Late in 2025, NAPC brought together senior health leaders from England and Wales for a two‑day event designed to deepen confidence in neighbourhood care, learn from international experience, and reflect on leaders’ roles in enabling change. Lawrence Hamilton, Executive Vice President with Kaiser Permanente (KP), offered insights from the KP system and helped shape the conversations throughout the event. This article reflects on one key element of leadership behaviour that surfaced during those discussions.
Shared Learning and Early Energy
The event opened with an overview of Kaiser Permanente’s model and a comparison with the NHS. Although the two systems differ in structure and scale, several themes resonated strongly with participants. They included the power of intrinsic motivators—common purpose, autonomy, and mastery—and the importance of engaging practitioners through this lens. Leaders also discussed the value of focusing on available resources rather than wishing for more, shifting from activity‑driven measures to outcomes, and concentrating on a small set of high‑level aims: quality and patient experience, staff feedback, financial stability, and health equity.
By the end of day one, leaders left energised and motivated to translate these insights into practice. That momentum carried into the next morning. Participants shared examples of strong neighbourhood health approaches already happening across the system—innovations that were real but fragmented, not yet systemic across regions. An exercise early on day two revealed considered optimism. Participants rated their belief that neighbourhood care could deliver meaningful improvement within 18 months on a scale of 1 to 10. A few were at the margins: some deeply doubtful, others highly confident. Most clustered around seven or eight, a pretty optimistic outlook, tempered by realism.
Optimism Meets Reality
As conversations shifted toward day‑to‑day NHS realities, a different narrative emerged. We heard statements like ‘this can’t be achieved without new money’, ‘other organisations are getting in the way’, ‘governance needs to be fixed before we can progress’, and ‘we need to improve these metrics before we can start on neighbourhood’. This revealed a disconnect; optimism about the concept coexisting with a narrative of learned helplessness about the practical barriers.
The Pull of the Scarcity Mindset
This tension is familiar in both the NHS and health services globally. Chronic pressure, rising demand, and constrained capacity often fuel a scarcity mindset. When individuals and teams face sustained strain, they may respond with heroics followed by exhaustion, moral injury, and burnout. Common symptoms include “surviving the day,” guarding time and resources, assigning blame, cynicism, or gallows humour. Over time, the line between healthy scepticism and corrosive pessimism can blur. Leaders are not immune to this erosion.
Why Leadership Narrative Matters
Alasdair MacIntyre, a Scottish philosopher said, “I can only answer the question, ‘What am I to do?’ If I can answer the prior question, ‘Of what story do I find myself a part?’” The stories leaders tell impact what people and teams do.
Major system change requires overcoming the gravitational pull of the status quo. Leaders must help people believe that positive change is not only possible but worth pursuing. This does not mean ignoring difficulties—acknowledging the realities of the current state is essential. But it does mean intentionally building a dominant narrative that inspires agency rather than resignation.
Humans naturally give more weight to threats than to progress. Without deliberate counter‑balance, fear and frustration can dominate. Effective leaders work relentlessly to articulate a compelling big picture, highlight signs of improvement, and reinforce the intrinsic motivators of purpose, autonomy, and mastery. This is how they help teams stay focused on what they can influence—even when progress is uneven.
A Leadership Opportunity
The experience senior leaders from England and Wales gathered by NAPC exemplified this duality: they demonstrated belief in the future while sometimes reinforcing the tendencies that make progress feel out of reach. Neighbourhood health will succeed only if leaders consistently choose courage and intentionality—choosing to amplify a constructive narrative, strengthen agency, and empower people across the NHS to help build the neighbourhood health they, and we, passionately want it to become.
