Leo Tolstoy once wrote that happy families are alike, but each unhappy family is unhappy in its own way. However, when it comes to healthcare systems, both successful and under-performing systems share commonalities. Successful systems exhibit effective communication, clarity around roles, and shared values, while under-performing systems suffer from a lack of these essential characteristics and rely on overly transactional relationships between partners.

To achieve happiness in healthcare systems, a strategic plan that incorporates critical success factors becomes imperative. The concept of planning backwards, successfully employed in various industries, holds significant potential for system redesign in healthcare. By defining a desirable end-state, such as a healthier population, and working in reverse to determine the necessary steps, timelines, and responsible parties, healthcare systems can achieve a more sustainable and effective approach to population health.

Planning backwards can be effectively applied to system redesign in the healthcare sector, considering domains such as improved outcomes, digital maturity, and workforce sustainability.

Examples such as China’s barefoot doctors’ programme¹ and the development of health maintenance organisations (HMOs) in the USA demonstrate the effectiveness of this approach. In the UK, the NHS Long Term Plan serves as a roadmap for achieving sustainable and effective healthcare by outlining specific steps, such as increasing investment in primary care, developing digital health solutions, and promoting population health.

However, it’s crucial to acknowledge that much of the existing literature focuses on relatively small projects. The scalability of this approach to complex healthcare system redesign remains largely untested.

Nevertheless, planning backwards remains a valuable tool for healthcare strategists, designers and architects seeking sustainable and effective healthcare for populations. 

Amid the struggle between history and progress, the most powerful allies are patience and time. Despite the potential misalignment between political cycles and the need for long-term strategic planning, healthcare systems must invest time in developing clear visions for the future and work backwards to determine the necessary steps to achieve them.

Identifying past challenges in the NHS

Political decisions and actions have significantly impacted the NHS, creating a challenging environment that raises concerns about the service’s sustainability. The following factors highlight the issues that have affected the NHS.   

Privatisation

One such political move was the introduction of market-oriented policies, including the Private Finance Initiative (PFI) and outsourcing of services. The NHS lost control over key aspects of its services, with private companies being given contracts to provide services such as cleaning, catering, and IT. This led to concerns about accountability and quality of care, and hospitals built through PFI contracts were more expensive than traditional government borrowing. Lack of contractual transparency made them difficult to scrutinise, and the long-term nature of the PFI contracts often locked hospitals into expensive arrangements that were difficult to renegotiate when circumstances changed. On the positive side, because time is money to contractors, project delivery was accelerated, and contracts incentivised operators to maintain buildings to a higher standard than the NHS typically achieves.

Funding cuts

Funding cuts resulting from austerity measures have also affected the NHS’ ability to provide quality care to patients, resulting in staff shortages, longer waiting times, and reduced access to services. The Covid-19 pandemic highlighted the UK’s low position relative to other OECD members, in terms of bed numbers, diagnostic capacity, and workforce relative to population. Reductions in capital expenditure have been particularly damaging, according to a poll of NHS leaders conducted by the NHS Confederation in June 2022².

Reorganisation

From 1974 to the present day, the NHS has been in an almost continuous state of what the Socialist Health Association calls “redisorganisation”³. In particular, the 2012 Health and Social Care Act introduced significant structural changes, raising concerns about fragmentation and reduced care co-ordination. While these reforms have now been largely abandoned – “I could and should have stepped in earlier,” former Prime Minister David Cameron admitted in his memoir – there is widespread suspicion that political leaders, having drunk the reorganisation Kool Aid, are unlikely to abstain from more tinkering in the future.

Political interference

Political interference has also affected the day-to-day running of the NHS, leading to industrial disputes. 

Brexit 

Brexit has had a significant impact on the NHS workforce, as many NHS staff are from EU countries. The uncertainty surrounding Brexit has led to a reduction in the number of EU staff coming to work in the UK, making it harder for the NHS to recruit and retain staff. 

World pandemics

The Covid-19 pandemic has had a profound impact on the NHS workforce, with staff working long hours under extremely challenging conditions. The pandemic has also highlighted existing capacity and workforce issues, such as staff shortages and the need for greater investment in workforce development. While the impact was felt worldwide, some countries fared better than others, recalling Louis Pasteur’s observation “fortune favours the prepared mind”.

Workforce planning

The NHS has also struggled with workforce planning in recent years, with shortages of staff in key areas such as nursing and general practice. This has led to increased reliance on agency staff and locums, which can be expensive and affect the continuity of care.

New models of care

The NHS has been exploring new models of care, such as integrated care systems and primary care networks, which have the potential to improve the quality and efficiency of care. However, implementing these models requires significant workforce development and investment, which may be challenging given current funding constraints.

Perpetual transformation

Transformation should have helped the NHS adapt to changing patient needs and preferences, and to respond to new challenges and opportunities. Instead, the word ‘transformation’ has lost all meaning, and, as Nigel Edwards from the Nuffield Trust noted at the launch event for this year’s European Healthcare Design Congress, we’ve become enthralled by transformation for transformation’s sake and seem to have lost focus on for whom we’re changing the system. Transformation can be challenging and it requires significant investment, engagement and commitment from all stakeholders to achieve its full potential.

Potential future challenges for the NHS: Making decisions that could have catastrophic impacts

What are some of the potential policy decisions that would have catastrophic impacts on the NHS?

We could pay for healthcare through a mix of public and private sectors, where patients are required to pay for certain services, or resort to private healthcare, mirroring the model seen in some other countries.

We could increase fragmentation by ensuring healthcare services are provided by a range of different providers, thereby dispersing responsibility among numerous entities, ensuring co-ordination and continuity of care will suffer, truly hindering the ability to provide comprehensive integrated care, resulting in disjointed services.

We could shift towards a predominantly curative healthcare model, focused on treating illnesses rather than preventing them, and making more use of medicine and surgical solutions, reducing the focus on health, wellbeing and social prescribing. Relying heavily on medical and surgical interventions could overlook the importance of proactive measures and holistic approaches to maintaining health. Such an approach might prioritise reactive solutions over preventive measures, potentially burdening the healthcare system with increased demands in the long run.

We could enable all NHS hospitals and healthcare facilities to be operated by private companies for profit. This commercialisation of healthcare may prioritise financial gain over patient care and the public interest, ultimately raising concerns about accountability, quality of care, and the potential exclusion of vulnerable populations.

Other structures we could try include:

• bigger hospitals that serve larger catchments away from people’s local communities, resulting in longer hospital stays and more MRSA cases;
• smaller hospitals that are more convenient for patients but have fewer specialist doctors, not enough facilities, and for which finding staff is difficult;
• localised services, such as community treatment centres or Cavell Centres; and
• no hospitals, where we let nature take its course!

We could aim to please everyone all the time, with agreement by committee, resulting in slow progress and diluted outcomes. Balancing competing interests and achieving consensus can be a cumbersome process that risks stalling necessary advancements and reforms.

We could strive for a ‘fair’ distribution of healthcare by providing baseline services universally, regardless of geographical location or community-specific needs, which could inadvertently lead to a reduction in specialised care and tailored healthcare provision. This would also result in a one-size-fits-all system, failing to adequately address the diverse needs of differing communities.

Securing an alternative future for the NHS: What needs to be done differently?

As we strive to ensure a sustainable and successful future for the NHS, it’s essential to consider the necessary changes and actions that will pave the way for a transformed healthcare system. Let us explore the key areas where improvements can be made to secure an alternative future for the NHS. 

New funding

Integrated care demands innovative funding models that incentivise collaboration and joint working between health and social care providers. This entails exploring payment models, such as capitation, bundled payments, and integrated budgets that align incentives and support the delivery of co-ordinated, person-centred care.

Increased funding

To maintain and enhance the quality of care that the NHS provides, it’s imperative to secure additional funding. The Government could achieve this by increasing taxes, redistributing spending from other areas, or implementing other innovative funding mechanisms.

One option would be to increase taxation to generate additional revenue for the NHS. This could include a specific health tax or an increase in income tax, national insurance contributions, or corporation tax. Another option could be to introduce a wealth tax, which would target the assets of the wealthiest individuals and could generate significant revenue for the NHS.

The Government could redistribute spending to the NHS from other areas, such as defence or foreign aid. Integrating social care into the NHS and reforming the way it’s funded could provide additional revenue for the NHS and improve the quality of care for patients. Investing in public health initiatives and promoting preventive measures could reduce the burden on the NHS by preventing illnesses before they occur.

Encouraging innovation and the adoption of modern technologies in healthcare could reduce costs and improve the efficiency of the NHS. This includes investment in digital health solutions, such as electronic health records, telehealth, and remote monitoring technologies, to improve patient care and streamline operations.

Workforce development

Investing in workforce development, including education and training, is crucial to equip healthcare professionals with the necessary skills and knowledge to provide high-quality care. It also involves promoting interprofessional collaboration, team-based care, and cross-sectoral co-operation. The impact of apprenticeships versus traditional university degrees on the healthcare workforce, as suggested by Amanda Pritchard, chief executive of NHS England, should also be carefully considered.

Integration of care

Fundamental redesign of care pathways is essential to achieve integrated care. This means breaking down traditional silos between health and social care, and developing new models of care that prioritise patient needs. By improving the integration of care across different providers and settings, including primary care, community care, and hospitals, fragmentation can be reduced, and the continuity of care for patients can be enhanced.

Preventive care

Greater investment in preventive care, including public health initiatives, can significantly reduce the burden of preventable illnesses. These initiatives may encompass promoting healthy lifestyles, vaccination campaigns, and early detection and treatment of diseases. Social prescribing, championed by Professor Tony Avery, NHS England's national clinical prescribing director, is set to play a larger role in improving long-term health. Initiatives such as free gym memberships, meditation classes, virtual reality (VR) escapism, gardening, and debt management advice can help manage chronic pain, depression and anxiety more successfully, and avoid addiction and the consequences of side effects. 

Patient-centred care

Shifting towards a more patient-centred approach, involving personalised care plans and shared decision-making, can improve patient satisfaction and outcomes.

Establishing shared goals and objectives

Integrated care necessitates collaboration and agreement on shared priorities. This involves bringing together health and social care providers, commissioners, and patients to establish common goals and objectives aimed at improving population health and wellbeing.

Creating a truly integrated health and social care system is a continuous, long-term endeavour that demands unwavering commitment from all involved parties. By undertaking these steps, the UK can progress towards a more integrated system that delivers superior outcomes for patients and the wider population.

Transparent and clear communication plays a vital role in achieving this transformation. It must flow effectively throughout the entire organisation, from the top down, and extend beyond organisational boundaries. Robust communication channels must be established between different healthcare organisations, colleagues, and clinical staff, as well as patients and their carers.

In the absence of a complete transformation, it becomes crucial to conduct a comprehensive diagnosis of the underlying causes of the problems plaguing the NHS. Merely identifying the problems is not enough. This process requires a steadfast commitment to addressing the challenges that the system has the capacity to tackle.

Making decisions, even if they turn out to be imperfect, is preferable to indecisiveness. Any decision, whether right or wrong, propels progress. The absence of decision-making results in paralysing limbo, as is currently witnessed with the New Hospital Programme.

An effective strategy involves identifying the 20 per cent of issues that give rise to 80 per cent of the challenges faced by the NHS. By pinpointing and addressing these core issues, resources and efforts can be concentrated where they will have the greatest impact, enabling the NHS to overcome obstacles and move forward.

As the healthcare landscape evolves, establishing shared goals, effective communication, diagnosing root causes, making decisions, and focusing on the most significant challenges are critical steps towards securing an alternative future for the NHS. With dedication and collaboration, the UK can transform its healthcare system into one that meets the needs of patients and achieves optimal outcomes.

About the authors

Melanie Relf is healthcare strategy and planning associate director, and John Kelly healthcare strategy and planning associate at Lexica.