Bringing the conversation
back to care

There are moments in leadership when something suddenly becomes clear. The circumstances may not have changed, and the problems may remain unresolved, but your understanding of what you must do changes.

For me, that moment came on 22 April 2026.

The preceding twelve months had been difficult. Much of the conversation within our Primary Care Network had become consumed by questions of governance, organisational structures, directorships and leadership arrangements. These were not unimportant matters. Good governance is essential, particularly when organisations are responsible for public money, clinical services and the trust of their constituent practices.

However, the discussions had become increasingly fraught. Relationships were strained. The same questions seemed to return without satisfactory resolution. Energy that could have been directed towards improving patient care was instead absorbed by arguments about structures, authority and organisational control.

Eventually, I decided to disengage.

This was not because I had stopped caring about the future of primary care. It was because I could no longer see how continuing to participate in the same conversations, conducted in the same way, was going to produce a different result. Sometimes stepping back is not an act of indifference. It is an acknowledgement that a particular way of working has ceased to be constructive.

For a while, I concentrated on my patients, my practice and the responsibilities immediately in front of me. Yet events have a way of drawing us back into the places we thought we had left. On 22 April, I found myself thrust once again into the cauldron.

This time, however, I made a different decision.

If I was going to re-engage, I did not want to return simply to another cycle of debate about governance and organisational design. Those questions still needed to be addressed, but they could not be allowed to become the entire purpose of our work. I wanted to bring the conversation back to clinical care.

It was a moment of clarity. The way out of our impasse might not begin with resolving every structural disagreement. It might begin by reminding ourselves why the structures existed in the first place.

They existed to help us care for people.

A model of care under increasing pressure

For more than a decade, I have argued that the traditional model of general practice must change.

The ten-minute consultation has served British general practice for generations. It remains an extraordinary exercise in clinical judgement, communication and human connection. Within a few minutes, a GP may need to identify the real reason for a patient's attendance, assess clinical risk, make sense of several symptoms, consider the patient's social circumstances, agree a plan and provide reassurance.

The difficulty is that the needs of many of our patients no longer fit comfortably within that model.

We are caring for an ageing population with increasing levels of multimorbidity, frailty, mental illness and complex social need. A patient may attend with diabetes, heart failure, chronic kidney disease, osteoarthritis, depression and the effects of poverty or loneliness. Each condition may have its own pathway, targets and professional team, but the patient experiences them as one life.

A series of isolated, ten-minute, single-issue consultations cannot always provide the continuity, coordination and depth that such complexity requires. The limitation is not the commitment or capability of general practitioners. The limitation is a model that too often asks one clinician, working within an exceptionally compressed period, to hold together problems that extend across several services and organisations.

We cannot solve that simply by asking GPs to work faster.

We need a model of care that is more proactive, continuous and coordinated. We need primary, community and secondary care professionals to work as a team around the patient. We need better use of population health information, stronger multidisciplinary working and a more intelligent relationship between general practice and the wider health system.

Neighbourhood care appeared to offer a possible way forward.

The promise of neighbourhood care

At its best, neighbourhood care is not another organisational layer. It is a way of bringing together the people and services that already care for the same population.

General practice develops an understanding of the patient over time. Community services bring expertise in rehabilitation, frailty, mental health and care closer to home. Hospital specialists provide skills that can help prevent deterioration and unnecessary admission when they are connected effectively with primary care. Local authorities and voluntary organisations understand many of the social realities that shape health long before a person reaches a consulting room.

The opportunity lies in connecting these strengths around the needs of a defined community.

This is why I became convinced that neighbourhood care must be part of the future. It offered the possibility of moving from episodic and fragmented care towards something more integrated, multidisciplinary and continuous.

Yet recognising the destination was easier than identifying the starting point.

Where should we begin?

Should we start by drawing new organisational boundaries? Should we create boards, appoint leaders and write terms of reference? Should we begin with a particular patient group, a clinical condition or a struggling pathway? Should we focus first on relationships between professionals, or should we wait for the governance arrangements to be settled?

These questions mattered because there was a real risk that neighbourhood care could become another exercise in organisational architecture. We could spend months designing structures while the daily experience of patients and clinicians remained unchanged.

I had seen enough of that approach.

Starting with clinical need

The conclusion I reached was that we should begin with clinical need.

We should identify the patients for whom the present model works least well. We should bring together the professionals who already care for them. We should understand where continuity is being lost, where responsibility is fragmented and where earlier intervention could make the greatest difference.

The structure should then support the work, rather than becoming a substitute for it.

This meant returning to the clinical challenges visible within everyday general practice. It meant thinking about people living with frailty and multiple long-term conditions. It meant examining how we support patients with heart failure, complex cardio-renal-metabolic disease and palliative care needs. It meant asking how community teams, hospital specialists and general practice could work together before a patient reaches a crisis.

It also meant restoring the voice of frontline general practitioners to the conversation.

Too often, healthcare transformation is discussed by people who are distant from the consulting room. Strategies are written, pathways are designed and governance structures are established. The frontline clinicians who understand how patients actually move through the system may be invited to comment only after the main decisions have been made.

Neighbourhood care cannot succeed in that way. It must be shaped by the professionals delivering care and, most importantly, by the people receiving it.

A different kind of re-engagement

Looking back, 22 April did not resolve the problems surrounding our Primary Care Network. It did not make the governance questions disappear, and it did not remove the tensions that had accumulated during the previous year.

What changed was my own sense of purpose.

I stopped asking whether I wanted to return to the old conversation. I began asking how I could help create a different one.

That meant moving the focus from positions to patients, from organisational control to clinical purpose, and from abstract discussions about collaboration to the practical work of building relationships across services.

It also meant accepting that change would need to begin somewhere specific. Neighbourhood transformation could not remain a broad ambition. It needed to be tested through real clinical work, with defined groups of patients, clear outcomes and the willingness to learn from what did not work.

The journey that followed has involved clinical transformation within my own practice, conversations with community and hospital colleagues, and a growing conviction that good transformation begins with relationships. Pathways, governance and organisational arrangements still matter, but they should emerge in support of a shared clinical purpose.

For me, the journey began with a realisation.

When discussions about the future of healthcare become trapped in structures, politics and organisational interests, clinical leaders have a responsibility to bring the conversation back to care.