So what is the big national discussion we should be having about change and the NHS? (ideas)

This week, I've been reflecting a lot on the national conversation around change and the future of the NHS. It’s been presented to us as a series of questions, which I’m sure you’ve also been thinking about.

If you caught my previous narrative earlier this week, you’ll have noted that I felt it was rather lacklustre—very leading in its questions and largely political as an exercise, rather than a truly meaningful discussion.

This has led me to think about what a meaningful conversation would look like, especially in the context of the three main priorities of technology, prevention, and a shift towards the community, as outlined by Labour in their manifesto.

Firstly, I think there are a couple of elements we need to consider regarding this contract. I use the term contract because the reality of the NHS is that it is not a new agreement, but an existing one that the tax-paying population of the UK is required to be part of without an option to exit.

There are wider roles and different kinds of responsibilities that play a part in this.

My concern, politically, is that we treat the NHS like a tasting menu that’s already been paid for by someone else, where we can go in and say, “Well, I’ve paid my taxes, here’s the list of options I want.” One particular question in the review, asking to select the top three things you’d like, felt very much like sitting there with a menu in front of me.

The challenge herein is that, as we saw recently in the Darzi review and have become all too aware of through news cycles, particularly those of us who follow the NHS closely, we are in a period of resource constraints. Any priority, proposition, or increase in NHS funding is a trade-off against something else.

If you look at discussions happening at an ICB board level, trust level, or nationally, you’ll see that offering one thing means we can’t offer another thing at the same level of quality.

The other element I’d like to add is the long-standing consumerist mindset we’ve had about the NHS. It always takes me back to what Yuval Noah Harari said in Sapiens, where he described contemporary society’s religion as having two elements.

The first part is the concept of the paternalistic state, where large institutions are expected to look after us in exchange for us relinquishing certain responsibilities—like childcare, healthcare, and community provision.

The second part is the dominant view of capitalism, where the measure of value in society is money. Many conversations about the NHS revolve around what we spend and what we get back.

For me, this is a problem because in any meaningful, bi-directional contract, a consumer mindset is not helpful. If our view of the NHS is that we put money in and get something back, and our expectation is that it will provide us with everything we desire, we’re setting ourselves up for disappointment.

We've seen the paternalistic role of this system grow, trying to tackle obesity, focusing on prevention, or even supporting families with specific health needs. The system, once about getting treatment when ill or dying, has now become one where we have medicalized and systematized our expectations of a health and care system. This, in my view, is problematic and damaging because it takes away our agency as individuals and communities.

Just look at the increasing lifestyle disease crisis, our lack of control over local communities, and the general state of our physical and mental health. This model is unequivocally failing us.

So what powerful questions could we ask?

So, let’s consider what questions we could ask if we were to take the role of the NHS, trade-offs in value, and the balance of input versus output into account. Drawing from JFK’s words: “Don’t ask what your country can do for you, but what you can do for your country.” This is particularly relevant in the three main areas of prevention, community focus, and technology.

Let’s start with prevention. I can’t recall the exact order they were presented, but I’ll begin here. In the context of prevention, focusing on resources means asking where we should allocate them.

Asking if the NHS should do more in prevention is a simplistic and reductionist question. Instead, we should ask where we want to change the investment that comes from our taxes. If you had £100 to spend, would you prioritise:

1. Preventative activities to improve the nation’s health,
2. Improving primary care and access to doctors,
3. Hospital care, including elective waiting lists and acute care

You could also include social care, given the health and social care system’s limited focus on this area, as well as mental health. Instead of asking what we want and letting us pick as many as we like, we should be discussing where to invest.

Prevention

The second point on prevention is about the contract between individuals, the community, and the system. This ties back to the issue of capital exchange. I see very little emphasis on the role of individuals or collectives in providing care. If we’re serious about prevention, why aren’t we discussing a more balanced contract between citizens and communities?

What responsibilities should we have, and what should we be empowered to change locally? If we continue to add responsibilities—mental health, lifestyle care, neurological diversity—without a clear societal debate, we risk overwhelming the NHS. The “tasting menu” of services will get longer, along with our expectations. So, we should be asking: What should we expect from ourselves?

I don’t expect this to be a politically popular question, but it’s necessary.

Tech

Moving on to technology, the problem is that we haven’t clearly defined it. “Technology” and “digital technology” are incredibly broad terms, covering almost every aspect of the NHS’s future. It’s convenient to use the term, but it’s not helpful.

My concern is that we have a perfectionist view of technology without considering the dynamics necessary for its implementation. First, we should ask about our collective vision for a technology-driven NHS.

Are we aiming for a more cost-effective - but less human - healthcare system through technology, and should that be our main investment focus, or should we prioritise more doctors and nurses?

The second question is about risk. If we want transformative technology, we must accept risk. Aiming for a perfect system is unrealistic; digital technology is complex and inherently imperfect.

Should we take more risks to integrate technology into the NHS or play it safe, potentially slowing technological progress? These aren’t easy questions, but the point is to capture the essence of what needs asking.

Community

Finally, there’s the issue of shifting care into the community. While the idea is appealing, reality is more complex.

Post-COVID, we’ve seen acute care move to community providers and general practices, but this shift has been challenging.

I’ve worked with community providers and NHS England on this topic, and it’s clear that these organisations face enormous pressure without sufficient transformation or vision. Are we willing to allocate resources away from secondary care to bolster community organisations?

This brings me back to the contract between citizens and the state. What is a community, and who are we talking about?

The 2019 King's Fund work on reimagining community services is a good reference. Are we referring to shifting to, and empowering, actual communities, as Cormac Russell describes in his asset-based community development model, or just shifting more work to community health services? Do we expect communities to play a more active role in improving care?

SUM

To conclude, it’s fantastic that we’re having a national discussion, but there’s a risk of creating hope only to lose confidence if the conversation isn’t right. If we continue oversimplifying what healthcare and social care need to be, we may end up with a model that doesn’t serve citizens’ interests. This worries me.

We face the danger of creating a conversation that glosses over the complexities of what is required to bring about a meaningful transformation. If we don’t engage with the detail of these questions—around the dynamics of community roles, the limits of a paternalistic model, and the boundaries of technological innovation—we might fail to meet the true needs of our society.

We need to question the basis of what we want from our health service, what trade-offs we are willing to make, and where we want our collective resources to be directed. Otherwise, I fear the current conversation will only lead to more dissatisfaction and unrealistic expectations.

My hope is that this process becomes less about rhetoric and more about co-design, involving real voices from all parts of the community, including patients, professionals, and policymakers alike.

It is crucial that we not only keep talking but also ask the questions that matter—ones that might be uncomfortable but are necessary if we truly want to achieve an NHS that meets the evolving demands of our society and genuinely reflects the values and needs of the population.

Footnote - with a new baby, a course and lots of clients I'm VERY time poor! HOWEVER, I have just the same amount of ideas and thoughts that I'd like to put out. So this has been an experiment where I have narrated an article in my kitchen whilst making coffee (then letting it get cold) and asking Chat GPT the following:

I have a transcript of an audio narration I've created, but it includes breaks and punctuation in incorrect places. Please improve the readability of the text by adjusting sentence breaks, punctuation, and structure only where needed. Do not change the content, meaning, or tone of what I’ve said and do not significantly cut content or significantly reduce the word count. I just want corrections to the main content. Maintain UK English spelling and phrasing as this is the language style I've been using. Please avoid introducing any new ideas, rewording content, or changing the subject matter.        

Surprise surprise, ChatGPT wants to be creative and slash the word count and add things in. So I basically kept repeating that I wanted it to stick to the script and sort out the language, until we more or less got there.

This article, posts and all of my thinking content is always generated by me, and always will be, however, AI is a fantastic tool for helping our productivity. In this case wrangling with ChatGPT made it less so, but I think my morning narration and ChatGPT editing could really help me get my articles out in a more productive way.

Either way I hope this read was provocative (in the right way) and enjoyable.

Liam

Liam Cahill is a trusted adviser to frontline providers and national bodies on all things digital, with nearly two decades experience of doing tech stuff in the NHS. He has mentored and advised some of the best known names in Healthtech, and they've usually said some nice things about his work. He has also released a comprehensive course on how to understand and respond to the intricacies of the NHS when trying to work with it.

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