Holding the
neighbourhood

Neighbourhood working is usually described through structures, pathways, contracts and outcomes. Less is said about the emotional work required to bring people together when authority, responsibility and influence do not neatly align.

In East Staffordshire, neighbourhood development brings general practice into conversation with community services, the acute trust, the integrated care system, local government, voluntary organisations and local communities. Each enters with different responsibilities, pressures, histories and sources of authority.

The place itself is not homogeneous. The needs of deprived urban communities in Burton are not identical to those of the surrounding semi-rural and rural populations. Practices differ in size, capacity, relationships and readiness for change. Organisations may agree on the ambition of integrated care while disagreeing about geography, governance, resources, leadership and pace.

This is not simply an organisational task. It is a leadership challenge shaped by uncertainty, identity, power and emotion.

The hidden work beneath the structure

Arlie Hochschild developed the idea of emotional labour to describe the management of feeling and emotional expression as part of work. There can be a gap between what someone genuinely feels and what their professional role expects them to display. Maintaining that gap repeatedly has a cost.

Neighbourhood leadership creates its own version of this labour.

Those trying to bring people together are expected to remain calm when discussions become tense, optimistic when progress is slow and receptive when their ideas are challenged. They must listen to resistance without becoming defensive, challenge decisions without damaging relationships and continue to show confidence when the direction remains uncertain.

From my position as a GP partner at Carlton Group Practice, I experience the need for neighbourhood working first through the consulting room. Fragmentation is not an abstract system problem. It appears when patients struggle to move between services, when responsibility is unclear and when the practice is left to coordinate care across organisational boundaries.

That creates an understandable urgency. Yet the wider system moves through consultation, governance, business cases and negotiation. The emotional tension lies in seeing the consequences of fragmentation today while trying to influence arrangements that may take years to change.

One of the hardest tensions in system leadership is feeling responsibility for progress without controlling the organisations, resources or decisions on which progress depends.

What kind of problem are we facing?

Keith Grint's distinction between critical, tame and wicked problems provides a useful way of understanding why neighbourhood working becomes so emotionally demanding. The categories are not fixed. A single programme can contain all three, and different stakeholders may frame the same situation differently.

A critical problem is a crisis requiring immediate action. When a vulnerable patient is at imminent risk, someone must establish priorities and coordinate the response. Prolonged consultation would be inappropriate.

A tame problem is not necessarily easy. It may be technically complicated, but there is reasonable agreement about the problem and sufficient expertise to address it. Establishing the terms of reference for an MDT or creating a reliable referral process may be difficult, but these tasks can be managed.

The overall development of neighbourhood working is different. It is a wicked problem because there is no single agreed definition of either the problem or the solution. Are we trying to improve access, reduce hospital use, strengthen general practice, address inequalities, integrate services, manage financial pressures or create new provider structures? All may matter, but different stakeholders will rank them differently.

Geography also changes according to the lens being used. Registered practice populations, deprivation, community identity, local authority boundaries and existing service footprints do not always produce the same map. The needs of inner Burton may justify a different response from those of outer Burton and the surrounding communities.

Moving one part of the system affects another. Shifting care closer to home has consequences for workforce, clinical risk, estates, information governance and funding. Greater integration may improve coordination, but it can also create legitimate concerns about organisational control, practice sovereignty and accountability. These concerns are not obstacles sitting outside the problem. They are part of the problem itself.

Problem framing is an exercise of power

Problem framing is the process through which we decide what the problem is, where its boundaries lie, whose knowledge matters, who should lead and what will count as success. It is not a neutral analytical exercise.

If neighbourhood working is framed mainly as a structural problem, the response will centre on organisational charts, contracts, boards and job descriptions. If it is framed as a financial problem, funding flows and organisational risk will dominate. If it is framed as a performance crisis, urgency may be used to justify centralised authority and restricted consultation.

A population-health and relational frame produces different questions. Do our arrangements reflect the different needs of inner and outer Burton? Do resources follow deprivation and complexity? Does frontline general practice have a meaningful voice? Are patients, communities and frontline teams helping to define what matters?

The frame determines not only the proposed solution, but also who is invited into the room.

This is why disagreement should not automatically be labelled resistance to change. It may express anxiety about legitimacy, the memory of previous failed transformations, concern about concentrated power or uncertainty about what practices are actually being asked to join. Listening to those concerns is not a retreat from leadership. It is part of diagnosing the problem honestly.

Five questions that test the frame

1. Who has defined the problem in this way?
2. Whose experience is included in that definition?
3. Whose voice or knowledge is missing?
4. What form of authority does this framing legitimise?
5. What becomes visible, or invisible, because of it?

When a wicked problem is made tame

There is a temptation to present neighbourhood transformation as a sequence of implementation tasks: agree the geography, appoint leaders, establish governance, create integrated teams and begin delivery. Each task may be necessary. Together, however, they do not automatically create integration.

A governance structure cannot manufacture trust. A job description cannot confer legitimacy. A new meeting cannot guarantee collaboration. A memorandum of understanding cannot ensure that organisations will share power or behave differently when under pressure.

When a wicked problem is made tame, plans create an expectation of certainty. If progress stalls, the response is often to produce more plans, hold more meetings or impose tighter deadlines. Failure may be attributed to poor engagement rather than to an incomplete understanding of the problem.

This creates emotional labour throughout the system. Those leading the work feel required to project confidence in uncertain arrangements. Frontline clinicians feel pressure to endorse structures whose consequences are still emerging. Practice leaders try to remain constructive while protecting their organisations and patients. Frustration becomes personalised even when it has been produced by the frame itself.

When a wicked problem is made critical

Urgency is not false. Patients experience fragmented care now, inequalities persist and the sustainability of frontline services cannot be ignored. Yet framing the whole task as a crisis can narrow participation and centralise authority.

Disagreement may then be treated as obstruction and consultation as an unaffordable delay. Decisions can be made quickly, but without the local ownership required to sustain them. Compliance is mistaken for collaboration.

Leadership does not require universal agreement before every decision. Sometimes movement is necessary despite uncertainty. The test is whether urgency is being used to protect patients and enable action, or to avoid legitimate questions about power, representation and accountability.

The danger of emotional over-responsibility

My own instinct is to respond to complexity with energy. When I see a clinical problem, I want to understand it, connect the right people and begin building a practical response. In frontline general practice, that instinct is often useful.

In system leadership, however, energy can become emotional over-responsibility. The leader starts to believe that if they communicate more clearly, attend one more meeting or produce a better proposal, the system will move. When it does not, the lack of progress feels personal and the leader invests still more energy.

This is particularly difficult when leading through influence rather than formal authority. A person may carry the emotional burden of the work while the decisive power remains elsewhere.

Resilience requires me to distinguish between my responsibility to contribute and my ability to control the outcome. I can bring the experience of Carlton Group Practice, advocate for patients, build relationships, propose practical models and ask difficult questions. I cannot make other practices or organisations choose a particular direction.

The boundary between contribution and control is not an excuse for passivity. It is a condition of sustainable leadership.

Resilience is not simply endurance

Emotional resilience is often described as the ability to recover from difficulty. In neighbourhood leadership, I increasingly understand it as the ability to remain in the right relationship with the problem.

It means being decisive when a critical situation requires action, disciplined when a tame problem requires reliable management and humble when a wicked problem requires collective learning. It also means recognising the difference between containing anxiety and absorbing it.

This kind of resilience rests on five disciplines:

1. Treat emotion as information. Frustration may reveal a gap between responsibility and authority. Defensiveness may signal that identity or legitimacy feels threatened.
2. Match the response to the problem. Use command for genuine crises, management for solvable processes and collaborative leadership for contested questions.
3. Replace reflexive resistance-management with curiosity. Ask what disagreement may be communicating before trying to overcome it.
4. Protect boundaries and share ownership. Responsibility without authority, time or collective support is not sustainable.
5. Know when to step forward and when to step back. Continued intervention sometimes adds heat rather than insight.

Stepping back is not necessarily withdrawal. It can allow practices and system partners to reveal their positions, exercise their own authority and accept responsibility for the direction they wish to pursue.

Holding the neighbourhood rather than owning it

No individual and no single organisation can own the solution to neighbourhood working in East Staffordshire. General practice cannot deliver integration alone. Neither can the acute trust, community services, the integrated care system, local government or the voluntary sector. Each holds part of the knowledge, authority and resources required. None holds all of them.

The work must therefore be built through distributed leadership, clear governance and practical collaboration. It must remain anchored in patient need while recognising the distinct circumstances of inner Burton, outer Burton and the wider East Staffordshire population. Relationships must come before pathways because pathways rarely survive where trust is absent.

Sometimes neighbourhood leadership means providing a clear answer. Sometimes it means establishing a reliable process. At other times, it means helping people remain with a difficult question long enough to understand it differently.