Dr Minesh Patel
NAPC Senior Leader
My last piece argued that health economics thinking needs to be built in everywhere — ICBs, neighbourhoods, providers — not treated as a specialist function called in occasionally. That’s easy to say. It’s much harder to ask of the GP, the community nurse, or the neighbourhood team member who’s already stretched thin. If we want clinicians to genuinely weigh where a pound or an hour does the most good, we need to be honest about what that requires of us, not just what it demands.
Here are three things I think we’re missing.
Enough time to decide well
Good stewardship starts in the consultation room. A shared decision — where a patient understands their options and a clinician understands what matters to them — takes time. Al Mulley’s work on the “silent misdiagnosis” showed what happens without it: patients end up on treatment pathways that don’t reflect their preferences, often more intensive and more costly than they’d have chosen with fuller information. That’s waste, but it’s also worse care.
The tension is that NHS England’s current centre of gravity is access — more appointments, faster throughput. Access matters. But access without enough time for decision quality just moves the inefficiency from the waiting room into the consultation itself. If we want clinicians to be careful stewards of population resources, we have to protect the minutes in which that stewardship actually happens.
Evidence at the point of care, not just at the point of cost
Most of what reaches a GP’s screen mid-consultation is cost information — generic versus branded, formulary choices. Useful, but narrow. What’s largely missing is comparative effectiveness: what actually works best for this patient, at what cost, versus the realistic alternatives, drawn from a shared evidence base rather than whatever guideline a clinician remembers from training.
Other systems have tried to close this gap directly into clinical workflow rather than leaving it as something you look up separately. If neighbourhood teams and ICBs are serious about resource decisions being evidence-led rather than habit-led, that evidence needs to sit inside the tools clinicians already use, at the moment the decision is being made — not in a report reviewed after the fact.
Seeing the whole population, not just the top of it
Risk stratification tools are good at finding the top 5% — the high-cost, high-intensity users everyone already knows about. That’s useful, but it’s a fraction of the population, and it tends to pull attention and resource toward crisis rather than prevention. A neighbourhood team trying to decide where falls prevention or social prescribing sits against everything else needs to see the whole distribution: who’s healthy now and likely to stay that way with a nudge, who’s drifting toward risk, who’s already there. Without that fuller population view, prevention keeps losing to whatever’s urgent today, exactly the pattern the Prudent Healthcare work in Wales was trying to break.
A fourth thing, less tangible: permission
Even with time, evidence and data, there’s a cultural barrier. Talking openly about trade-offs can feel like talking about rationing, and that’s an uncomfortable place for most clinicians to stand. Systems that do this well seem to treat these conversations as a normal, expected part of clinical and neighbourhood leadership — not a scandal waiting to happen. That takes explicit permission from the top, not just tools from the middle.
The next stretch: budgets that follow the person, not the pathway
There’s a further challenge waiting just beyond these four. Decision quality and good evidence will increasingly tell us that the best use of a pound isn’t a clinical service at all — it’s stable housing, a VCSE befriending service, debt advice, or something else entirely outside our usual toolkit. Personal health budgets and social prescribing have shown this is possible at small scale. The harder test is whether ICBs, INTs and IHOs can build the mechanisms to purpose real budgets this way routinely — trusting non-clinical solutions with clinical-grade seriousness, and trusting clinicians and neighbourhood teams to direct resource somewhere other than a traditional service, when that’s genuinely what the evidence and the person in front of us are pointing to.
Over to you
None of this is a criticism of the ambition behind ICBs, INTs or IHOs — it’s a checklist for making it real. So I’ll ask the question directly: if you’re a GP, a neighbourhood team member, or anyone expected to weigh where resource does the most good — what’s actually missing for you? Time, data, evidence, permission, something else entirely?
