures and does not face the same direct democratic pressure.

There are also differences in leadership culture and language. Without deliberate effort to translate and understand each other’s perspectives, misunderstandings can quickly emerge. Leaders can find themselves defending their own organisations rather than working together to improve outcomes. The communities both systems serve are the ones who ultimately pay the price.

The role of national government

National government has a role to play in creating the conditions for collaboration.

The first requirement is to align incentives with prevention. At present, many financial and performance frameworks reward activity rather than reducing demand. If prevention works, organisations can find themselves financially worse off.

The second requirement is stability. Structural reform cycles that come and go every few years consume enormous leadership energy and destroy the relational capital that collaboration depends upon.

The third requirement is clarity about accountability for population outcomes, rather than simply organisational performance metrics, which can often be gamed.

The fourth is investment in leadership development. System leadership – the ability to lead across organisational boundaries – is not automatically produced by seniority. In my experience, seniority can sometimes reduce the likelihood of it being rewarded.

National government should not micro-manage how collaboration happens locally. It should provide frameworks and hold systems to account for population outcomes, but trust people to work out how best to deliver them.

What local leaders can do

Local leaders need to make the most of the agency they already have. One of the things I notice when working with leaders in both the NHS and local government is how much time is spent discussing things that cannot be changed – national policy, political decisions or funding settlements.

Local leaders can use their authority more actively to move beyond institutional defensiveness and focus instead on what works for communities.

Recognising this shared responsibility can transform the way systems operate. In practice, that often means leaders taking calculated risks, building relationships across organisations and prioritising joint outcomes rather than protecting individual budgets.

Making neighbourhood health real

The growing focus on neighbourhood health offers a major opportunity to embed collaboration locally. But it also carries a risk: that systems create new governance structures without clarity about their purpose. The first step should be to define the intention behind any new neighbourhood arrangements before designing the bureaucracy around them.

Neighbourhood approaches should be genuinely co-designed with communities, not simply for them. This requires transferring real power so people can shape decisions and actions in new ways alongside clear and consistent communication that shows their voices have been meaningfully heard.

There are practical tests that any new service should pass. It should reduce the number of places people have to go to get help. People should only have to tell their story once. And outcomes should not vary because of the colour of someone’s skin or the size of their wallet.

A call to action

Collaboration requires shared risk, distributed leadership and a tolerance for ambiguity. Those things are not always comfortable in systems that are used to command-and-control behaviour.

But when institutions stop defending their turf and start sharing responsibility for outcomes, something different becomes possible.

For senior leaders across local government and the NHS, the opportunity is clear. By focusing on shared outcomes, empowering communities and using their authority to build partnerships, they can move collaboration from aspiration to everyday practice. And when that happens, the benefits are felt by everyone – and particularly by the people and places they serve.

Victor Adebowale is founder and chair of Collaborate CIC and chair of The NHS Alliance.