Seeing the system clearly: Why neighbourhood working needs a ‘Diagnostic first’ approach

Phil Whatling is a GP partner in North Devon with interests in continuity, system behaviour and the everyday realities of general practice. He is on LinkedIN

Those of us working in general practice can feel the system shifting again. This time the shift is towards neighbourhood working. The Neighbourhood Health Framework sets out a clear ambition. Care organised around natural communities. Integrated teams. Better access. More proactive care. Stronger relationships with community partners.¹

The ambition is right, but the conditions we work in every day tell a more complicated story.

Across the country, practices are working in systems shaped by rising demand, fragile continuity, uneven digital maturity, stretched community teams and relationships that vary from place to place. Rurality and transport barriers shape behaviour in ways that policy documents rarely acknowledge. Many Multi-Disciplinary Teams (MDTs) exist on paper but struggle to hold shared work. Digital tools often increase workload rather than reduce it. Staff feel the emotional weight of a system that is always slightly beyond its limits.

Neighbourhoods will inherit all of this. If we do not understand the conditions we are standing on, we risk building structures that collapse under their own ambition.

Some places have already shown what it looks like to work differently. Stockport developed neighbourhood working around local communities, bringing together health and social care teams with voluntary and community organisations.² Wigan invested deeply in relationships, community power and staff experience, with independent evaluation showing the importance of cultural change and long-term commitment.³ Tower Hamlets built integrated working on long-standing relationships and collaboration across organisational boundaries.⁴ Cornwall has adapted its models to the realities of a dispersed, rural and coastal population, where geography creates significant access and service delivery challenges.⁵ North West London developed shared information systems that allow professionals across services to access relevant information and support population health management.^6,7 Scottish experience of primary care MDTs shows the importance of the practical conditions and capability needed to make multidisciplinary working effective.^8,9

These places did not start with structure. They started with diagnosis.

A diagnostic approach

A practical way of doing this diagnostic work deliberately is to bring together six complementary lenses. They draw on ideas from organisational theory, relational coordination, place-based care research, implementation science, primary care evidence and human factors. The six lenses are: Structure. Trust and Relationships. Reality of Place. Intelligence. Delivery Capability. Experience (I find that STRIDE makes a memorable acronym).

‘Structure,’ asks how the system is built. Where demand originates. How people move. Whether boundaries reflect real communities. Where assets and gaps sit. Stockport’s experience shows the importance of organising neighbourhood working around local communities and bringing different parts of the system together around them.² When neighbourhoods are drawn around administrative convenience rather than lived reality, the system spends years fighting its own geometry.

‘Trust and relationships,’ ask how people work together. Who collaborates. Who avoids whom. Where psychological safety exists. Where it does not. Tower Hamlets illustrates how relationships can become the operating system of integrated care. Its long history of collaboration across health and care organisations was an important foundation for the development of Tower Hamlets Together.⁴ Without relational capital, MDTs become meetings rather than engines of shared work.

‘Reality of place,’ asks how geography shapes behaviour. Rurality. Transport. Deprivation. Community identity. Voluntary, Community, and Social Enterprise (VCSE) ecosystems. Anchor institutions. Cornwall showed that place is not a backdrop. It is a determinant. Its geography creates significant accessibility and equity challenges, with dispersed populations, extensive coastline and island communities requiring different approaches to service delivery.⁵ Neighbourhoods that ignore place end up designing for somewhere else.

‘Intelligence,’ asks whether teams have usable insight. Not dashboards. Not spreadsheets. Real situational awareness. North West London showed what becomes possible when teams share information across organisational boundaries. Its Whole Systems Integrated Care system allows professionals to see selected information from different care providers, while its neighbourhood dashboard supports a population health management approach.^6,7

‘Delivery capability,’ asks what the system can actually hold. Ambition is infinite. Capability is not. Scottish evidence on primary care MDTs illustrates the importance of understanding how multidisciplinary teams are implemented in practice and the factors that help make them successful.⁸,⁹ Below that threshold, MDTs can become coordination exercises rather than vehicles for proactive care. Capability is the limiting factor. Not enthusiasm. Not policy. Not goodwill.

‘Experience,’ asks what the system feels like for staff and patients. Experience is data. Wigan showed that listening to lived experience is not a soft exercise. It is a source of intelligence. Its work demonstrated that cultural change, staff autonomy, relationships and the experience of working differently with communities were central to the transformation.³

When you look through all six lenses, you end up with something rare. A system that can see itself. This becomes the current state. Not a report. A shared understanding. It reveals where the system is strong, where it is fragile, where the friction is, where the energy is, what the system is ready for and what it cannot yet hold.

Once the system can see itself, the sequence becomes clearer. Diagnose. Design. Test. Formalise. Scale. Taken together, these examples suggest a sequence that can help avoid the common pitfalls of structural overreach, relational fragility, digital overload and operational strain.

Neighbourhoods do not need bigger plans. They need better diagnostics. A six-lens diagnostic approach offers a way to understand the conditions that shape neighbourhood readiness. It does this not by adding complexity but by paying attention. It helps teams see the system as it behaves today rather than as we imagine it behaves.

Neighbourhood working is one of the most promising ideas in the NHS. But it will only succeed if we understand the conditions that shape it. A diagnostic first approach is a way of seeing those conditions clearly and designing with honesty, humility and compassion. It offers a practical starting point for safer and more sustainable neighbourhood implementation.

Deputy editor’s note – on a related theme by this author:

• https://bjgplife.com/when-the-system-only-sees-the-end-of-the-story-nottingham-jesss-rule-and-the-hidden-structure-of-tragedy-reviews/
• https://bjgplife.com/misfires-propagation-and-the-neighbourhood-layer-a-gp-view-of-demand-and-inequality/
• https://bjgplife.com/could-it-be-that-general-practice-isnt-running-out-of-appointments-but-running-out-of-resolved-work/

References

1. Department of Health and Social Care and NHS England (2026) Neighbourhood health framework. London: Department of Health and Social Care and NHS England. Available at: https://www.gov.uk/government/publications/neighbourhood-health-framework (Accessed: 11 September 2026)
2. New Local (2023) In Practice: Neighbourhood working in Stockport. Available at: https://www.newlocal.org.uk/practice/neighbourhood-working-stockport/ (Accessed: 11^th September 2026)
3. Naylor, C. and Wellings, D. (2019) A citizen-led approach to health and care: Lessons from the Wigan Deal. London: The King’s Fund. Available at: https://www.kingsfund.org.uk/insight-and-analysis/reports/wigan-deal (Accessed: 11 September 2026).
4. Tower Hamlets Together (n.d.) About Tower Hamlets Together. Available at: https://www.towerhamletstogether.com/about(Accessed: 11 September 2026).
5. NHS Cornwall and Isles of Scilly Integrated Care Board (2025) Our Green Plan 2025–2030. Available at: https://docs.cios.icb.nhs.uk/DocumentsLibrary/NHSCornwallAndIslesOfScilly/Organisation/StrategicReportsAndPlans/EnvironmentalSustainability/OurGreenPlan2025To2030.pdf(Accessed: 11 September 2026).
6. NHS North West London (n.d.) Whole Systems Integrated Care (WSIC). Available at: https://www.nwlondonicb.nhs.uk/professionals/digital-and-it/whole-systems-integrated-care-wsic (Accessed: 11 September 2026).
7. NHS North West London (n.d.) Whole Systems Integrated Care (WSIC): Information for care professionals. Available at: https://www.westandnorthlondon.icb.nhs.uk/our-work/programmes/whole-systems-integrated-care-wsic/information-care-professionals (Accessed: 11 September 2026).
8. Scottish Health Technologies Group (2023) An evidence review on multidisciplinary team support in primary care. Healthcare Improvement Scotland. Available at: https://shtg.scot/our-advice/an-evidence-review-on-multidisciplinary-team-support-in-primary-care/ (Accessed: 11 September 2026).
9. Public Health Scotland (2024) Primary care reforms: Multidisciplinary team feedback survey. Available at: https://publichealthscotland.scot/publications/primary-care-reforms-multidisciplinary-team-feedback-survey/primary-care-reforms-multidisciplinary-team-feedback-survey/ (Accessed: 11 September 2026).

Featured photo by Randy Fath on Unsplash