March 4, 2019

NHS ‘What If…” Report



As NHS leaders announced their long-term plans in 2019, we invited  the views of a group of people seldom heard from, to see how they’d improve the NHS.

The group we spoke to are all Turnaround and Improvement professionals on the front line of making the NHS a better service.

We asked each of them the same question:

“Putting all politics aside, if you could change one thing about the NHS, what would it be?”

Their views are summarised in this booklet. Some highlights are featured below from various functions across the NHS. These are just honestly held views of professionals who are passionately engaged with improving our NHS. These views were prevalent pre-Covid — but many are still relevant today. Although expressed in 2019, many seem still relevant in 2021, as changes unfold.

What about you? Putting politics aside, what would you change?


Philip KENT
Deputy Director of Nursing and Governance professional 
Director of Nursing & qUALITY IN A ccg, NOW A CONSULTANT   

Good Governance

“I’d love for the NHS to be removed from political change. I know this is a Nirvana-like state but we can all dream. Over the past 25 years that I have known the NHS, there have been so many changes that have altered, abolished, re-organised or just shaken what is an amazing institution. Some of the changes the NHS has undergone have been well intentioned, like the introduction of general management in the 1960s, but others have been damaging, brought about in response to political fashions or to capitalise on the perceived public mood.”

Embed Collaboration

“It would be to ensure collaboration and cooperation are embedded into every aspect of the NHS. I have seen first-hand, the power that collaboration has in delivering sustainable high quality services.

There is a significant amount of evidence supporting collaboration to meet the challenges faced by health and social care providers, with Integrated Care Systems leading this work and focusing on developing strong partnerships. However, I still observe organisations focusing on their own interests, isolating themselves from the wider system.”


Demand Management

We’ve been talking about integrating health and social care for many years now – and yet evidence of meaningful progress is rarely seen.

What stands in the way? Well many things I’m sure – but in my view one ‘culprit’ is the clumsy and ineffective way that funding is allocated via the ‘contracting process’. Having observed several adversarial lose:lose contracting rounds, this is the one thing I would change in an instant.

Systems need to recognise the affordability envelope that they are given – and all parties within that system need to own this. None of this is easy – and structured turnaround discipline is needed to make any complex change happen. But let’s help ourselves by finding a better way of allocating resource – sharing control totals.”


Managing at Scale

“It would be with management structures. The great companies have one thing in common: a world-class management system. One that cascades from top to bottom of the organisation, allowing management of their business at all levels and a clear line of sight from board to shop floor. One that links organisational, operational and individual performance. One that looks forward, allowing management to intervene with support where risks are emerging rather than after they have hit. 

Resource for health care will always be limited. Having a management system that can make the right economic and quality based decisions is essential if we are to have a thriving world class health care system”.     Read More

peter bullivant
programme director

Aligning Incentives

I would change the financial incentives so that all organisations are rewarded for the achievement of patient-determined outcomes.

This would facilitate the design of healthcare as a value-based system and not archipelagos of isolated organisations with competing priorities, driven through perverse incentives. Organisations do not deliver healthcare, people deliver healthcare and we do not currently work together as a system. 

We could develop systems that operate across organisations to promote feedback and communication around common goals; we need to change how we support people and populations not just where.”


Long-Term Planning

“Apart from the obvious wish for enhanced funding to arrive, the greatest limitation I have found with the NHS is the inability to plan service delivery (and thereby cost savings) over a long period.

Short-termism stymies innovation and compromises true service transformation. I have seen too many sound medium to long-term strategies either cut short or watered down, so that achievements are greatly restricted. Changes in work-force models, for instance, can provide not only long term sustainability, but also greater economies of scale.

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