The NHS Missing Middle: Rethinking the Space Between Primary and Acute Care

When the estate no longer matches the pathway

The consequences of this ‘missing middle’ are already visible across the system. Acute hospitals are under sustained pressure, managing high volumes of patients whose needs may be clinical, important and time-sensitive, but not necessarily acute. At the same time, primary care is constrained by space, workforce and infrastructure limitations that make it difficult to expand the scope of services it can safely deliver. Patients are often caught in the middle. They may be directed to hospital because diagnostics, assessment or treatment are not available elsewhere at the right scale. Others experience fragmented pathways because the services they need sit across different organisations, buildings and referral routes. In many cases, the issue is not only whether care is available, but whether it is being delivered in an environment properly matched to the patient’s needs.

The result is a system stretched between two poles. Hospitals become congested with activity that could be delivered differently, while community and primary care estates are asked to expand their role without always having the physical capacity or clinical infrastructure to match. Francis’ point is that the middle is already carrying much of the future of healthcare delivery, but it has not yet been given the same level of definition as either the GP surgery or the acute hospital. In practice, this means that systems are often trying to deliver new models of care through old spatial assumptions.

A strategic value of the middle

Recent policy direction has begun to acknowledge the importance of this middle ground, particularly through the emphasis on neighbourhood health, integrated care systems and place-based delivery. These models all depend on care being organised closer to people, across organisational boundaries and around the needs of local populations. Yet while the service model conversation is advancing, the infrastructure response often remains under-defined. Too frequently, the middle is treated as an abstract concept rather than a clinical, architectural and operational reality that requires intentional design. Neighbourhood health cannot be delivered through policy language alone. It needs places where multidisciplinary teams can work together, where diagnostics and treatment can be accessed more easily, and where services are organised around patients rather than institutional boundaries.

This is where the missing middle has strategic value. It can provide the physical bridge between high-volume community need and high-complexity acute provision. Properly defined, it allows systems to move beyond a binary choice between expanding hospitals or stretching primary care. It creates a third category of infrastructure, one capable of absorbing complexity without defaulting to acute models of delivery. For senior leaders, the challenge is that this middle ground is still often approached through individual programmes rather than as a coherent estate typology. Community diagnostic centres, neighbourhood health centres, elective hubs, urgent treatment centres and integrated care facilities all contribute part of the answer. Each has value and each can relieve pressure in a specific part of the pathway. But without an overarching view, the system risks creating a series of disconnected assets rather than a connected layer of healthcare infrastructure.

The same discipline is now needed across the broader missing middle. Systems need to ask what kinds of buildings should sit between primary and acute care, what clinical functions they should support, what level of acuity they can safely manage, and how they should connect into hospitals, neighbourhood teams, mental health services, diagnostics, digital platforms and social care. These are not abstract design questions. They are strategic questions about how the NHS allocates capital, manages demand and builds resilience.

Building continuity into the healthcare estate

The missing middle should not be understood simply as a way of moving activity out of acute settings. Its value lies in creating a more continuous system of care. For patients, that could mean being assessed, diagnosed and treated in a setting that feels accessible and proportionate to their needs. For clinicians, it could mean working in environments that support multidisciplinary decision-making rather than fragmented referral chains. For systems, it could mean creating the capacity to intervene earlier, manage risk differently and reduce unnecessary escalation.

This requires a different design mindset. Intermediate healthcare environments need to be more clinically capable than traditional community buildings, but less complex and capital-intensive than acute hospitals. They need to support change because the service models around them will continue to evolve, and they need to be efficient, but not so tightly specified that they become obsolete as pathways shift. As Francis puts it,

The opportunity is to establish a more coherent typology of intermediate healthcare environments, places that are clinically capable, operationally flexible and embedded within communities

In other words, the middle cannot be defined only by what it is not. It needs a clearer identity of its own, rooted in the kind of care it is there to support. This is where design becomes more than a question of space. The middle has to be able to support diagnostics today, more integrated outpatient care tomorrow, and new digitally enabled models of assessment, monitoring and treatment in the future. It also has to give different organisations a practical place to come together. Integrated care is often discussed in terms of governance, pathways and partnerships, but it becomes more tangible when there are environments where collaboration can happen in practice. Buildings do not create integration on their own. But they can make it easier, or they can make it harder. The opportunity in the missing middle is to design places that help the system work as one, rather than asking patients and staff to navigate the gaps between its parts.

The next layer of healthcare infrastructure

From an infrastructure perspective, defining the missing middle also allows for more strategic decision-making. Intermediate facilities can be designed with different cost, risk, and adaptability profiles than acute hospitals, enabling quicker delivery, greater standardisation, and more efficient use of capital. They also provide a clear clinical anchor for service integration, translating policy ambition into a physical environment that clinicians, patients, and communities can understand and use.

Ultimately, addressing the missing middle is about shifting from a system defined by extremes to one defined by continuity. By investing in the spaces between primary and acute care, the healthcare system has an opportunity to better match infrastructure to need, support integrated service delivery, and create a more resilient, accessible, and patient centred estate. The challenge now is not whether this middle exists, but whether we are prepared to work to define it clearly and design for it deliberately.