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What do we need to change to make the NHS sustainable?



The NHS has to change. Everyone says so but no one says from what to what or how. Health secretary Jeremy Hunt says the NHS must change and GPs must do more. How, what and where? He doesn’t say. NHS chair Malcolm Grant, the man who is too posh to be a patient in the NHS, says the GPs are all on the golf course, but doesn’t say how he’s going to entice them back into the surgery.

Services must be reconfigured, working practices must change, doctors must change, nurses must change, managers must change, out of hours service must change, the patients must change and the weather must change. Everything must change.

Isn’t the core issue sustainability? Is the NHS sustainable? Changing everything at once is stupid and undermines sustainability. The approach to change is the key to sustainable change. We need to change how we ‘do’ change, using the techniques of ‘sustainable change’.

Killer facts

To do serious change, impacting a lot of people with different perspectives and vested interests you need facts, evidence and proof. Wading into ‘failing’ hospitals on the basis of Hospital Standardised Mortality Ratios (HSMRs), only to have the man doing the wading to pronounce HSMRs are not a good enough indicator of ‘failure’, is an embarrassment.

To condemn an entire Trust because a curtain in A&E, insufficiently closed, allowing an inspector a glimpse of a patient, however discourteous, is not proof of anything but a momentary oversight that can be fixed, there and then. To single out Trusts with frail balance sheets as ‘failing’ is to recognise the failure of allocations and high-lights their heroic attempts to survive. The charge of the Change Brigade must be armed with killer facts.

Change must resonate in the real world

To enjoin change demands providing practical alternatives: recognisable, real-time, oven-ready, different and better ways of doing things. Calls for innovation, integration and leadership are pointless. Asking people to support theory is asking for trouble.

The NHS is practical and hands on. Hypothetical solutions are of no interest. Examples of ‘nurses at St Someplace Foundation Trust find this works’, delivers imitation, buy-in and results. The NHS is a ‘me too’ environment working in the real world.

Leaders, show up

Leaders are visible, have a vision and share it often. Visiting to look and learn and leave with a smile is one thing. To change, leaders visit, share their vision, get buy-in and leave behind disciples, believers and acolytes.

Better than what?

Change implies; to what? Cheaper, faster or better? Or all of the above? How will we know when we get there? How far away are we? Simple key indicators, never more than three, become the flagpole the whole service can rally around. Disaggregated targets mean disaggregated effort. NHS staff are harassed and confused, over-managed and distracted by politicians. To march in step they all need to hear a simple tune.


The NHS is a whole system. Fiddle with one bit and some place you never knew existed will have a bit that drops-off! Please one group and hack off another. Expect rows and argy-bargy.

NHS people have been changed, modernised and liberated to death. They have been reported on, inspected and regulated to the point where the frontline has become the ragged-edge. Is it any wonder people push back? The trick is to provide a realistic achievable, describable, doable, attractive vision that is so enticing they will volunteer to change.


You can’t change anything based on a lie. A sustainable NHS?  We spend -8% of GDP on the NHS. The Netherlands spends 12% and Germany 11%.  Austria, Denmark, France and Luxembourg manage more than us per head. As do Switzerland, Norway and Iceland (more very good OECD comparisons here).We are a long way from ‘unsustainable’.

So, now what?  Does anyone have any real, workable ideas? A vision for the future? An explanation for Jeremy Hunt’s panic?

I think, “Despite our financial and economic anxieties, we are still able to do the most civilised thing in the world – put the welfare of the sick in front of every other consideration.”

Not my words; Aneurin Bevan, 1948.

So tell me: what, exactly, do you want to change?

Roy Lilley is a healthcare writer, broadcaster, commentator and conference speaker, and editor of This article originally appeared as an e-newsletter, which you can subscribe to for free here.

Further reading:

On this day in 1948: the National Health Service is born

UK population grows to 63.7m but growth should be ‘managed’

On this day in 1957: cancer and smoking linked

Investing sustainably in an ageing population