London School of Hygiene & Tropical Medicine

For the past thirty years the NHS, like all health care systems in high income countries, has sought improvements in the quality of its services and its productivity through increased assessment and greater accountability to the public. We have seen the development of countless guidelines advising clinicians how to practice, advice for managers on how to effectively organise services, financial incentives to encourage clinicians to behave in certain ways, databases comparing the performance of doctors and hospitals, and the use of market forces by separating the purchasing and provision of health care.

Each of these initiatives have had some notable successes. We have seen dramatic improvements in survival and other outcomes of care. The productivity of the NHS has increased faster than that of the national economy. And until recently, public satisfaction with the NHS was improving.

However, all is not well. Many staff are dispirited, productivity is highly variable across the country, the quality of many providers is deemed inadequate, care is often insufficiently oriented to the patient's needs, resources continue to be focused on acute hospitals, and administrative complexity is both wasteful and a barrier to the seamless health and social care sought.

While technological advances, better financial management, increasingly sophisticated ways of assessing the performance of the NHS and greater provision of public information will continue to contribute to improvements in the future, it is also clear that these approaches are not going to prove sufficient.

The era of assessment and accountability that has dominated the past 30 years has had some unintended adverse effects. Regulation has become burdensome for practitioners and providers; we have created a system in which trust is low, in which managers fear for their jobs if they don't meet the standards set by central bureaucracy and staff are discouraged from trying new untested approaches to care.  Management and regulation, with its focus on the component organisations - local commissioners, hospitals, general practices - has perpetuated a silo culture, discouraging integration. If we set out with these goals in mind, we could not have designed a better approach to achieving them.

To meet the needs of the public within inevitably limited resources, we are going to have to adopt radical new approaches. While additional funding, particularly for social care, would help, without fundamental changes in the ways we think about health and care needs, extra expenditure will only be a sticking plaster not a cure.

The good news is that the situation can be salvaged. It will need a shift in thinking at all levels from hospital porters and social care assistants to the Secretary of State for Health and Social Care. Assessment and accountability needs to be moderated by a change in the way we think about systems. Our focus on trying to improve the functioning of each component organisation of the system needs to shift to the relationships and connections between them. This will facilitate the radical changes that are needed to the way services address public needs. It will also allow a greater orientation to populations and away solely from those in care. Such systems management will cope much better with the complexity and uncertainty of the health and care challenges we face.

The other key change requires us to release and nurture the amazing creativity that lies dormant and repressed within current services. Among the 1.4 million NHS staff and social care staff, there are those with social entrepreneurial skills and great ideas as to how the services they know most about could be better organised and made more patient-centred. Add in the ideas that patients and their lay care-givers have, the challenge will be coping with the plethora of innovative ideas.

But this will only succeed if those who are currently considered to be in charge are prepared to let go, to loosen the reins and provide support and backing to these social entrepreneurs. This will require courage, as sometimes what appear to be great new ideas will turn out not to be so. We have to move from punishing innovation failure to an environment where those who try to improve services are recognised and encouraged.

The new era will be demanding but it is perfectly feasible. Indeed, it lies at the heart of the Five Year Forward View and policies to develop accountable or integrated care systems. But the success of the new era of systems and creativity will lie with staff struggling to provide services to a local community.

There are plenty of wonderful examples already of what can be achieved taking this approach. The Living Well Network in Lambeth has almost halved the need for referral to psychiatric outpatients; in Gateshead specialist old peoples nursing has halved emergency admissions to hospital; a rapid response team run by paramedics in Nottingham has halved the number taken to A&E; and in Frome, community welfare developments such as talking cafes have reduced the need for hospital admissions by a fifth. These are just a few examples.

The triumphs and achievements of the past 70 years should be celebrated. But we face severe challenges which, if not addressed in new ways, will jeopardise the cherished goals of the NHS. New ways of managing systems and of releasing the creativity of staff and patients offers us exciting possibilities and a prescription for future success.

This expert opinion piece is the last in a series that LSHTM has published in the lead up to the 70^th anniversary of the NHS (5 July 2018). You can read more about our NHS 70 series and join the conversation online using #NHS70LSHTM.