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Public Services

Fit for the Future: A Modern and Sustainable NHS Providing Accessible and Personalised Care for All


Paper5th July 2023

Our Future of Britain initiative sets out a policy agenda for a new era of invention and innovation, based on radical-yet-practical ideas and genuine reforms that embrace the tech revolution. The solutions developed by our experts will transform public services and deliver a greener, healthier, more prosperous UK.


Chapter 1

Foreword

We have the technological and scientific means to transform health and care to safeguard the founding principles of Beveridge and Bevan. Without fully embracing the tech revolution, there is no future for the NHS.

The NHS was founded on the principle that health should not be dependent on wealth. Of course, we know poorer people have a harder time living healthy lives; social deprivation begets health deterioration. But the NHS at least guarantees that if you are sick, particularly seriously sick, you’re cared for irrespective of your bank balance.

The post-war generation was liberated by the creation of the NHS and, rightly, that basic decency underpins our support for the NHS today. It made a reality of care based on need, not income.

However, over the years, other realities have emerged, and the NHS now requires fundamental reform or, eventually, support for it will diminish.

If the NHS cannot provide timely care – if waiting lists are long, seeing a GP difficult, accessing care complicated and inefficient – then people who can pay will pay. That is why in the past few years the numbers of those using private health providers have rocketed.

Despite pockets of excellence the NHS is falling further behind other health-care systems, and many services – including high-volume, low-complexity work – remain slow and unresponsive to digital transformation.

The NHS workforce feels both overstretched and undervalued; although there are record numbers of staff, morale is poor.

The result is that, as in the 1990s, the NHS must either change or decline. And funding will be tight, because of the state of the economy.

However, there are two major differences between health care in the late 20th century and health care as we get well into the third decade of this century. Both are the consequence of the 21st-century technological revolution.

The first is how people live today. They operate digitally, make choices continually and want to control their own lives rather than have others do it for them. A service that is essentially top down and paternalistic doesn’t work for them.

The second is the massive advances in life sciences and in medical treatment already with us, something that is going to accelerate hugely over the coming years as the artificial intelligence (AI) revolution takes shape and people understand fully the relationship between the accumulation of data and AI’s capacity to analyse it productively.

So, today, we need a health service that changes fundamentally the relationship between the citizen and the service; one that is open to new providers and new partnerships that operate outside the system; one where the incentives of funding and accountability are designed to encourage innovation, particularly through the use of technology; and one in which the workforce is reshaped around what makes sense today, not the traditions of a health-care system from a bygone era.

As this report sets out, we keep the principle of health care based on need not on the ability to pay – the originating principle of the NHS – but change radically the way the system works to incorporate not only what modern technology makes possible, but also the best from health-care systems around the world.

  • We should use digital technology to change the relationship between citizen and service. Each person will have their own Personal Health Account, delivered through the NHS App. This will be owned by the patient not the service. It will store health data, including self-testing and diagnosis as such things become available, and from wearables like smartwatches or Fitbits; it will be transferable around the system so anywhere within the NHS or with a private provider, health data, with the consent of the patient, can be accessed. The patient will be able to receive, via the app, information about new services, including from accredited private providers, and suggestions to improve personal responsibility for individual health. Citizens will be able to book appointments and, in defined cases, self-refer to consultants as they can in private systems. Those unfamiliar with or unable to use the technology will be able to access the service in the traditional way.

  • The NHS will step by step create cloud infrastructure to connect health data centrally. This will enable the creation of Personal Health Accounts, delivery of more sophisticated care and better resource planning and procurement, as well as the development of new data and AI applications to provide more accurate and real-time analysis of health care. These data, with appropriate safeguards and consent, can then also be used by external partners as a national asset, to help our life-sciences sector deliver world-leading research.

  • The proposed new structure of Integrated Care Systems – 42 in number – to replace the monolithic NHS system is right. But they should be given real freedom along with transparency of outcomes. They need multi-year budgets to be able to keep efficiency savings for redeployment in better services, to use private providers freely, and to allow patient choice across GP practices and hospitals in their region.

  • There should be active encouragement of new providers to enter the system, particularly for high-volume, low-complexity services, many of which can now be provided digitally. The NHS App is creating a vibrant marketplace for digital providers to enter the NHS centrally in ways that were not possible before, creating opportunities for greater choice and competition; and for partnership between the private health sector and the NHS. This can include the availability of co-payment options to expand more rapidly or offer additional features. Finally, a lot of basic health care can be delivered through pharmacies, by employers, in gyms and in supermarkets making care easier to access.

  • The NHS workforce should be overhauled to make sense of what technology can either do directly or assist humans to do better. Traditional demarcations must be broken down, training reformed and the right incentives put in place to motivate staff. New skills must also be brought into the NHS, particularly for digital. No less important, investment in productive capacity, including capital infrastructure, will be essential to increase retention and reverse the drop in productivity.

  • The Genomic Medicine Service should be taken out of the backwoods of the NHS and turned into a full-fledged part of the system, with the aim of providing whole-genome sequencing to all patients upon diagnosis, to all newborns and to healthy populations with known risk factors including a family history of disease. This, in time, should become a vital part of ensuring the health-care system moves from a focus on sickness to supporting prevention, wellbeing and personalised care.

  • The NHS is not just an important part of British society. It will, in the future, properly reformed, be an economic asset for life sciences and more broadly for enterprise, offering new opportunities for the private sector, particularly with AI technology, to develop products and services.

Change is never easy and requires brave political leadership. If we do not act, the NHS will continue down a path of decline, to the detriment of our people and our economy.

Tony Blair

Executive Chairman


Chapter 2

Executive Summary

On its 75th birthday, the National Health Service (NHS) is failing. Patient outcomes are declining. Public satisfaction is at a 40-year low. And the service is in the grip of unprecedented strikes and rising vacancy rates. At the same time, the British economy is on its own sickbed – with falling productivity, low growth and more than 2.5 million people out of work due to long-term ill health.

It is both a social and economic imperative that the government acts to transform the health of Britain. This requires leadership and a commitment to reform. The NHS was founded on the principle that health should not be dependent on wealth. With health care available to all, free at the point of use and funded through general taxation. This remains a core principle of life in the UK and should be at the heart of a modern health-care service.

But the fact that the NHS has been so important for the past 75 years means politicians and the public are in danger of believing its established methods of delivery are inevitable or non-negotiable. They are not.

Dedicating more money to an outdated delivery model will not solve the challenges the NHS faces. The country needs a fresh debate about its future. It must move from a health-care model set up to treat episodic sickness to one that prioritises continuously improving individual and population health.

Put simply, the NHS needs to transform if it is to survive.

This will require a culture of innovation and a radical change in policies, incentives and levers across health care and beyond. Accountability for the nation’s health must be shared across the whole of government rather than allocated solely to the NHS and the Department of Health and Social Care. Furthermore, the traditional top-down, centralised approach must be abandoned in favour of local decision-making, greater patient choice and a new partnership between the public and private sectors.

Reform will be difficult, and the state of the economy means funding will be tight.

The government must look to 21st-century technologies to drive change, from the use of digital platforms to empower patients to take control of their own health to rapid advances in life sciences, medical treatments and artificial intelligence (AI) that will continue to transform health care in the coming years.

And the government must enact policies to create a motivated and supported workforce that can harness the power of technology and innovation to deliver better patient care. There are talented people throughout the NHS, but they are too often expected to create positive change without the appropriate tools and incentives to do so. Investing in technology and innovation will allow them to be more productive and focus on what they do best – caring for patients.

In this paper, we propose six areas for reform where radical-but-practical policy action will begin to transform the future of the NHS and deliver better patient care:

  1. Put patients in control of their own health: First, the government must provide every person with a digital Personal Health Account (PHA) that offers a simple, single digital front door to the NHS and wider health-care services. It will become the portal through which people interact with the NHS, allowing patients to have direct access to services, including general practitioner (GP) appointments, at-home diagnostic services and even opportunities to participate in clinical trials. Most importantly, it will give people direct access to and ownership of their health data, including information provided by third-party providers or wearable technologies.

  2. Create new access routes for services and providers: The range and availability of health-care services must increase to reflect citizens’ demands and their increasingly complex needs. Pharmacies, gyms, supermarkets, workplaces and other spaces should all be able to provide or facilitate the provision of health care, bringing services closer to patients and reducing demands on general practice. Most importantly, the PHA will create a new marketplace for services. This should focus on high-volume, low-complexity services – for instance dermatology – to make them directly available to patients. Introducing multiple providers, including third parties, will offer patients greater choice through the ability to balance outcomes, waiting times and costs.

  3. Harness the power of genomics and other “omics” platforms to personalise care: The NHS Genomic Medicine Service should be made accessible to more patients for a greater range of conditions to improve early diagnosis, prevention and treatment. Specifically, universal clinical whole-genome sequencing should be offered to all patients upon disease diagnosis, all newborns and all healthy populations with known risk factors, including a family history of disease. As science progresses, other omics disciplines such as proteomics and metabolomics, should be integrated into routine clinical care, to improve the prevention, management and treatment of disease.

  4. Create a locally led and self-improving system: There must be a new deal for accountability and autonomy between Whitehall and the Integrated Care Systems (ICSs). This must allow local leaders to operate with much greater freedom and hold them to account for delivering a set of clear and transparent outcomes focused on creating and improving health, rather than simply treating sickness and delivering against activity targets. ICSs should also be given multi-year budgets that are adjusted for the needs of their local population. And they should be allowed to keep and redeploy savings from innovating and improving care. Finally, quality and care outcomes should be made transparent and available to patients to empower them to make an informed choice between GPs and secondary care providers within an ICS.

  5. Invest in new and more efficient infrastructure to deliver better care: NHS productivity and efficiency must be transformed through investment in basic technology as well as increasingly powerful AI, and by enhancing existing infrastructure. This will require upfront investment but will be offset, at least in part, through increased automation of processes and by finally tackling wastage across the system. The future operating model we are setting out in this paper will be much more capital intense, much more efficient and much less reliant on labour.

  6. Energise and modernise the NHS workforce: The new NHS Long Term Workforce Plan is welcome and will provide much-needed investment to help create a pipeline of future talent, increase long-term capacity and provide new training routes to increase workforce diversity across the NHS. However, the NHS is facing an immediate workforce crisis with concerns over staffing pressures and pay that must be resolved. In addition, putting more staff into an outdated and unproductive delivery model is not sustainable and much greater focus is needed on harnessing the potential for technology to improve the efficiency of services, help to reduce the demands on frontline services and improve outcomes for patients. In addition, a comparable commitment and long-term plan is needed for social care and public health to create fully supported health and care services.

Finally, at the political level, leaders must resist the knee-jerk urge to constantly reorganise health-care structures. Instead, the focus must be on creating the right incentives and tools to drive real and lasting improvements in service delivery and to instil a culture of constant innovation and self-improvement. Only then will we create a truly modern and sustainable NHS that is fit for the future.


Chapter 3

The Case for Change

The current NHS model was created to respond to the health-care challenges of 1948. Life expectancy was just 65 years for men and 70 years for women, the average age was 33, and many deaths were still caused by diseases such as polio, measles and mumps.

Seventy-five years later, our population and our health-care needs look very different. Life expectancy has increased by almost two decades, the proportion of the population over 65 has more than doubled[_] and the demands on the health-care system have grown rapidly, becoming increasingly complex and costly. At the same time, the single-earner-family model, on which much of William Beveridge’s welfare state was based, has all but disappeared.

These changing demands have chipped away at the NHS over time. For the past decade, prevailing trends have indicated a steady decline in performance exacerbated by chronic underinvestment in equipment and technology, which has led to a rapid decline in health-system productivity, efficiency and outcomes.

Previous policy initiatives aimed at addressing these issues have relied on top-down structural change that has clearly not worked. As a result, the NHS is one of the most restructured health-care systems in the world and yet one of the most under-transformed, as we laid out in The NHS Refounded: Delivering a Health Service Fit for the Future.

In recent years, a global pandemic and rising population ill health, alongside chronic understaffing and underfunding of public health, have brought the NHS to the brink of collapse. Patients are paying the price, whether through an inability to get an appointment at their local GP, record-long waits for accident and emergency (A&E) services[_] or poor survival rates for strokes, heart attacks and cancer. This is leading to a fall in UK life expectancy and exacerbating longstanding health inequalities.

What’s worse, as outcomes deteriorate, costs continue to rise. Health now accounts for record levels of day-to-day government spending,[_] NHS staff vacancies stand at over 110,000 (approximately 10 per cent of the entire workforce) and productivity continues to fall.

We’re spending more and more to receive less and less.

These challenges will only grow more acute over the coming years as health-care needs and population size continue to rise. Without rapid and drastic change, the NHS will quickly become unaffordable, and the British people and economy will face the consequences.

At the heart of this issue is the longstanding failure to properly harness the power of cutting-edge science and technology – including the advent of artificial intelligence (AI) – to transform health-care delivery.

Instead, innovation continues to be suffocated by a lack of incentives and a conservative culture that has permeated the health and care systems. This has to change. This paper sets out the conditions to enable rapid uptake of innovation and best practice across the NHS.

A Different Future Is Possible

The rising demand for, and cost of, health care are complex problems that many countries face. There are no easy answers, but simply providing more resources without modernising delivery will only delay a terminal decline. In recent years, additional resources have been allocated to plug gaps and manage annual crises rather than to drive necessary reforms.[_]

Change will be difficult, but it is critical. For our six proposed reforms to succeed they need to take place alongside a wider transformation of the UK’s approach to health and care. This means rebalancing investment to drive health creation and prevention, ending the almost sole focus on treating sickness. We have previously set out a policy framework for achieving this in Fit for the Future: How a Healthy Population Will Unlock a Stronger Britain. It also means moving towards a more preventative model of social care and community support that meets the specific needs of individuals and their families – helping them to spend more time living independently in the place they call home.

Only once these changes have been made will we have a realistic chance to improve the health of our population and support people to live healthier and more productive lives. As the health of the population improves it could serve as the basis for a resurgent UK economy. Health spending would be more sustainable, the number of people out of work due to long-term sickness would fall and UK economic growth could rise to the highest sustained levels in the G7.

Figure 1

Reducing demand and increasing capacity to improve outcomes for the public, the NHS and the economy

Demand, Capacities and Outcome table

Source: TBI


Chapter 4

Making It Happen

We propose six areas for reform where radical-but-practical policy action will help to create a modern, patient-centric and innovation-friendly health system. The first three policy areas focus on empowering patients, giving them better access to care and personalising services. The second three offer a viable operating model for the future of the NHS, with the right incentives and accountability structures in place, alongside sufficient capital and labour investment.

This is a blueprint for NHS transformation that will protect its founding principles while ensuring the service adapts to be fit for the future. Investment will be needed to drive reform and these proposals will need to be fully costed. However, substantial savings are available in exchange for investment and the price of inaction is clear – a continued rise in demand, ever-increasing costs and a rapid decline in patient outcomes.

The role of technology and patient choice is central to this approach. Together they will transform access to services, empower local decision-making, and help create a self-improving and sustainable service that delivers better care to patients across the country.

1. Putting Patients in Control of Their Own Health

In every other aspect of modern life, new technologies and data-driven approaches are creating hyper-targeted recommendations and giving individuals more control.

People have every right to expect the same level of personalisation, choice and control over their health. But this is simply not possible in a rigid system designed 75 years ago that puts the clinician in control of a single route to accessing services, which creates bottlenecks.

We propose giving patients access to – and ownership of – their own health data by creating a new digitally enabled means of accessing a wide range of NHS services.

Recommendation: The NHS must create Personal Health Accounts (PHAs) that give people direct control of all their health data and provide a single, simple front door to NHS services.

The NHS App has more than 10 million active users and could be expanded to house a newly created PHA that would provide all patients with direct access to their medical records. They would have the power to book medical appointments, order repeat prescriptions or at-home diagnostics and, where appropriate, self-refer directly via their smartphone or tablet.

A new approach to interoperability would be key to delivery. This would require care providers to record data on all care episodes in a central, secure, cloud-based health-care record. This approach avoids having to link existing electronic patient record (EPR) systems – something that has been tried many times in the past without success – and avoids issues such as vendor lock-in.

In time, the PHA could be further developed to provide personalised notifications and to increase engagement in research. This would begin with basic reminders, for example for vaccinations and other appointments, before being extended to provide tailored and proactive communications, working with generative AI to offer preventative, personalised insights. This could include best-practice guidance for relevant treatments, opportunities to participate in new clinical trials and even suggestions for programmes to improve individual health – mirroring best practice in other developed markets, including LumiHealth in Singapore. In addition, effectively anonymised data could be made available for use as a collective national asset to help our life-sciences sector to conduct world-leading research.

Finally, the PHA would enable greater competition and choice by providing patients with direct access to a range of accredited digital tools and providers, including third parties. This could include accredited apps for mental-health and musculoskeletal conditions as well as third-party providers for high-volume, low-complexity (HVLC) issues, such as skin complaints. Allowing patients who need to receive care in primary or secondary settings to choose between NHS providers within their Integrated Care System (ICS, see “Creating New Locally Led and Self-Improving Systems” below) would provide greater choice and enable them to balance waiting times and quality of care with other relevant considerations. At the same time, transparency of outcomes and quality of care would provide an impetus for innovation among providers.

Trust in data security and privacy would be fundamental to the PHA, with individuals in control of deciding how and with whom their information is shared. Further work would be vital to ensure that suitable controls were in place for those with additional needs, for instance those living with dementia, and to ensure that this digital shift did not exacerbate existing inequalities, particularly for those who are digitally excluded. A good user experience would also be crucial and the service must learn from other industries that are successful in attracting and keeping users engaged digitally.

Figure 2

The current failed approach to interoperability between EPRs puts the EPR vendor and clinician in control of patient-health data

Figure 2 infographic

Source: TBI

Note: API = application programming interface

Figure 3

A new model for interoperability would put patients directly in control of managing and curating their own health data

Figure 3 infographic

Source: TBI

Recommendation: The NHS must harness the power of at-home diagnostics, wearables and personal devices to give patients greater control over their health.

The pandemic transformed the British public’s understanding of, and willingness to conduct, routine at-home diagnostic tests. This has been the impetus for an explosion in remote testing and monitoring technology, from new tests for infectious diseases such as hepatitis B and C, to new mobile diagnostics for metabolic diseases including diabetes. At the same time, there has been a rapid expansion in the use of wearables that can provide a constant stream of real-time health data. Together, these technologies offer individuals the opportunity to test for a wide variety of diseases and to continuously monitor their health from home.

The NHS must harness the power of and demand for these innovations to empower patients, reduce demands on frontline services and increase convenience to drive early diagnosis. This should include national commissioning where appropriate, for example for certain age-related cancer screening such as smear tests, and local commissioning to respond to specific needs within an ICS, such as sexual-health tests.

Importantly, no matter where these tests are commissioned or undertaken, the results should be captured in a patient’s PHA and proactively generate any necessary onward care. For example, any significant risk factors, such as high cholesterol, should lead to a patient receiving an automatic referral to receive further preventative care or testing – in this case an inclisiran injection at their local community pharmacy. Moreover, by providing patients with the ability to upload additional data to this central record, including from third-party providers, the NHS could vastly improve health-care data coverage and quality. These data could then be used to further tailor individual health management and improve future engagement with health-care services.

All of this could happen without ever requiring action from local GPs, leaving them free to focus on complex cases and vulnerable patients who have the greatest need of their skills and expertise, and for whom continuity of care is vital.

2. Creating New Access Routes for Services and Providers

For the first time in its history, the NHS is no longer guaranteed to be there for people when they need it.

At the root of this problem are the delays and bottlenecks caused by its rigid, one-size-fits-all approach and chronic underinvestment in capacity.

Nowhere is this more apparent than in primary care. GPs still operate as the main gateway to NHS services, patient lists still dictate patient choice, care quality varies enormously across the country and the 8am scramble for appointments results in long delays for patients and inefficient rationing of GP time and resources.

None of this needs to be case. Instead, we must move towards greater community-based care and the creation of a neighbourhood health service, with more routes for direct patient access, to ensure services are available when and where people need them. These should all be accessible through a single, simple digital front door to the NHS.

Recommendation: ICSs should create a “neighbourhood NHS” model that is adapted to the local population’s specific needs and that provides more preventative and diagnostic services within the community.

Across other sectors, industry invests heavily in detailed customer segmentation to tailor its services to meet individual needs. Yet across the NHS there is a very poor systematic understanding of patient needs or the underlying drivers of need. At the highest level, it is possible to broadly distinguish between health promotion and prevention, episodic care of mostly healthy people and chronic long-term conditions.[_] Even at this high level, it is clear that a one-size-fits-all service model is not effective.

As the availability and granularity of health-care data improve, the opportunity exists to create a much deeper understanding of specific patient needs and to design services to meet them, particularly in primary care.

We already know that patients across the board are struggling to access primary care. As a first step the NHS should therefore focus on expanding the number of services available at existing sites within the community, including pharmacies, supermarkets, workplaces and gyms. This will make services easier to access and reduce demands on GPs. Our Future Health,[_] the UK’s largest-ever research study into prevention, is leading the way by providing its screening services predominantly through community pharmacies.

Many more services could and should follow suit, beginning with those that are a) focused on prevention and early diagnosis, b) require low levels of upfront capital investment and c) are relatively simple to administer. From annual flu vaccinations to human papillomavirus (HPV) screening services, routine blood-pressure checks and cholesterol monitoring, these preventative services should increasingly be made available in convenient locations.

Once these foundations are in place, new ways of providing additional care in community settings could be created. This could be done, for example, by establishing open-access hubs offering community-based diagnosis and early intervention to support people with mental-health and musculoskeletal conditions, or through expanding the Pharmacy First scheme to allow commissioning pharmacists to prescribe medication for a wider range of conditions, such as hypertension and sexually transmitted diseases. We set out the potential to expand the role of community pharmacists in A Prescription for Community Care: Expanding the Role of Pharmacies. This would make full use of the fact that all pharmacy graduates will qualify as independent prescribers from 2026, which could free up a massive 30 million GP appointments in England every year.[_]

In the longer term, community care must evolve to ensure it is better able to meet the specific needs of each local population and to address wider determinants of health.

Using health-care data will be a key component of this, but ICSs will need to work more directly with their local communities, including voluntary organisations and employers, to truly understand complex needs and to earn the trust of their local population. The power of this approach during the pandemic was evident[_] and some regions are building on this momentum. For example, Growing Health Together,[_] a collaborative programme born out of a traditional primary-care setting, is working with its local population to co-create the conditions for health and wellbeing. This is generating local social capital, and services are being developed with patients to address their specific circumstances, rather than being shaped by a rigid, predefined structure.

For many ICSs, it may be sensible to create more formal NHS “neighbourhood hubs” that bring together a range of services under a single roof, allowing patients to access a “one-stop shop” to meet most of their health-care and wider social needs. Boots is already demonstrating the potential of this approach in its St Albans Health Hub.[_] The specific mix of services would depend on local needs, but could include traditional pharmacy, optometry and audiology services, routine diagnostics and preventative health-care measures, including screening, vaccinations and smoking-cessation services, traditional primary-care services, local social-care services and even opportunities to engage with cutting-edge research like Our Future Health.

Figure 4

The traditional one-size-fits-all model of community health care

In the existing model the GP is at the centre, which limits patients’ options to access services

Figure 4 diagram

Source: TBI

Figure 5

A modern approach to community care

This new model would increase patient choice and access to community services, freeing up GP capacity to focus on complex and long-term conditions for which continuity of care is important

Figure 5 diagram

Source: TBI

Recommendation: The NHS should improve patient access and outcomes by increasing competition and enabling direct access to HVLC services such as dermatology screening using digital tools.

Many modern providers actively curate digital marketplaces to help make services more accessible. As digital platforms continue to mature and more health-care services can be provided digitally, the NHS should adopt the same approach. Efforts should focus on national commissioning of digitally enabled HVLC services, such as dermatology or certain aspects of physiotherapy,[_] which can then be made available directly to patients via the PHA and be open to self-referral, where appropriate.

Opening up HVLC services will encourage multiple providers to offer options. This includes third parties from across the private and voluntary sectors who meet quality standards in terms of diagnostic efficacy. All providers would be commissioned based on volume-adjusted payments, providing patients with greater choice, creating additional capacity in the system and driving innovation through effective market competition. Importantly, this would also enable individuals with complex needs or who are unable to self-manage their condition(s) to gain faster access to more traditional forms of care, including through their GP, ensuring that capacity across the system is used as effectively as possible to meet patient needs.

As a result, the PHA would become the trusted “digital marketplace” through which individuals directly access nationally commissioned digital services without a prescription or recourse to primary care.

This approach also offers an opportunity to revisit the role that contestability and competition can play in driving innovation (see “Creating the Conditions for Self-Improving Health and Care Systems” below). For example, the PHA could be used to provide access to a wider range of approved but non-NHS-funded services open for direct pay or co-pay by patients. However, this would require careful management to avoid undermining equitable access.

At the same time, establishing a single digital marketplace for nationally commissioned digital services would directly respond to the frustration of many digital providers who currently face high transaction costs and entry barriers to the NHS, due to having to transact with hundreds of individual organisations or 42 ICSs.

3. Harness the Power of Genomics and Other “Omics” Platforms to Personalise Care

Currently the NHS uses cohort-based risks, such as socio-economic status, weight and age, to manage various diseases and conditions and our health-care system is focused almost solely on treating sickness rather than preventing ill health.

In the future we need to move to a more preventative and personalised approach that is based on a detailed understanding of the risks faced by each individual, underpinned by a comprehensive picture of how their bodies will respond to different treatments, environments and lifestyle choices.

The rapidly expanding field of genomics, and omics more widely, is providing the technologies and techniques to drive this shift. The UK is well placed to lead the charge thanks to our deep expertise in UK Biobank, Genomics England and Our Future Health.

Recommendation: The NHS must expand the Genomic Medicine Service (GMS) to make it available to more patients, including all newborns, all patients upon disease diagnosis and all healthy populations with known risk factors.

First, the NHS must address the backlogs in the GMS, given some patients are waiting months for whole-genome-sequencing (WGS) results.[_] Turnaround times need to be reduced to approximately seven to ten days to support effective integration of these technologies into clinical care. This will require significant investment in infrastructure and staff, including targeted support for regional pathology and tissue-pathway infrastructure, the expansion of capacity at Genomics England, the recruitment and training of additional clinical scientists and the successful introduction of data-federation technologies that allow data to be analysed across multiple sites.

Once delivery times improve, the GMS should be expanded to provide clinical WGS to all patients upon disease diagnosis, all newborns and all healthy populations with known risk factors, including a family history of disease.

This would help transform disease prevention and give patients access to tailored treatments that meet their individual needs. For example, the prevention and treatment of diseases like cancer would be transformed. Rather than waiting for the disease to manifest before treatment begins, we could use a patient’s genomic profile and real-time data to understand and manage their exposure to risk and to intervene early if the disease does materialise. As a result, rates of cancer and other diseases would decline and diagnosis at early stages would increase significantly, helping people live longer and healthier lives.

Finally, in the coming years, the GMS should expand beyond DNA sequencing and integrate proteomics,[_] metabolomics[_] and other emerging techniques into routine clinical care. This would further refine diagnostic and prognostic accuracy, and further personalise treatment-planning for patients with complex diseases, leading to fewer side-effects from traditional broad-spectrum treatments such as chemotherapy. It would also help to transform our understanding, monitoring and management of metabolic diseases like obesity and diabetes so that treatments can be more effectively tailored and progression can be prevented.

Given the ethical questions these technologies raise, the NHS should also pioneer the development and use of a permanent citizens’ assembly to help resolve policy trade-offs in real time and ensure high levels of trust are maintained.

4. Creating the Conditions for Self-Improving Health and Care Systems

Following the passage of the Health and Care Act in 2022, the future of the NHS lies in greater devolution and local leadership to respond to the complexity of need and the determinants of ill health. There is now overwhelming evidence that modern care cannot be run from Whitehall.

At the heart of this shift are the newly formed ICSs, which will work with local government and the voluntary and private sectors to address the specific health- and social-care needs across their population.

As a first principle, we propose no further structural changes to NHS delivery models for at least two parliaments, to give ICSs and their integrated care boards a chance to settle in and develop properly.

But to do that, they first need a clearly articulated and properly supported operating model. At present, their governance is unwieldy, accountability is confused, and incentives are misaligned. Unless this is addressed as a priority, these new structures will be declared a failure before they have a chance to deliver.

Our proposed approach draws heavily on best practice from health systems around the world where integrated and devolved care has been shown to work. It embeds innovation and self-improvement at the heart of delivery to ensure the NHS has the incentives in place to remain sustainable and effective into the future.

Recommendation: NHS England must grant local ICS leaders more autonomy in exchange for smarter accountability, underpinned by increased transparency and the use of real-time data to drive improvements in outcomes.

Previous attempts at devolution in health care have failed because of an inability to resolve the apparent conflict between greater autonomy to innovate and the need for robust accountability in a taxpayer-funded national system.

A modern public-service model can square this circle. Autonomy to innovate without loss of accountability is possible. The very same advances in technology, data and participatory levers that enable the personalisation of care also make it possible to replace top-down accountability with a new “accountability network” that involves patients, clinician peers, citizens and local government – and that puts a different vision at the heart of the health service. We set out the principles and practical steps to create this new deal based on local autonomy and accountability in detail in The NHS Refounded.

To breathe life into this approach, the NHS needs to continue to invest in the development of the federated data platform (FDP) and secure data environments to provide greater access to real-time and high-quality data on outcomes that can be harnessed by local leaders and used to hold them to account. The ability to assess interventions in real time should enable inspection-regime reform and a much stronger focus on learning without abdicating personal responsibility for sustained underperformance or catastrophic failure.

To ensure accountability and empower patient choice, this information must be made available through the PHA. This would help patients understand what good care looks like, level the playing field between care professionals and enable patients to make informed choices about where they receive care.

Finally, transparency must be deployed in tandem with direct democratic levers and a commitment to work with both the public and local government to resolve wicked policy issues. For example, citizens’ assemblies should be used to engage the public in significant budgetary or policy decisions that have trade-offs or may exacerbate health inequalities. In addition, making more explicit use of locally elected representatives in shaping health and care services will ensure any variation has greater democratic legitimacy.[_]

The devolution of ownership and accountability for day-to-day service delivery will free up Whitehall and NHS England to focus on areas that demonstrably benefit from centralisation such as delivering the digital and data infrastructure needed to provide real-time data and ensuring regulators take a pro-innovation approach – as set out in Professor Dame Angela McLean’s recent report.[_]

Recommendation: Government and the NHS must introduce the right financial incentives to drive innovation and focus on outcomes not inputs.

Under the current NHS funding model, there are few incentives to drive innovation, the delivery of longer-term efficiencies or a shift towards prevention. If we are to make progress in improving population health, it is critical that ICSs have strong financial incentives linked to improved health outcomes.

Each ICS should therefore be provided with a multi-year budget, adjusted for the size, risks and needs of their population. Budgets could be provided over five years initially, rising to a decade for ICSs that demonstrate they can operate efficiently and deliver improvements in population health. This will help to decouple health care from the five-year political cycle.

The provision of multi-year funding must be linked to clear expectations about service delivery. While ICSs are bedding in, and to support recovery from budget deficits and deteriorating performance, these expectations could be based on the delivery of specific inputs and outputs (activity-based targets). However, as greater investment becomes available and baseline performance improves, ICSs should be given the opportunity to transition to an earned-autonomy model, akin to NHS foundation trusts, which is based on delivery of key outcomes including improvements in healthy life expectancy.

ICSs that prove successful should also be given the opportunity to share savings with government, keeping a portion for reinvestment – creating a clear incentive to increase efficiency and improve outcomes. Specifically, this will give regional leaders a direct incentive to invest in innovation, focus on prevention and use their resources efficiently to maximise population health.

Recommendation: The NHS must introduce meaningful choice and competition between providers to increase patient choice, improve outcomes and incentivise innovation.

Currently, the NHS offers all patients the choice of where to receive secondary care. However, this choice is mostly theoretical as it has been almost impossible for patients to compare services meaningfully across different providers, let alone clinicians.

We therefore welcome the new function within the NHS App that allows a patient to compare waiting times and quality when referred from primary care for specialised treatment in hospitals.

However, the NHS needs to go further to drive continuous improvement in care. A reformed choice model within an ICS is necessary and desirable to align with the overall fiscal and organisational principles of locally devolved care systems that are incentivised to improve the health of their population as efficiently as possible. We propose several changes to enable greater and more meaningful choice.

First, the NHS should discontinue patient lists in primary care within an ICS, enabling patients to choose from any primary-care provider in their locality.

Second, to make population-based, risk-adjusted budgets meaningful, we propose restricting the choice of secondary-care providers to hospitals within an ICS unless the ICS commissions services from another region or there are overriding reasons, such as safety or urgency. This would be necessary to enable ICSs to plan resources effectively and is common in both the United States and Europe. However, this restriction would need to account for natural population turnover and cross-ICS movement.

Third, these changes would require accurate real-time information on the quality and availability of care. The previous sections set out why these are necessary for wider reform objectives and how they can be achieved.

Finally, as set out above, we are proposing to allow certain services to be contestable, so that patients have a choice between different providers offering comparable services. This may appear counterintuitive given that the most recent NHS reforms explicitly stepped away from internal markets. However, we believe that the emergence of digital services combined with the proposed PHA offer opportunities for a more differential and efficient commissioning model.

Specifically, we propose that:

  • Each ICS should commission most primary and secondary services through the population-health-based funding model set out above.

  • Highly specialist and tertiary services, such as transplants and major trauma, should continue to be provided in a small number of centres across the country and paid for centrally.

  • As set out above, HVLCs that could be provided digitally, such as dermatology or certain aspects of physiotherapy, should also be commissioned nationally. These services would be available directly to patients via the PHA and they will be open to self-referral, where appropriate.

Figure 6

Proposed models for balancing patient choice and competition against demand and accountability

Source: TBI

Note: *** = high, ** = medium, * = low, - = not feasible

5. Investing in New and More Efficient Infrastructure to Deliver Better Care

We need focused government action at a national level to invest in the technologies needed to modernise service delivery and unlock efficiencies across the NHS. Productivity is declining and capital investment is critical.

Initial estimates suggest this “invest to save” approach could make several billion pounds per year available to invest in service transformation.

Recommendation: Government and the NHS must invest in capital infrastructure.

During the past decade, the UK spent about £33 billion less in capital investment on health compared with its peers in Europe.[_] This has left the NHS with significant “technical debt” in technology, equipment (beds, computerised tomography (CT) scanners, magnetic resonance imaging (MRI) scanners) and estate maintenance, as highlighted in the recent report by the King’s Fund,[_] all of which is driving falling productivity and undermining health-service resilience. The government must address the lack of investment in NHS capital infrastructure and inefficient commercial arrangements as a priority.

The Department of Health and Social Care’s capital expenditure has increased in the past two years and is set to remain elevated over the current spending review period. This should remain the case, at least over the next parliament, and more stringent, legally binding measures should be put in place to keep capital budgets ringfenced to address the NHS maintenance backlog, which now stands at a colossal £10.2 billion.[_]

Recommendation: The NHS must invest to scale up adoption of technology including AI to improve back-office efficiency, transform clinical care and improve patient outcomes.

To truly unlock efficiencies and deliver the operating model set out in this paper, the NHS must move away from the existing approach, which focuses on increasing staff headcount to improve efficiencies, and invest more capital in technology and infrastructure that will enable the existing workforce to operate more efficiently.

This should begin with the creation of a coherent and up-to-date strategy to harness the power of data, technology and AI in particular. The latter has been transformed in recent years, with the emergence of large language models opening untold new opportunities in health care.

The NHS should prioritise applying innovative technologies to improve and automate back-office functions and routine processes. It is welcome to see the recent partnership with Microsoft[_] and robotic process automation referenced in the NHS Long Term Workforce Plan, though without further spending commitments.[_] Much of this is not necessarily about cutting-edge technology but rather applying existing, proven approaches that are standard in many other industries to drive productivity.

Once comprehensive real-time data are made available through the FDP, AI could increasingly be used to optimise operational planning within the NHS, to ensure maximum utilisation rates, for example of hospital beds, across a local health-care system, similar to applications for airlines and hotel chains. This will help to even out demand and minimise underuse. As a result, ambulance queues and patients staying longer in hospital than needed would become increasingly rare.

AI is already being used in areas like radiology and pathology to speed up the efficiency and accuracy of diagnosis. But there are myriad other areas where the capacity of AI combined with the skills of health-care professionals can deliver huge improvements in patient safety and quality of care, from more accurate stroke prediction to more effective management of A&E demand.

We therefore welcome the recent announcement that AI technology will be rolled out to cut waiting times for cancer patients[_] and that £21 million will be provided to accelerate the development of new AI-enabled diagnostics and treatments.[_] However, much more investment is needed to implement the use of these technologies across the NHS to ensure they drive efficiencies and improve care for all patients. In addition, this investment in AI must not detract from investment in existing technologies that are ready to be deployed to address low-hanging fruit such as scheduling and waiting-time management.

In a tight fiscal environment, these significant investments can be offset by intelligent automation leading to a rise in productivity, which has fallen by one-quarter in recent years. They can also be offset, at least in part, by finally tackling wastage across the system. For example, NHS purchasing power could be more fully leveraged to limit wholesale margins on medicines, bringing the NHS in line with other European markets, and by introducing a “comply or explain” process to encourage all health-care professionals to procure products from centrally negotiated tenders.

6. Energising and Modernising the NHS Workforce

Despite a string of investments in recent years, staff-vacancy rates remain high and sickness rates have hit record levels. While the total workforce has expanded in recent years, NHS productivity continues to fall as overworked and burnt-out staff shoulder the burden of an under-resourced and repeatedly restructured service that suffers from systemic bureaucracy.

At the same time, real-terms wages have fallen by up to 16 per cent since 2010, which has led to unprecedented strikes across the service.[_]

The transformative power of technology, patient choice and a self-improving system are vital to create a more sustainable NHS and reduce growing demands on staff. Yet in many parts of the service, technology is not just missing; it is actively making life harder, where it is poorly integrated or designed.[_]

A modern NHS must create the right conditions and culture for its staff to succeed and utilise technology to increase efficiency and deliver better patient care.

Recommendation: The government must build upon the NHS Long Term Workforce Plan[_] to address immediate pressures and ensure staff are properly incentivised to harness research and innovation to improve patient care.

The NHS’s new workforce plan is welcome and, at least partly, answers a long-standing call from NHS leaders and staff for a strategy to ease pressure on the service.

There are many positives in the plan, including the increase in overall NHS capacity by 2037, with specific commitments to increase annual medical-school training places to 15,000 per year, alongside a 50 per cent increase in GP training places and a 92 per cent increase in adult nurse training places by 2031–2032. This will help secure the future talent pipeline for the NHS and, alongside the commitment to recruit 22 per cent of all clinical staff through apprenticeship routes by the same period, will help to increase diversity across the services.

There are also some welcome examples of innovative and digitally enabled approaches being used to address capacity issues and increase patient access to care. One such example is the NHS Emeritus Doctor Scheme, which will allow recently retired consultant doctors to use a digital platform to offer outpatient appointments (virtually and in person). This will help to increase patient access and address backlogs in care. In time, the service should form part of the PHA.

However, the NHS plan has arrived without a clear operating model for the health and care services sitting alongside it. The lack of blueprint for the way the NHS intends to operate makes it hard to assess whether the workforce plan is futureproof.

We have set out a possible operating model in this paper and important workforce implications follow. For example, ICSs operating risk-adjusted long-term budgets urgently require analytical and actuarial skills alongside clinical skills. The plan is generally silent on the need to expand the number and improve the quality of management and wider support staff across the NHS.

As a result, it risks channelling more people and resources into an outdated delivery model, which will not address falling productivity and will only ever delay long-term decline.

Notably, before the government can shift its focus to implement its long-term plan for the workforce, it must commit to engaging the unions to resolve the current impasse over staffing pressures and pay. Otherwise, service standards will continue to degrade and longer-term reforms will rapidly become unachievable.

Greater support for local workforce reform is also critical. While the NHS plan does reference the creation of new community roles focused on prevention and proactive care, there is a lack of concrete commitments. And these changes need to go further to harness the greater freedom available for ICSs to engage in wholescale workforce reform so that they can meet specific needs in their local communities.

Supporting all staff to harness the potential of research, technology and innovation to improve service delivery and patient care is important, and it is welcome to see this called out in the plan. However, real change will require a shift in NHS culture, driven by the introduction of clear incentives, like those recently recommended by Lord O’Shaughnessy, for staff to support commercial clinical research,[_] or the rapid adoption and spread of proven and cost-effective technologies across the system.

Finally, the plan will only be successful if it comes alongside actual investment in the infrastructure set out above – and if government provides the same long-term funded workforce commitments for social care and public health. Only by investing in all of these areas will we be able to create health and care services that have the capacity necessary to meet demand and provide the care that people need.

Where Do We Go From Here?

The founding principle of the NHS – a taxpayer-funded system that is available to all and free at the point of use – remains as strong and relevant as ever.

However, the way this principle is delivered must change. We must create an NHS that is fit for the future, driven by strong incentives to continually improve and to harness the power of science and technology to transform patient care.

Success will require investment. But most importantly, it will require political courage and a firm commitment to reform.

If we fail, it is unlikely the NHS will survive to see its 80th birthday.

Footnotes

  1. 1.

    https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/ageing/articles/livinglongerisage70thenewage65/2019-11-19#traditional-versus-prospective-population-ageing

  2. 2.

    https://news.sky.com/story/nhs-waiting-list-hits-all-time-high-of-7-22-million-with-one-in-10-waiting-12-hours-in-a-e-12856347

  3. 3.

    https://ifs.org.uk/articles/ever-growing-nhs-budget-could-swallow-all-weeks-tax-rise-leaving-little-social-care

  4. 4.

    https://www.kingsfund.org.uk/blog/2018/10/short-history-nhs-winter-funding#:~:text=Winter%20funding%20is%20sometimes%20referred,and%20seasonal%20surges%20in%20activity

  5. 5.

    https://www.england.nhs.uk/publication/next-steps-for-integrating-primary-care-fuller-stocktake-report/

  6. 6.

    https://ourfuturehealth.org.uk/

  7. 7.

    https://thecca.org.uk/pharmacy-first-could-be-a-game-changer-for-primary-care-if-government-and-the-nhs-demonstrate-ambition/

  8. 8.

    https://www.kingsfund.org.uk/publications/communities-and-health

  9. 9.

    https://growinghealthtogether.org/people/

  10. 10.

    https://www.boots.com/healthhub

  11. 11.

    There are increasing numbers of digital providers offering services remotely, meaning patients are no longer required to visit a care facility. Almost all of these are enabled through everyday digital devices and/or delivered to patients’ homes. Sexual-health services are established online, for example in London, and have a degree of competition that has driven service experience and uptake: https://www.economist.com/britain/2019/03/16/sex-clinics-show-how-competition-can-improve-englands-nhs.

  12. 12.

    https://www.theguardian.com/society/2023/apr/03/backlog-in-nhs-genome-service-leaves-families-facing-long-wait-for-results

  13. 13.

    Proteomics, the study of all proteins in a biological system, is increasingly being used by clinical researchers to identify biomarkers of disease. These biomarkers are applied to several areas of patient care including disease prediction, diagnosis, staging, monitoring and the assessment of drug efficacy.

  14. 14.

    Metabolomics seeks to evaluate and predict health and disease risks in an individual by investigating metabolic signatures in body fluids or tissues, which are influenced by genetics, epigenetics, environmental exposures, diet and behaviour.

  15. 15.

    Important lessons are emerging from devolved and combined local authorities in Manchester and the North East (see: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667%2822%2900198-0/fulltext and https://www.gov.uk/government/publications/north-east-devolution-deal--2/north-east-devolution-deal).

  16. 16.

    https://www.gov.uk/government/publications/pro-innovation-regulation-of-technologies-review-life-sciences

  17. 17.

    https://www.health.org.uk/news-and-comment/charts-and-infographics/how-does-uk-health-spending-compare-across-europe-over-the-past-decade

  18. 18.

    https://www.kingsfund.org.uk/publications/nhs-compare-health-care-systems-other-countries

  19. 19.

    https://nhsproviders.org/news-blogs/news/billions-needed-to-plug-growing-nhs-maintenance-backlog

  20. 20.

    https://news.microsoft.com/en-gb/2023/06/29/nhs-england-microsoft-deal-maximises-time-for-care/

  21. 21.

    https://transform.england.nhs.uk/media/documents/RPA-Guidance-May-22.pdf

  22. 22.

    https://www.bbc.co.uk/news/health-65988768

  23. 23.

    https://www.gov.uk/government/news/21-million-to-roll-out-artificial-intelligence-across-the-nhs

  24. 24.

    https://www.channel4.com/news/factcheck/factcheck-how-much-has-junior-doctors-pay-fallen-and-what-pay-rise-do-they-want

  25. 25.

    https://cep.lse.ac.uk/pubs/download/dp1801.pdf

  26. 26.

    https://www.england.nhs.uk/publication/nhs-long-term-workforce-plan/

  27. 27.

    https://www.gov.uk/government/publications/commercial-clinical-trials-in-the-uk-the-lord-oshaughnessy-review/commercial-clinical-trials-in-the-uk-the-lord-oshaughnessy-review-final-report

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