Special Article: Navigating the NHS Desert Island – Principles, Challenges, and the Path Forward

Reimagining the NHS Desert Island

The ingenious concept introduced by Ray Plumley, which encourages individuals to reflect on their lives using eight musical tracks, a book, and a luxury, has long captured my imagination. Remarkably, this idea has endured for even longer than the NHS itself. In this context, it is not too far-fetched to substitute those eight tracks with core organisational principles essential for an institution in its 77th anniversary year, deeply rooted in the contemporary political landscape of the United Kingdom. It’s also opportune as the Government prepares its 10-year plan of NHS reform, to review and reflect on tenets I considered essential to underpin any future NHS back in 2023.

Top Tracks: Non-Negotiable Principles for the NHS

• Workforce: Prioritising and developing a skilled, motivated, and sufficiently resourced healthcare workforce.
• Training and Education of Clinicians: Ensuring lifelong learning and continuous professional development for postgraduate doctors, along with recognised support for clinical and educational supervisors.
• Productivity and Capacity: Streamlining processes, removing unnecessary duplication, leveraging technology, and acknowledging the necessity for adequate capacity to ensure efficient care delivery.
• Clinical Leadership: Empowering clinicians to design, shape, and actively participate in leadership roles within the NHS.
• Systems Learning: Focusing on the ongoing improvement of safety and quality within the health system.
• Governance and Ethics: Upholding robust governance frameworks and unwavering ethical standards to foster public trust and maintain transparency in decision-making.
• Global Research and Global Reach: Encouraging international collaboration and research to address global healthcare challenges, such as climate health and global health emergencies.
• Clinical Accountability and Autonomy: Promoting a culture of accountability while preserving the clinical autonomy necessary for delivering personalised, patient-centred care.

The NHS at a Crossroads: Pride and Public Perception

Two years ago, Dan Wellings highlighted in his King’s Fund blog that, seventy-five years after its founding, the NHS remains the institution that most inspires pride among the British public. Paradoxically, it also received its lowest ever approval ratings for service provision in the same period, as reported by the very people who value it most.

This apparent contradiction may stem from a tension between the original utilitarian principles underpinning the NHS and a growing focus on individualism and rights, a societal shift that gained momentum in the late twentieth century and now propels the demand-driven culture of the twenty-first. No matter how inventive the funding model, it is unlikely to adequately support a system fuelled by individual demand while maintaining universal, free-at-the-point-of-need provision. This dilemma remains unresolved, and the prospect of an independent NHS – akin to the Bank of England model -guiding the institution’s core pillars for the future appears distant. At nearly seventy-seven, the NHS continues to face an existential crisis.

Public Satisfaction and the Challenge of Universal Care

Looking at the 2022 British Social Attitudes survey, the primary reason for public satisfaction with the NHS – cited by 78% of respondents – was its free-at-the-point-of-use principle. The pressing question, then, is how to construct a realistic, fair, and sustainable system of universal healthcare for the twenty-first century that continues to meet the ‘needs of the many’.

Acknowledging Division and the Need for Change

A first step is to recognise the necessity for change, not as a reaction to political expediency but as a strategic overhaul of our ambition for the nation’s health. The NHS, which we treat as a unified national institution, is already divided – marked by devolved administrations and by primary and secondary care sectors with distinct funding principles. The traditional gatekeeping role of primary care physicians is weakening, just as new commissioning and service delivery systems in England struggle to become established.

Some argue that the gatekeeping approach is outdated but eliminating it without developing alternative ways to manage unlimited demand is placing the system under unsustainable pressure and leading to unintended, often detrimental, patient outcomes. A notable consequence is the growing disparity in health outcomes between those experiencing poverty and those in more privileged socio-economic circumstances.

The Impact of Social Determinants on Health

There is extensive literature on how social determinants – such as poverty, inadequate housing, and poor air quality – contribute to health problems like cardiovascular, cerebrovascular, obesity, substance dependency, and chronic respiratory conditions. While the COVID-19 pandemic starkly revealed these issues, they are far from new. Social deprivation remains a powerful predictor of mortality from all causes, and addressing these determinants may be the most crucial factor in developing a sustainable healthcare strategy. These arguments are echoed in publications as diverse as The Big Issue and the BMJ.

Reorganisation in a Challenging Climate

A second complicating factor is the decision to reorganise both NHS structures and commissioning in England immediately following a pandemic. While this may be justified in the long term, the transition has introduced additional uncertainty and reluctance among clinical leaders to commit to long-term, strategic change.

Before implementing change, certain realities must be acknowledged:

• – Funding approaches should follow clinical strategy, rather than dictating it.
• – The interface and interdependence between health and social care requires urgent attention.
• – Preventative healthcare and rehabilitation medicine must be given equal emphasis and developed in partnership.
• – High standards of palliative and end-of-life care should be the standard for all, regardless of geography.
• – In a system free at the point of delivery, there will always be a need for rationalisation and prioritisation of care—this should be led by clinicians.
• – Service models based on single diseases will become less relevant over time; services should be organised around clusters of conditions (for example, metabolic medicine or Geroscience, as highlighted in the CMO’s 2023 report for England).
• – Acute medical and surgical service requirements can be predicted, so workforce and bed capacity planning should be based on known needs, rather than continuing to reduce inpatient bed numbers.

 

To illustrate this last point, acute hospital bed numbers have fallen by 44% over the past three decades. In 2017, the NHS set a safety benchmark of operating at no more than 92% capacity; the Royal College of Surgeons and the Royal College of Emergency Medicine have suggested a safer threshold is 85%. Both figures have been regularly exceeded since 2018. Recent Health Foundation analysis suggests that, just to maintain 2018/19 levels of care as the population ages, the NHS will require an additional 23,000 to 39,000 beds by 2030/31 – the equivalent of 38 to 64 hospitals and at least £17 to £29 billion in capital investment. This far exceeds current expansion plans.

Socio-Political and Economic Context

The broader social, political, and economic environment makes these priorities even more urgent. Office for National Statistics data reveal that NHS productivity has declined since 2018, but it is inadequate capacity – rather than workforce numbers alone – that is impeding improvement.

Choosing a Single Essential Principle

Returning to our ‘desert island’, where one is asked to select the single most vital track for survival, my personal choice would be Autonomy and Accountability. These two concepts, at many levels, are the glue that holds NHS professional activity together and should underpin all new structures and services. As a profession, we must advocate for managerial (leadership) accountability, financial (governance) accountability, and clinical accountability—closely linked to continuity of care.

The erosion of both accountability and clinical autonomy may help explain the high levels of burnout and dissatisfaction among professionals. Only a third of consultants report feeling in control of their workload some or all of the time. When accountability is lost from everyday clinical practice, tasks become disconnected from patient outcomes and from building meaningful professional relationships -both key to job satisfaction. It is reasonable to suggest that a decline in autonomy has contributed to reduced wellbeing among doctors in training and I have previously reflected on the importance of clinical, professional, and personal autonomy for clinician wellbeing, and in sustaining long-term commitment to healthcare careers. Of all the ‘tracks’ to salvage, this is the one I would save above all others.

The Book and the Luxury

Finally, in the tradition of the radio show, comes the choice of a book and a luxury. For those outside of the clinical world wishing to better understand the priorities and common sense that underpin good medical practice, Being Mortal by Atul Gawande is an excellent choice. This moving and insightful book highlights patient-centred medicine and echoes the contemporary calls for ‘referring wisely’, ‘realistic medicine’ and the importance of seeing the person, not just the patient.

As for a luxury, it is difficult to justify indulgence in these difficult times. However, borrowing from the spirit of another well-known television show, we should all give ourselves space and time to “phone a friend” in times of personal doubt or clinical uncertainty.

[Article originally published July 2023.]

Photo copyright: Freepik