Article Summary
The left shift is widely recognised as essential to the future of the NHS, yet progress remains slow. Drawing on insights from a FORTIS discussion with Justin Harris, Global Practice Group Director at Arcadis, this article explores why the left shift continues to stall and what NHS estates leaders can do to help turn strategic ambition into practical delivery.
The idea of a “left shift” in healthcare of moving care out of acute hospitals and into community settings has been widely accepted as both inevitable and necessary. It sits at the heart of nearly every major NHS strategy and is widely seen as essential to creating a more sustainable health system. Yet despite years of policy alignment and strategic consensus, progress remains limited. Acute hospitals continue to carry activity they were never designed to hold long-term, community services are expected to absorb increasing demand without the infrastructure required to support it, and estates teams are left maintaining ageing buildings without clarity about whether those assets still fit the future model of care.
The problem is not lack of intent, the NHS has been discussing left shift for more than a decade. The problem is that many of the conversations required to deliver it remain unfinished. The article draws on insights from a FORTIS discussion with Justin Harris, Global Practice Group Director at Arcadis, exploring why the shift from hospital to community care continues to stall and what the system must address if it wants to move from strategy to delivery.
The Problem with Staying Strategic
At a national level, the vision for the future of the NHS is relatively clear. Hospitals are expected to become smaller, more specialised environments focused on complex and acute care, while a greater share of planned activity, prevention and long-term management moves into community settings. On paper, this model is coherent and widely supported. The challenge emerges when organisations attempt to translate that vision into operational decisions. Across many systems, left shift is still discussed in broad terms – fewer admissions, fewer outpatient visits, more prevention- but these statements rarely define what should actually change on the ground.
They don’t define which services move, how much activity is involved, or what kind of infrastructure is needed to deliver care safely outside of the hospital setting. As Justin observed during the discussion, the problem often begins with the scale of the conversation itself,
People talk about left shift at a very macro level, and if you talk about it at a macro level, it becomes impossible to do
When transformation is framed only in strategic language, it quickly becomes abstract. Every exception becomes a reason for hesitation, and operational complexity overwhelms the original intent. Real progress only starts when the conversation moves down to the level of clinical activity. As Justin noted, “If you get down to clinical activity level, that’s when it becomes a much more realistic conversation.” Until decision‑makers start defining left shift in terms of specific procedures, pathways and volumes, estates teams are left planning against assumptions rather than evidence. The result is often reactive decision-making: maintaining, refurbishing or expanding buildings without confidence that those investments align with the future model of care.
A Structural Funding Gap
Even when systems begin to define what activity might move, another structural barrier quickly emerges: funding. In theory, shifting activity into the community should relieve pressure on hospitals and free up resources. In practice, the financial architecture of the NHS often makes that shift extremely difficult. Acute Trusts continue to rely heavily on activity‑based income, reductions in hospital activity can threaten organisational financial stability. Community providers, meanwhile, are asked to absorb more services without any guarantee that funding will follow. Justin captured this dynamic, “Acute is never going to let go of activity unless they know what’s happening to the funding. And the community is never going to take it on unless they understand where the money is going to come from.”
The result is a system-wide stalemate. Everyone recognises the inefficiencies of the current model, yet the financial risks associated with moving first remain too great. Acute providers cannot afford to reduce activity, community settings cannot afford to expand without clarity and local authorities often know demand is coming their way, but not what kind or how much.
This is why the left shift so often remains an ambition rather than an operational reality. It is not simply a planning problem or a cultural barrier; it is the result of a system where the key decisions are happening at different stages. Clinical activity is discussed in one conversation, estate planning in another and funding decisions in a third. Until those conversations are brought together, progress will remain slow. The system may agree on the direction of travel, but without clarity on who carries the financial risk, no organisation can comfortably take the first step.
Estates Caught in the Middle
No part of the system feels the consequences of an unfinished left shift strategy more directly than estates teams. They sit at the intersection of ambition and reality, trying to plan for a future that has not yet been clearly defined while maintaining an estate shaped by decisions made decades ago.
Across the NHS, backlog maintenance has become one of the most visible pressures facing organisations. Ageing infrastructure, failing mechanical systems and outdated clinical environments all require significant investment simply to maintain safe operations. In many cases this work is essential. In others, however, it reflects a deeper issue: capital is being invested into buildings without clarity about their long-term role in the future healthcare system. As Justin observed during the discussion,
There’s almost a panic investment going on… you’re repairing an asset which you probably don’t really need anyway
When organisations have not yet defined which services will move or what the future estate should look like, the default response is often to maintain everything. The result can be a cycle of reactive spending, where capital goes to the wrong places, for the wrong reasons, at the wrong time, while the community infrastructure required to support new models of care remains underdeveloped. The consequence is a system attempting to maintain buildings designed for yesterday’s model of care while simultaneously trying to prepare for tomorrow’s. Until strategic planning, clinical activity modelling and estate investment are brought together, the NHS risks continuing to invest in buildings that no longer fit its future.
What Integration Makes Possible
One of the most instructive contrasts discussed was the difference in how England and Wales approach the same challenge. Both systems recognise the need for left shift, but the way they organise themselves to achieve it is fundamentally different.
In Wales, health boards hold responsibility across both acute and community services. That structural alignment means decisions about activity, funding and estates are made as part of a single conversation. As a result, the future model of care tends to shape the sequence of investment, rather than infrastructure decisions being made in isolation.
During the discussion, Justin pointed to the impact this has had on community infrastructure. In recent years Wales has delivered a number of community-based health and wellbeing centres, not simply because buildings happened to be available, but because the system first understood what activity needed to move, where it should go and what kind of estate would be required to support it. By building the community platform first, the system creates the conditions that allow the acute sector to evolve. Hospitals can gradually focus on higher-acuity care because the capacity to deliver lower-complexity services already exists elsewhere.
The acute sector in Wales has at times felt the pressure of this approach, as resources have been directed toward developing community infrastructure. But strategically, the logic is clear: once the community platform is in place, meaningful transformation of the acute estate becomes possible. In England, the pattern is often reversed. Acute pressures tend to dominate the conversation because they are immediate and visible, while investment in community infrastructure although widely recognised as necessary, often follows rather than leads. Neither system offers a perfect model. But the Welsh experience demonstrates what becomes possible when activity planning, funding and estate strategy are considered together rather than treated as separate conversations.
Starting Smaller to Move Faster
One of the recurring challenges in left‑shift discussions is the scale at which they take place. Conversations frequently attempt to address the entire transformation in one move: transform urgent care, reduce outpatient volumes, reshape the community offer, redesign prevention, modernise digital pathways – all at once, and all within the same conversation.
The ambition is understandable, but the scale can make progress difficult. When conversations stay at this level, operational complexity quickly overwhelms strategic intent. Every exception becomes a reason to pause, and momentum is lost before meaningful change begins. The problem is not the ambition itself, but the starting point. A more effective approach often begins smaller and digs deeper. Instead of debating what should happen to “outpatients” as a broad category, systems can begin with more practical questions: which specific procedures could move safely into community settings, at what volumes, supported by what workforce and delivered in what type of environment?
Once those details are understood, the implications for estate design, digital infrastructure and workforce planning become far clearer. Estates strategies stop being theoretical and start being grounded in actual demand, digital tools are introduced where they genuinely add value and capital investment becomes a strategic enabler rather than a reactive response.
Turning Left Shift into Reality
The left shift will not become reality through strategy alone. Progress depends on the NHS completing the conversations it has started – defining activity with precision, aligning funding with function, and linking estate investment to the service model rather than historical assumptions. For estates teams in particular, the implications are clear. They cannot wait for a perfect vision of the future, but neither can they continue maintaining every inherited asset in the hope that it might be needed.
The opportunity now is to reshape the process itself. When activity planning, clinical modelling and capital decision‑making are brought together early, estates teams move from being the recipients of strategic intent to active contributors in shaping it. They become the mechanism through which left shift becomes deliverable, by identifying the spaces, facilities and sequencing that make service transformation possible in practice rather than just in principle. This also requires a shift in how systems approach change. Instead of attempting transformation at a system-wide level from the outset, progress often begins by starting smaller, working from clinical activity outward, and investing in the community platform before attempting to redesign the acute estate. The experience of Wales demonstrates the power of integrated decision‑making. When services, funding and estates are planned as part of the same conversation, transformation becomes far easier to deliver. When they remain separate, progress slows and uncertainty persists.
For NHS estates leaders, the role is therefore not simply to maintain buildings, but to help the system decide which buildings matter. It is about understanding what can be repurposed, what must be replaced and what can be released to enable new models of care. Left shift will remain an ambition until systems align their decisions around it. But once community capacity is built, activity is clearly defined and estates strategy is grounded in evidence rather than assumption, the NHS can finally move from acknowledging the need for left shift to actually delivering it. And in that transition, estates teams are not a supporting function. They are central to making the shift possible.
