Shane DeGaris runs an organisation with a budget of £2.7 billion and a workforce spread across five hospital sites in east London. As group chief executive of Barts Health NHS Trust, he oversees one of the largest acute providers in the country, and he has told colleagues across the health service that hospitals like his are being asked to carry an unreasonable financial risk. The cause is not clinical failure or falling productivity. It is a funding mechanism that removes money from acute budgets before it can be spent, on the promise that community-based care will eventually absorb the patients those funds once supported.

The policy behind this shift has a name inside NHS England: the left shift. It describes the ambition, set out in the government's ten-year health plan, to move care away from hospital buildings and into neighbourhood settings closer to where people live. Fewer admissions, shorter waits, care delivered by local teams rather than specialist departments. As an aspiration it commands wide support, including from DeGaris himself. The difficulty lies in the mechanics of getting there, and it is this gap between ambition and financial architecture that has prompted his warning.

Top-slicing works by taking a percentage from acute trust budgets at the point of allocation and redirecting it toward neighbourhood health schemes before those schemes have demonstrated they can reduce hospital demand. DeGaris has described the resulting programmes as well-meaning but largely unproven, and the pattern he has observed is not encouraging: rather than easing pressure on emergency departments, patients often end up routed back to hospital, the same hospital that has just had part of its budget removed. The trust is left carrying fixed costs, staff contracts, buildings, equipment leases, that cannot be unwound simply because a community pilot has launched down the road.

North East London offers a live illustration of the tension. System partners there are working through exactly this friction in real time, weighing how to fund neighbourhood care without destabilising the acute sector that still has to absorb whatever those schemes cannot manage. DeGaris has been clear that his objection is not to the principle of community care. It is a financial settlement that strips resources from trusts while leaving those same trusts fully accountable, in law and in their annual accounts, for the consequences.

That concern is not confined to one trust or one chief executive. The Royal College of Physicians has raised a parallel warning, arguing that the drive toward neighbourhood teams must not come at the expense of safe and sustainable hospital services. The college's position adds institutional weight to what might otherwise be dismissed as a single organisation's budgetary complaint. It suggests a structural problem in how the transition is being financed, one that extends beyond any individual trust's balance sheet.

The consequences of making a mistake in this matter are real. Without specialist expertise and proper diagnostic capacity built into community teams from the outset, patients who cannot be safely managed locally will simply queue at another point in the system, likely in the emergency department the policy was meant to relieve. That outcome would not represent a failure of the left shift as an idea. It would represent a failure of sequencing, where funding was withdrawn from hospitals before community services were equipped to do the job being asked of them. For NHS leaders, policymakers and the trusts caught in between, the lesson emerging from east London is that reform without a credible financial bridge does not shift the burden of care. It simply relocates the risk.