When I first stepped into a leadership role in primary care it was almost entirely inward-looking. My job, as I understood it then, was to engage GP practices, build trust, and find some quick wins that proved working together was worth the effort. I concentrated on service delivery: shared roles, extended access, smoothing operational problems. Outcomes were discussed, of course, but if I’m honest, they were rarely tracked effectively and often got lost as service design took centre stage.
That approach made sense at the time. We were entering a new and fragile world of primary care at scale. Practices were tired, sceptical, and understandably protective. Much of our collective energy went into holding things together – convening partners, mediating tensions, and translating national policy into something that wouldn’t immediately collapse under local pressure. Leadership felt very much about stewardship and survival.
Over the last few years, something has shifted – both in what the system is asking of us, and in how I understand my own role within a wider leadership team.
In recent months, my time has been spent less exclusively in clinical or operational spaces and more out in the community, alongside colleagues from across primary care, local government and the voluntary sector. Together, we’ve met with local businesses to talk about health and employment, appeared on local radio, sat down with councillors and our MP, and hosted roadshows in supermarkets to listen to people who would never normally engage with the NHS in more formal ways.
None of that looks much like “service delivery” in the traditional sense. There are no immediate KPIs, no clear outputs, no neat project plans. And yet, paradoxically, this work feels far more focused on outcomes than much of what we did before.
What’s changed is my understanding of control – and of leadership.
Earlier in my leadership journey, I implicitly assumed that progress came from designing the right service and then implementing it well. If outcomes didn’t follow, the answer was usually more structure, tighter governance, or another iteration of the model. Increasingly, both through experience and through challenge from colleagues, I’ve come to see how limited that mindset is when we talk about neighbourhoods.
Neighbourhood working isn’t something a single organisation – or leader – can deliver. It’s not a service you own, a contract you hold, or a pathway you manage. It’s an ecosystem. And effective leadership within it is necessarily shared.
My role has become less about directing activity and more about convening people who each hold different pieces of the puzzle. Less about certainty and more about creating space for conversation. Less about having the answer and more about ensuring the right voices are in the room – including those we don’t traditionally hear from.
That shift has required a different kind of leadership posture from all of us involved. One that is more comfortable with ambiguity, and more honest about the limits of our influence. Conversations with local businesses don’t lead neatly to action plans. Engagement with voluntary groups surfaces needs that general practice cannot – and should not – try to solve alone. Public conversations expose frustrations that don’t have quick fixes.
Leading in that space requires humility. The willingness to listen, to acknowledge uncertainty, and to recognise that progress often comes through relationships rather than structures.
This has been a journey, and it is far from complete. As a team, we still find ourselves slipping back into delivery mode, drawn to the reassurance of defined services and measurable outputs. That instinct is understandable – it’s how the system has trained us. But neighbourhood working demands something different.
If neighbourhoods are to succeed, leadership has to evolve before structures do. The future role of primary care leaders will be less about being the provider of everything, and more about being trusted connectors within a wider system. People who can bring partners together, hold difficult conversations, and maintain a shared focus on outcomes even when no one organisation controls all the levers.
That doesn’t mean abandoning accountability or service improvement. But it does mean accepting that some neighbourhood outcomes – whether reducing inequality, improving wellbeing, or strengthening communities – will be co-produced, messy and slow.
For those of us who have grown up in a system that rewards delivery, certainty and ownership, that’s an uncomfortable shift. But it’s also a hopeful one. Because when leadership moves beyond the walls of general practice and becomes genuinely shared across a neighbourhood, the conversation about health starts to change.
And perhaps that’s the change we need most.
Dr Duncan Gooch is chair of the Primary Care Network at the NHS Confederation and managing partner and clinical Director of Erewash Health Partnership, a consortium of practices that provides healthcare services to over 100,000 people. This is his first quarterly column for Pulse PCN.