Why the NHS is Broken & How We Can Fix It

The National Health Service (NHS), has famously been labelled as ‘broken; by the new Minister for Health. This sentiment reflects widespread concern about the effectiveness of the system, but what is the real reason behind its struggles, and how can we fix it?

The Darzi Report Evidence For A Broken NHS

A recent report by Lord Darzi  found that the NHS is in ‘critical condition’. 

• That the health of the nation had deteriorated with many more suffering from long term conditions.
• Most of the key performance statistics are being missed by wide margins. 
• People are struggling to access healthcare including GPs and hospitals. With A&E waiting are at 74% being seen within 4hours vs a target of 
• Waiting lists for community and mental health services have also surged.
• Whilst hospital waiting lists have also ballooned. 
• Cancer has a higher mortality rate than other countries.
• The NHS budget is not being spent where it should be.

A Broken NHS Puts Targets Over People.

When of the core reasons that the NHS is broken is that it too often puts targets and processes over people. Whereas, according to its constitution, the core function of the NHS is to improve the health and wellbeing of the population

To do that the start and end point of the NHS MUST be the health and well being of the population.

But that is NOT the start and end point of the current NHS.

The start and end point is achieving targets through top down plans. Whether it’s reducing waiting times or meeting referral quotas, the system is reactive, not proactive. This means that care is often provided at the most critical, and therefore most expensive, stages, such as when patients are admitted to hospitals.

Consider the issue of waiting lists. As of July 2023, a staggering 7.7 million people were waiting for routine NHS treatment in England, the highest on record. This backlog puts immense pressure on hospitals, leading to delayed care, which can worsen health outcomes​. 

A Cycle of Failure Leading to a Broken NHS

Yet, every time a target is missed, the response is to create another plan. Put in place targets and actions and increasing controls and ‘assurances’ that the targets will be hit. When failure is inevitable it’s time for a new plan. I’ve described this cycle in detail in this post.

We have had year after year of big plans being implemented with much kerfuffle.

It is time to recongnise that approach does not work. We end up with expensive reactionary process which treats people after they get sick and when they are most at need. Meaning that we typically diagnose and treat people far too late and at the highest cost. (hospital)

Failure Demand is Breaking the NHS.

The NHS is overwhelmed by what John Seddon describes as “failure demand”. Using overly simple solutions to people’s complex problems violates Ashby’s Law of Requisite Variety. Resulting in the NHS being overwhelmed by it’s own failures, the workload generated by its own inefficiencies. By treating patients too late, the system is creating more demand than it can handle, pushing itself closer to collapse.

Community Health & Wellbeing The True Measure of Success

The real measure of whether the NHS is broken or functioning should not be top down targets are hit, but whether the health and wellbeing of communities are improving. If we make that the test; we start shaping the normal as that people are healthy and happy where they live with the people they live with. A more effective NHS would focus on enabling people to live healthy, fulfilling lives in their communities, preventing illness rather than reacting to it.

According to the King’s Fund, the NHS spends only 4-5% of its budget on prevention, despite numerous studies showing that early intervention can significantly reduce long-term healthcare costs​.

Evidence for Investing in Community Care and Prevention.

Integrated care models, including early intervention strategies, have shown significant reductions in emergency admissions (15-50%), readmissions (10-50%), and length of hospital stays (1-7 days). (BMJ)

Social factors like isolation and mental health problems are significant predictors of long-term conditions that increase demand for health services. Another 2019 study by the British Medical Journal found that social isolation increased the risk of developing heart disease by 29% and stroke by 32%​. By focusing on improving community health and preventing these conditions, we can significantly reduce hospital admissions and lower costs.

Moving from Targets to Communities

Communities matter: isolation and mental health problems are massive predictors of high demand long term conditions and demand for future care. When people start to struggle that’s when we need to intervene with the goal of them coping with their every day life.

The problem with the top down planning approach is that no matter how well intentioned and well meaning it cannot possibly understand the real experience of people living in their communities. (If you would like to learn more about starting and community projects I’ve created this guide.)

The Danger of Focusing on Targets Rather Than People.

If it focuses on the targets and the plans to fill those targets then people’s health and wellbeing becomes invisible and irrelevant to the NHS plan. The NHS needs to move it’s focus from the top and the expensive hospitals to the communities.

Top-down targets fail to address the realities of communities across the UK. What works in one area may not apply in another. For instance, rural communities face different health challenges than urban areas. By focusing on centralised targets, the NHS loses sight of the specific needs of its population. We need to stop separating the NHS from the society that supports it.

A decentralised approach, which gives more power to local health teams and empowering frontline leaders, would allow the NHS to better address regional health disparities. Data shows that areas of higher deprivation suffer worse health outcomes. The Office for National Statistics (ONS) reports that people in the most deprived areas of England live 19 fewer years in good health compared to those in the least deprived areas​. Focusing on community-based care, particularly in deprived areas, could improve health outcomes across the board.

A Bottom-Up Approach to Fixing a Broken NHS

So, how do we begin to fix the NHS?

1. Community-Centred Healthcare
   The NHS needs to prioritise healthcare at the community level. It can do it, a successful example of this is the “Healthy New Towns”. This programme integrated health services into housing developments, focusing on prevention and health promotion. Early evaluations show that the programme has helped improve physical activity levels, reduced loneliness, and enhanced mental wellbeing among residents​.

Whilst a great start the fundamental error that NHS England made was thinking that these could simply be scaled up across different places. The focused moved to conformance and compliance: telling people what to do. Without realising it was the pilot approach itself that was successful, and that is what needed to replicated in bottom up way.

2. Preventative Care as a Priority
   Prevention should be at the heart of the NHS. Research by the Health Foundation shows that every £1 spent on public health interventions can return between £4 and £12 in long-term savings by reducing the demand for emergency and hospital care. Simple preventative measures, like improving access to early screening or promoting healthier lifestyles, can prevent the onset of chronic conditions that put immense pressure on the system.
3. Empowerment Over Targets
   Local teams must have the autonomy to respond to their community’s health needs rather than rigidly following centralised plans. Evidence from Scotland’s ‘Realistic Medicine’ initiative shows that empowering clinicians and communities to make localised decisions can reduce unnecessary treatments, improve patient satisfaction, and lower overall healthcare costs​.

A New Future for the NHS

Fixing the NHS doesn’t require more grand plans or massive cash injections. Instead, it requires a fundamental shift in perspective: enabling frontline leaders to place people and their communities back at the heart of the service. By adopting a community-first, preventative approach, we can significantly reduce the burden on hospitals and improve health outcomes across the country.

What You Can Do

I am building a community for health and wellbeing innovation. Where people can inspire and learn from each other in a dynamic way, to help our populations stay fit and healthy and successfully manage their long term conditions. If you are interested in joining please sign up here.

If you would like to learn about starting community projects I’ve created this guide to help you.

Conclusion

There is plenty of evidence that the NHS is broken. By understanding 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. This would help the NHS to move away from the targets and processes of a dysfunctional bureaucracy and instead refocus on serving the actual needs of the nation.