A cake with N H S candles to mark the 75th anniversary of the NHS.

After 18 hours in labour, Edna Rees was confused when the midwife stopped telling her to push and urged her to hold on.

Too exhausted to argue, Edna complied and baby Aneira became the first baby to be born in the National Health Service (NHS) at one minute past midnight on 5th July, 1948. That meant Edna avoided having to pay the midwife one shilling and sixpence.

The NHS continues to provide comprehensive healthcare, available to everyone, based on clinical need, not an individual’s ability to pay.

Those guiding principles remain unchanged for 75 years, providing continuity as the NHS has evolved and adapted to meet the needs of subsequent generations.

Today, pressure on NHS services is greater than ever, but social surveys continue to show overwhelming support for those founding principles. The pride, appreciation, and love that so many feel for the NHS is often difficult for people from other countries to comprehend.

The NHS is the world’s oldest universal health system and one of the largest, managing 1.6 million patient interactions every day. Only five organisations – including Amazon, Walmart, and the People’s Liberation Army of China – employ more people than its 1.5 million staff.

It is also one of the most affordable and best performing healthcare systems globally. The Commonwealth Fund’s Mirror, Mirror report in 2021 suggested the UK had a more affordable healthcare system than nine comparable countries (including Germany, France and the USA). On performance, only Norway, the Netherlands, and Australia fared better.

But as the NHS celebrates its 75th birthday, it faces numerous issues. The service is tackling the consequences of Covid-19, including larger waiting lists for care, longer waiting times, and pressure on emergency care, general practice, and mental health.

NHS workers have also been profoundly impacted by their experiences during the pandemic. Recovery is likely to take several years.

At the same time, a rapidly ageing population presents increasingly complex healthcare needs, which will require innovative care delivery models.

There are significant skill shortages and vacancies are rising. The process of training and upskilling staff, and rethinking job roles, needs to accelerate.

Deep health inequalities exist, with significant regional variations in life expectancy and years lived in good health. The pandemic deepened that disparity.  The emphasis must shift upstream to improve population health, rather than focussing largely on treating illness.

There is agreement that, going forward, healthcare and social care has to be more joined up. We need to think less about “services” and more about “people”. This means providing integrated support for the whole person, rather than disjointed hospital services, primary care, and social care. Future patients are likely to be more demanding and care will need to be more personalised, with greater focus on preventative wellbeing and self-care.

Technological and scientific advances are revolutionising healthcare and the NHS needs systems and culture that are “innovation-ready” to ensure that every person who uses NHS services gets consistent, high quality, evidence-based care.

It might seem that these challenges are so significant they can only be addressed by government policies and the most senior NHS leaders.

But the history of the NHS has shown us that successful change doesn’t always start at the top. More often, it comes from those with good ideas who test out innovations in local contexts and get better results with the same resources as their peers.

Whilst many challenges do need policy-level intervention, leaders at all levels of the system can help to build momentum for another 75 years of success.

Here are seven factors, distilled from hundreds of NHS change initiatives, which separate innovations that succeed from those that fail.

  1. Relationships are key to delivering change across boundaries. As the NHS moves into an era of integrated care, a focus on building relationships for collective action is even more important. High levels of “social capital” - relationships within and between groups that form trust, connection, and collective capacity - create the strong foundations on which change initiatives can dock.
  2. Large scale change in the NHS is typically the outcome of many smaller cycles. Change is more likely to be achieved by mobilising increasing numbers of people who aspire to a future that’s better than the status quo and getting them involved in change initiatives than it is by top down schemes.
  3. Trojan mice are more effective than Trojan horses. Having many people across the system who can test small, well focussed changes (Trojan mice) nearly always works better than large pilot and roll out projects (Trojan horses).
  4. To gain commitment to act, build attraction to the change. Change that is done “to” or “for” people does not create attraction. Every person is unique and will be attracted to change in different ways. Change needs to be approached one person at a time, even for large scale change in the NHS. Approaches such as storytelling can act like a magnet to attract diverse groups to a shared view.
  5. Real, profound change is difficult unless the "space" for change is created. People in big systems like the NHS need "space" for learning, reflection, re-design, and new forms of emergence. That means designing space into organisational processes and routines, through networks, communities, summits, learning debriefs, peer-assists, virtual platforms and huddles.
  6. A sense of belonging, built around shared purpose, enables diverse groups of people to unite behind change. Building a sense of belonging is a significant task for leaders in the NHS, for instance, when it comes to retaining people and building cross-boundaries groups for change. When people feel they belong, and are seen and valued for their own unique selves, they thrive and there is more courage for creativity and new ideas.
  7. Having constancy of purpose is critical for sustainable change. Many large scale change efforts in the NHS have just fizzled out. Successful change needs leaders who keep the faith through interest and energy. Don’t meddle when results don’t come quickly and stick with the change priorities.

Many of us in the UK cannot imagine a future without the NHS. However, it will need to change significantly to meet the needs of future generations. A special characteristic of the NHS is that it is part organised healthcare system and part social movement.

Never underestimate the power of the shared purpose that unites the population, patients and people who work in the service. Whatever challenges the NHS may face, it is our NHS and will continue to be so for years to come.

Further reading:

Five-year NHS trial sees thousands of hours saved and services improved

Hold each other to account for behaviours, not just outcomes

Change leader takes on new challenge as WBS Professor of Practice

Helen Bevan is Professor of Practice in Health and Care Improvement at Warwick Business School. She was previously Chief Transformation Officer at NHS Horizons, Chief of Service Transformation at the NHS Institute for Innovation and Improvement, and Director of Innovation and Knowledge at the NHS Modernisation Agency.

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