At the end of October, the UK Health Secretary called on the entire nation to shape the government's plans to fix the NHS. Years ago, health improvement guru W. Edwards Deming argued that 94 percent of most possibilities for improvement can be found at the level of the system, not the individual. It's reasonable therefore to ask: what exactly is broken? It isn't the level of staff effort nor the intention to provide safe and appropriate healthcare free at the point of use. Rather, it is the systems within which the NHS operates that require serious attention.
Fixing Health and Care Systems
With a change in government and renewed discussions around growth, strengthening public sector productivity has become more urgent than ever. However, as discussed in a previous commentary, these issues cannot be resolved simply by incentivising staff with carrots, threatening them, or preaching to them. As Sam Freedman argues in his recent book, Failed State: “People matter, but systems matter more, and we will get nowhere until we fix our systems.”
It is time to address the bigger picture of the NHS. What would it take to deliver the three big shifts outlined by the Health Secretary: moving from hospital to community care, transitioning from analogue to digital, and shifting the focus from treating sickness to preventing it?
Of course, it is not just about systems. We also need to acknowledge the severity of the problems caused by chronically low spending levels. The UK would need to spend over 17 percent more on healthcare per person just to match Denmark in 2022—and even then, it would still fall short of what France, the Netherlands, and Germany spend.
Public sector healthcare productivity took a substantial hit during COVID-19 and has yet to recover.
Furthermore, low levels of capital investment in health have compounded these issues. Alongside this, there has been a national failure to address long-term challenges, even when the need for a long-term approach has been widely agreed. The issue of social care is a prime example. The damaging consequences of a short-term, Treasury-centred mindset have also diverted attention away from systemic, long-term change. The first module report of the UK COVID-19 Inquiry (PDF) reinforced the view of an NHS lacking resilience and preparedness: “This Report concludes that, in reality, the UK was ill prepared for dealing with a catastrophic emergency, let alone the coronavirus (COVID-19) pandemic that actually struck.”
Public sector healthcare productivity took a substantial hit during COVID-19 and has yet to recover. Meanwhile, as productivity struggles, waiting lists continue to grow. As the Darzi review of the NHS in England recently noted, care is deteriorating, even as frontline staff report they are working harder than ever.
What Needs To Be Done?
Fixing Systems
Problems in one system, such as healthcare, quickly have repercussions in others, like employment. Whole-systems thinking is required to address these issues. There are three systems connected to the NHS that are not fit for purpose and need to be changed over the next five years if we are to escape low productivity and underperformance in health and care. These systems underpin the government's three big shifts.
Decisionmaking
There is now a substantial body of literature on incorporating systems thinking into policymaking. But what about the policymaking system itself? The system is dysfunctional in at least three interconnected ways: it favours short-term views over long-term thinking, there is an uneasy division of responsibilities between overburdened central decisionmakers and local expertise, and it is poorly positioned to join up the multiple players at local and regional levels.Innovation and Improvement
NHS systems are designed to perform several important functions, but they do not systematically drive innovation and improvement. Instead, we have layered innovation initiatives on top of the core NHS systems, and they frequently do not work well together. We need a new approach that connects the systems supporting patient safety, professional autonomy, and managerial accountability to innovation. Early signs from NHS IMPACT (the new, single, shared NHS improvement approach) suggest that there are at least some foundations to build upon.
Reports by various bodies, including RAND Europe, have highlighted key barriers to innovation and what is needed to help successful innovations develop, spread, and scale up. Currently, there are multiple, disconnected programmes designed to promote innovation, but this is not what is needed. Instead, a more considered, long-term approach is required, with embedded evaluation practices to identify lessons and assess their broader applicability across the health and care system.
Improving healthcare also means creating a culture where improvement is part of everyday work. Quality improvement initiatives are often seen as additional work on top of the day job. However, as soon as attention shifts elsewhere or funding ends, there is a gravitational pull back to routine ways of working. The aim should be to embed improvement into job descriptions, performance indicators, professional training, and working culture.
Accountability, Evaluation, and Learning
In the public sector, accountability means being required to explain one's actions to the public or an organisational representative of citizens' interests, with consequences if this requirement is not met or if actions fall short of expected standards.
Accountability should be grounded in multi-level decisionmaking and should establish priorities for innovation and learning, driving performance proactively. Accountability to citizens should underpin all public policy and delivery; this is what distinguishes the public sector from private companies.
However, this foundation has fractured. To whom is the NHS accountable? The Minister, the public, patients, or professional integrity—none of these align well. The National Audit Office does great work documenting lapses in accountability but often lacks influence over decision-makers. Denmark is an example of healthcare services being held accountable for using data to improve quality; accountability can drive improvement. Restoring trust in government work involves demonstrating that government deserves this trust, which is challenging given some unavoidable realities:
- Involving multiple public and private providers risks patients and the public losing track of who is responsible and how to navigate the system.
- As more of us live with multiple health conditions, information about our needs becomes fragmented across various specialist services.
- We are only just beginning to understand how new technologies create new pathways to accessing appropriate health and social care, and our accountability systems are slow to adapt.
This means bringing together the patchwork of accountabilities into a coherent, public-facing system, unifying the disjointed organisations that currently form an almost unnavigable network—from local authorities to government departments, health commissions, boards, and more.
Success Means System Change
According to the UK Royal Academy of Engineering, “systems that work do not just happen; they need to be planned, designed, and built.” Success will resemble a social movement more than a rigid plan. It will start with people's experiences. It will reflect the horror over the deaths of nearly 30 children at Bristol Royal Infirmary, or the inadequate maternity and neonatal services revealed in recent years. It will draw on what young people are telling us about our mental health services. By engaging people on the meaning of prevention is better than cure, we will gain a more nuanced understanding of the balance needed. System failures were experienced by service users and professionals long before analysts tried to assess them, so let us use these experiences in designing better systems. We need to move beyond talking about a broken NHS and start building one that earns our trust and our taxes.
