Skip to content

The radical reform that’s been staring the NHS in the face


There is no getting away from the fact that the health and care system is under enormous pressure. Public satisfaction is declining, there are long waits for care and staff are exhausted and demoralised. A decade of under-investment, avoidance of crucial policy decisions on social care, lack of a funded workforce plan, under-ambitious public health measures, the Covid-19 pandemic and a cost-of-living crisis have all contributed to this.

As a result, we are seeing more and more debate about the future of the NHS: can it survive, does the funding model need to change, do we need a totally new vision? We’ll shortly be publishing our views on some of the alternatives that are being debated.

'But I’m not sure there is a need for a new vision for care.'

But I’m not sure there is a need for a new vision for care. Over many years, and certainly for the 29 years that I’ve worked in health and care, successive governments and indeed the World Health Organization have been clear about what health and care services should look like – able to provide proactive, co-ordinated, personalised and responsive care closer to where people live, moving care away from hospitals and with an increasing focus on individual and local community assets.

However, it’s clear that this vision is very far from being achieved. There are of course pockets of excellent practice and endless case studies of fantastic models of care. But overall we still have a system centred on hospitals and emergency care. As Simon Stevens, then Chief Executive of the NHS, said in 2016:

'If anyone ten years ago had said: ‘Here’s what the NHS should now do – cut the share of funding for primary care and grow the number of hospital specialists three times faster than GPs’, they’d have been laughed out of court. But looking back over a decade, that’s exactly what’s happened”.'

And not much has changed since then. Many parts of the primary and community workforce continue to shrink, including numbers of district nurses, health visitors, general practitioners and a social care workforce that isn’t growing to match demand. The recently published primary care access plan still only scrapes the surface of what will actually be needed to deliver improved access and waits for community services are not given the priority of those in acute care.

It’s clear that the problem is not a lack of ideas, or that there are opposing views on what the solutions should be. The challenge, then, is how to make a reality out of the long-held ambition to shift the focus away from hospitals, towards primary and community care.

'The challenge, then, is how to make a reality out of the long-held ambition to shift the focus away from hospitals, towards primary and community care.'

At The King’s Fund we’ve launched a major new project to try to understand clearly why this has not happened and to suggest what will be needed if the health and care system in England is to actually achieve the vision that most people seem to agree is the right one. We’re going to investigate the structural, political, financial and cultural barriers that have prevented the vision being implemented. We will aim not to shy away from addressing intractable issues, and we’ll draw on what we know about how change happens in complex systems. We will also look at national and international evidence and experience as systems around the world grapple with similar issues.

We hope to be able to share our findings at The King’s Fund’s Annual Conference in November, and publish them more widely afterwards. We hope that these insights will be taken on board by whoever forms the next government, to make good on the longstanding but illusive ambition to create a community-focused NHS.

I hope that in the future we won’t need to reiterate Simon Stevens’ quote.

If you are interested in hearing more about the work, or sharing your experiences, do please contact me or one of the research team: Deborah Fenney, Danielle Jefferies, Ros West.