Creating a ‘neighbourhood NHS’ will demand a different mindset, unfamiliar ways of working and difficult decisions on finances and staffing. Middle managers as well as senior leaders will play a big part in making it happen, writes Nigel Edwards.

Since the publication in 2022 of Claire Fuller’s stocktake report on integrating primary care, we have seen growing interest in creating teams around neighbourhoods in the NHS. This interest was given more impetus after the 2024 election when health secretary Wes Streeting set out his vision for the development of a neighbourhood health service in England.

NHS England’s 2025-26 planning guidance includes a substantial section on developing the neighbourhood model. As well as improving services for patients and reducing inequalities, this will create both challenges and opportunities for health and care managers in the next few years.

The development of integrated teams and place-based partnerships will create systems that can be held to account for health outcomes and in some cases wider objectives related to the government’s key missions. The challenge with this has always been reconciling the objectives and finances of individual organisations with the wider goals of improving health, investing in prevention and shifting care from hospital into the community.

The current performance regime reinforces the natural tendency for managers to focus on local and organisational goals, which for board members are a key element of their role and identity. Leading organisations through this will be a challenge. In particular, acute providers will need to release resources – staff and in some cases money — to support the wider development of the system. This might be in the form of lower spending growth, which is easier than releasing cash, but it’s still hard, particularly where organisations are already in deficit.

The development of multidisciplinary teams based around primary care has significant implications for how staff are deployed and services are designed. For community staff, working with defined teams may require changes to how they work and who they work with. For example, complex processes for referral and triage, rigid caseload models and the operation of lots of siloed teams are not compatible with an approach based on teamwork.

Breaking down the barriers, simplifying processes and removing some of the administrative burden associated with these ways of working will require time and improvement methods that not everyone knows about.

For acute providers there is a requirement to work with the system to standardise the response to urgent care demand and to develop new ways for specialists to work with neighbourhoods. All of this requires an ability to work across boundaries, think about the objectives of the system and not just those of the organisation, and a more patient and population focused approach than has often been the case in previous reforms.

Improving health and wellbeing and reducing inequalities will increase the need to work across organisational boundaries even further. The social determinants of ill-health and inequalities do not directly relate to services provided by the NHS, and leaders in the system will need to become much more effective at working with other agencies and communities more generally to make a difference in this area.

The risks are that neighbourhood health is seen as an NHS strategy, not one shared by local government and other agencies, or that the NHS is seen as trying to take over responsibilities that belong to others. Again, this is a challenge requiring diplomacy and interpersonal skills.

One opportunity that neighbourhood working provides is the ability to work with communities to tackle the issues that statutory services can’t reach. Many very deprived communities have an ambivalent relationship to these services or at the very least find that they do not offer services in ways that they can easily use.

Many of the needs of these communities are complex and only some can be met by the NHS. One answer to this has been the development of local community action – often using the principles of ‘asset-based’ community development. In contrast to the approach and mindset commonly found in statutory services, these models ask what assets and strengths the community has rather than focussing on all its problems. Services operating on asset-based models demand a different approach from managers:

While formal processes and governance have their place, they are generally not what creates success with neighbourhood working. They are necessary but not sufficient. Experience in developing multidisciplinary working shows that a number of other components need to be in place.

These elements help to create an environment of ‘psychological safety’ in which staff can voice concerns, try out ideas and talk about things that have not gone well. This is also closely associated with high levels of team effectiveness, innovation, productivity and care quality. In addition, mentoring, peer support and feedback on progress are needed to help with the continual development of the team and sustaining progress. These approaches also mean that team members need to understand each other’s roles and capabilities, which also helps to improve cross-referral and problem solving.

Many of the changes require an approach that is less hierarchical than many people have been used to and calls for more working across organisational boundaries. In a number of cases, it is also messier and more organic. Other elements of the change will require process design, improvement and change management skills which are not always available. They also demand patience, which the system tends to be short of.

The role of managers at all levels in supporting these changes is vital. This is particularly true for mid-level managers and team leaders. The NHS has a tendency to focus on top leaders but this is a multi-level leadership challenge and middle-managers are a key part of managing these complex changes. //