Can the NHS Be Fixed With a New Plan?  How To Avoid Repeating The Mistakes Of The Past.

The NHS is broken according to the UK Prime Minister. The NHS is at a crossroads once again, with fresh discussions of reform and yet another plan being proposed aimed at ‘fixing’ what’s deemed a broken system. But will a plan work? Can we learn from how other plans failed to avoid repeating the mistakes of the past?

Why Is the NHS Broken?

Lord Darzi created a report that provides plenty of  evidence that the NHS is broken. In this post, I discuss how by understanding why the NHS is broken and the causes of the current crisis, we can transform the NHS into a service that not only helps people who are sick, but actively works to prevent them getting sick in the first place.

A History of Plans To Fix The NHS

Whilst the attempt to ‘fix’ the NHS is admirable, there’s plenty of evidence these grand plans won’t work. Since 2012, we’ve seen no fewer than five different plans to reform the NHS, each heralded as the solution. 

Since 2012, there have been several significant plans and reforms aimed at improving the NHS. Here are some of the key initiatives:

1. The 2012 Health and Social Care Act: NHS plan decentralised control, increased competition, and gave budgetary power to GP-led Clinical Commissioning Groups to improve efficiency and patient outcomes.
2. 2014: Five Year Forward View – This plan set out a vision for the future of the NHS, focusing on prevention, integration of services, and patient-centered care1.
3. 2019: NHS Long Term Plan – This plan aimed to improve the quality of care and health outcomes over the next decade. It included commitments to increase funding, integrate care services, and address workforce shortages2.
4. 2021: Health and Care Bill – This bill aimed to reverse some of the reforms introduced under the Health and Social Care Act 2012. It focused on reducing bureaucracy and encouraging closer collaboration between health services34.
5. 2022: Elective Recovery Plan – This plan was introduced to tackle the backlog of elective surgeries and treatments that had built up during the COVID-19 

The NHS Planning Results: A Broken NHS.

This was a lot of change to happen and after a big kerffufle things settled into the old familiar problems.The recurring failures aren’t due to a lack of planning. I would argue that the fundamental premise is wrong. Rather than a plan being a pathway for success, it is actually a cause of failure. Every time a grand plan is implemented a new plan is needed to fix the problems created. 

The NHS Planning Fallacy

The idea of a plan is that a small number of powerful people in the centre, can diagnose the problems with the NHS and come up with a fix. But a centrally devised plan can address the deep-rooted, multifaceted issues facing a health system serving over 70 million people with an increasing aged and unhealthy population. So we seem to be going around in circles as I point out in my blog post about the bureaucratic approach to change. 

The Machine Metaphor: A Misguided Approach

Describing the NHS as “broken” and proposing to “fix it” perpetuates the same old outdated machine metaphorm, one where a few leaders at the centre can diagnose problems and implement quick fixes, like repairing faulty parts in an assembly line. But the NHS isn’t a machine; it’s a complex, living system that evolves continuously.

In fact, the “machine thinking” approach often creates more issues than it resolves. Implementing a top down solution tends to generate unforeseen consequences, leading to additional plans and layers of management, rather than empowering frontline leaders to make a real difference.

A Complex System, Not a Sausage Machine

The NHS is the fifth largest employer in the world, with 1.6 million employees and an ever-increasing range of treatments and interventions. It serves a diverse population, of 70 million people, with unique health and wellbeing needs spanning from birth to old age. How can a single plan, no matter how well thought out, capture this complexity?

Unplanned for Demand

Evidence suggests that the NHS’s issues aren’t simply management failures or resource constraints. Instead, they’re symptoms of a healthcare system stretched by an ageing population, the increasing prevalence of chronic diseases, and widening health inequalities. These challenges require a more nuanced approach than simply following a checklist of objectives and targets.

Increasing Complexity of Healthcare Needs

The NHS is truly complex and getting more complex all the time, as we have an ever expanding range of drugs treatments and interventions for a population that is both getting increasingly elderly and unhealthy with an increasing number of mental health issues across the whole population. 

The Pitfalls of Centralised Planning

Each new plan since 2012 has been followed by a cycle of setting new targets, monitoring progress, and reporting KPIs. Essentially telling everyone what to do. This has resulted in clinicians and frontline workers spending more time proving their compliance with these targets rather than addressing the real needs of patients right in front of them. This is illustrated by the growing backlog and record-breaking A&E waiting times, of 7.8 million (in the latest figures) which disproportionately affect the elderly and those with mental health challenges. For example, in December 2023, a third of patients over 80 had to wait more than 12 hours in A&E​. (Kings Fund)

Has the endless planning targets, reporting KPIs, business cases and micromanagement of everything in the NHS created an NHS empowered to respond to people’s needs. The broken label suggests not. The reality is that no plan devised by a small group of policymakers can encapsulate the lived experiences and day-to-day operational challenges faced by frontline staff. 

Rethinking the Planning Approach to Fix The NHS

If we want to truly ‘fix’ the NHS, we need to shift our approach from centralised planning to empowering local teams and communities. This doesn’t mean abandoning plans altogether, but rather reframing them as flexible frameworks that enable staff to respond to local needs and make decisions based on what they observe.

By promoting local autonomy and encouraging problem-solving at the frontline, we allow clinicians and communities to co-create solutions. Research has shown that local teams that set their own goals and have the freedom to experiment can produce more meaningful improvements than those dictated by a central authority​.

Frontline Leadership by Example.

For example, in Costa Rica, a community-driven approach to healthcare has successfully reduced health inequalities at a much lower cost than top-down interventions in wealthier countries like the UK​. (CommonWealth Fund)

The NHS should also look at integrating a more holistic approach that considers the social determinants of health: such as housing, education, and community support systems, when addressing health outcomes. These are factors that frontline staff are often acutely aware of, but that get overlooked in broad, one-size-fits-all national strategies.

The Way Forward: A Plan for Empowerment to Fix the NHS

Instead of another top-down reform plan, we should focus on a strategy that enables the NHS to respond dynamically to the challenges it faces. This includes:

1. Decentralising Decision-Making: Allowing local health teams to take ownership of solutions that work best in their communities.
2. Supporting Community-Based Care: Shifting the focus from hospitals to community-led interventions, as evidence shows they can address health issues more effectively and at a lower cost.
3. Focus on Prevention: If we can stop people getting sick in the first place and enable them to manage their conditions better we will reduce the demands and pressures on the NHS and fulfil the NHS core role.
4. Embracing Complexity Science: Viewing the NHS as a complex system where change happens through small, iterative improvements rather than grand redesigns.

Conclusion: Embracing Complexity, Not Fighting It

We need to abandon the idea that the NHS can be fixed with a single plan. Instead, we should embrace the inherent complexity of the system and focus on empowering people at all levels: staff, patients, and communities, to contribute to solutions. Real progress will come not from imposing more plans and targets, but from fostering an environment where innovative solutions can emerge from the ground up.

The NHS is not a sausage machine. It’s a living, breathing organisation intertwined with the health and wellbeing of every person in the UK. And it’s time we started treating it that way.