Prof Andy Brooks
NAPC Clinical Chair
Have you had a chance to read the recently published government guidance on Neighbourhoods? If not, here is a one-page summary. I have been reflecting on the growing tension at the heart of these reforms. On the one hand, we have an NHS system that is focused on targets—access standards, waiting times, activity measures. On the other, as part of wider public reform, we are being asked to build something quite different: neighbourhood health, rooted in relationships, communities and people’s lives.
Both matter, and yet, at times, they feel fundamentally at odds.
The comfort of the metronome
The NHS has, over many years, become very good at using targets, perhaps even too good. There is a certain comfort in them. They provide clarity, comparability and a sense of control. We can see where we are, track improvement, and hold organisations to account. Targets act a bit like a metronome: setting the tempo, keeping everyone in time, attempting to avoid chaos.
In a system as large and complex as the NHS, this matters. Without some shared rhythm, it would be difficult to ensure equity, consistency or public confidence. And yet, a metronome has its limits.
The reality of the band
Neighbourhood health is not a metronomic exercise. It is much closer to a band. It brings together different players—primary care, community services, mental health, local authorities, secondary care, and the voluntary sector. Each with their own instruments, histories and ways of working. Each contributing something essential.
But unlike a metronome, a band cannot function through rigid timing alone. It requires listening, adaption, trust and shared purpose.
The shift we are being asked to make—from hospital to community, from treatment to prevention—is not simply about relocating care. It is about moving from a largely transactional model to a deeply relational one. One that holds complexity, works across organisational boundaries, and is shaped by the communities it serves.
You cannot reduce that to a single beat.
Where the tension lies
The difficulty is not that targets are wrong, nor that neighbourhoods are right. It is that they operate with different logics. Whereas targets depend on standardisation, neighbourhoods depend on context. Targets measure activity and throughput, and neighbourhoods
create relationships and resilience. Targets assume that the system behaves predictably, however, neighbourhoods deal with people whose lives rarely do.
So, we find ourselves in a situation where we are trying to measure the success of a relational, community-based model using tools designed for an industrial, institution-based one. It is no surprise that the tension shows up. An over-reliance on targets can pull effort back into acute and organisational priorities, fragment neighbourhood working and reinforce the boundaries we are trying to dissolve. We end up optimising parts of the system, while missing the whole.
We see it when:
- A same-day access target competes with the time needed to build trust and continuity with someone with complex needs
- Reducing admissions becomes the dominant goal, rather than improving the conditions that lead to them
- Organisations are pulled back towards their own performance metrics, rather than leaning into shared community outcomes
In these moments, the metronome gets louder—and the band struggles to hear itself.
This is not because people are unwilling. Quite the opposite. Across the country, there is energy and commitment to making neighbourhood health a reality. At NAPC we have seen this as we support the National Neighbourhood Health Implementation Programme. But the gravitational pull of targets is strong. It shapes behaviour, attention and ultimately, what gets prioritised.
From metronome to conductor
A conductor does not ignore timing—but nor do they obsess over it. Their role is to hold the whole, balance the parts, draw out the strengths, respond to what is happening. In other words, to lead something that is inherently relational and dynamic.
In a neighbourhood context, this means:
- Holding national priorities alongside local realities
- Creating space for communities to shape what matters
- Supporting teams to work across boundaries, not retreat behind them
- Balancing performance with purpose
Targets still have a role. They can set a broad tempo. They can signal what matters at a national level. But they should not be trying to play every instrument.
A different kind of measurement
This also means rethinking how we measure success, we need to value:
- Continuity of care
- Patient and staff experience
- Strength of relationships
- Community wellbeing
The national neighbourhood guidance does start to address this balance—combining minimum goals with locally defined outcomes shaped by neighbourhood plans. The opportunity now is to harness that, rather than defaulting back to what is easiest to count.
Not everything that matters can be measured in beats per minute.
Implications for leadership
For leaders, this is not straight forward. It requires holding two different ways of seeing the world at the same time: the need for assurance, grip and delivery and the need for trust, adaptation and emergence. It means being willing, at times, to turn the metronome down. To create space for teams to listen to each other. To work with communities, not just for them. To accept that progress may look less tidy, but more meaningful.
It also requires a shift in how we think about control. Neighbourhood working is as much about ceding control as it is about exercising it. About creating the conditions in which others can contribute, rather than directing every move. At NAPC we have a leadership development programme designed to equip those developing neighbourhood health to do just this.
