No New Money. No Neighbourhood Contract. So What Do We Do?

We talk about this all the time.

Resources are stretched. The ask is growing. Neighbourhood health is the direction, and the infrastructure isn't there yet.

Primary care leaders know this. The frustration isn't the context; it's what comes next. Or rather, what doesn't.

At PCN Plus this year, I embarrassed myself a little. I got quite passionate (more than I expected) about the frustration of trying to move the conversation forward. We all know there's no new money. We all know there's no neighbourhood contract. I was trying to say: so what do we actually do with that?

Leadership in Chaos

The Satir Change Model describes how systems respond to disruption. It moves through resistance, into chaos, the phase where the old model no longer fits, and the new one hasn't formed yet.

Effort goes in. Clarity doesn't come back out.

That is not failure. It is a predictable stage of change. But it doesn't make it easier to lead through, especially when the performance pressure remains regardless.

Perceived Heroes and Villains

At a talk I gave at Best Practice last year, I described the characters that tend to show up when change is being asked of a group.

The perceived hero. The perceived villain. The supporting cast.

And I use "perceived" deliberately, because these are not fixed roles. They are how people read each other in the moment.

Almost everyone in these rooms believes that more integrated working would improve patient care. That's rarely the divide.

The divide is resource and capacity.

➡️ Some people are trying to find a way forward regardless of the constraints.

➡️ Some people genuinely cannot see how to do it without more time, more money, more capacity than they have.

➡️ And some are watching both positions and trying to work out which one is more true.

The perceived villain is often just the person saying out loud what others haven't quite put into words yet. This takes a kind of courage, but it is not often seen this way.

This is what leadership in the chaos phase actually looks like. You're not navigating a values question. You're navigating a resource reality in a room full of people trying to figure out the same thing.

The Permission Question

There is also the pressure to be seen as doing something.

Neighbourhood working comes with a gravitational pull. Government direction, system expectations, peer pressure. Saying no, or even not yet, can feel like positioning yourself as resistant, difficult, or not a team player.

Saying yes to something with no additional resources, no contract, and no clear ask to some makes you look like you are endorsing a ridiculous strategy.

If you genuinely believe that more integrated working improves care for patients, this is your why, but you risk burning yourself out against the tide of “No money and No contract!!!!

If you believe it in principle but cannot see how to do it without more resources, it of course needs to be said, but what do we do from here?

Choosing not to pursue something is a legitimate strategic position. The networks that do it well make the choice deliberately, own it, and move on, rather than half-committing and burning out in the process or saying no and then spending all your energy on explaining your position.

The Options

So what are the options?

➡️  Keep naming the problem:  This has its place, but on its own, it doesn't move anything. If you want a more structured way to think through what your network should actually be doing, I've written a framework for that here.

This blog and framework help you think through what you must do, what you could do, the trade-offs, and the risks and implications

➡️  Hold steady: Sometimes the right call; not every workstream is ready to move, and burning resources on things that aren't is its own risk

➡️  Work with what exists: The small movements that are possible within current constraints

What now?

The temptation in the chaos phase is to keep raising the alarm or go quiet and just cope.

Neither moves things forward.

The work is staying focused on what can actually shift. The relationships, governance, small decisions while the bigger picture continues to form.

The context is hard. Everyone knows it. The question is what you do next.

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