ANALYSIS
This approach will help rebuild confidence and trust in the NHS. We are not proposing structural changes or going back to structures such as regional health authorities, but looking for behavioural change and new approaches such as citizens ’ assemblies, where patients and the public can better engage in governance and decision making, alongside other stakeholders. 29 Local services and planners need to think about how patients, the public, and community groups can be connected at the most local level and feel part of the efforts to care for themselves, their fellow citizens, and communities. Some of the loss of trust in the NHS appears to be about the role of politics in its management. This is why we recommend a method for independent scrutiny of plans and policies. Technology and data The importance of advances in technology can be exaggerated, but it is clear that increasingly “ Science, technology, and data will determine much of the framing and the language of health, shaping how health workers think about health problems and possible solutions, and how they act. ” 30 Technology and data are themes running through all the BMJ Commission ’ s articles and have so much to contribute to improving health, healthcare, and wellbeing in the future. NHS data on tens of millions of patients over many years, for example, are extraordinarily valuable for research and development. However, artificial intelligence could also be used for private gain or disruptive purposes, and this relates directly to issues of trust and confidence in the NHS. Poor performance of the English 111 service has already led to criticism of diagnosis by algorithm, and suspicion of motives will make this worse where private companies are involved, as in the Post Office scandal. Mitigating these risks requires the NHS to adopt a principle of values based innovation and to put in place robust governance arrangements to protect the core principles and values from trade-offs and dilution. One of the authors (JM) has published recommendations for how to secure appropriate governance. These cover use of NHS data for training AI algorithms, accountability, technical validation, prevention of vendor lock-in, economic evaluation, and the potential for AI screening of the population. 31 This would support development of the NHS as a Learning Health system driven significantly by data, as well as digital and predictive AI. 32 Recommendations We have argued that the NHS founding principles are, with the qualifications noted, still appropriate now and provide a strong foundation for the future. But we need to make major changes to how these principles are put into practice. These include updating service models to make them fit for the 21st century, greater use of technology and data, developing an approach that encompasses all of society in creating health and preventing disease, and a focus onpeople — trust, engagement of patients, citizens, and staff, the development of human and social capital — and changes to professional education. Implementing change at this scale is difficult and it is useful to look back at the major reforms introduced in 2000, which the King ’ s Fund reported as leading to the most significant sustained improvements in the history of the NHS. 33 Lessons can be learnt about what worked and what didn ’ t. 34 Three key actions enabled those reforms. They involved people from across the NHS and its partners in developing a 10 year plan. 35 This
secretary of state to ensure that all new housing promoted health, safety, and wellbeing. 25 • Understanding that the health of an individual is intimately linked to the health of their family, community, the health of wider society, and the health of the planet, and introducing measures to promote health and wellbeing at all these levels. • Recognising the importance of promoting and creating health and wellbeing, as well as tackling the causes of disease and preventing disease and injury. Health is not simply the absence of disease. 26 Factors that promote health include having a social network, meaning and purpose in life, an increased degree of autonomy, and access to nature and green spaces, as well as the more familiar factors such as exercise, good diet, and good conditions of employment and living. • Treating improved health and wellbeing as a positive contributor to the country ’ s economy and not, as too often happens, a cost. This involves a recognition that human development and “ human capital ” are central to the wellbeing and prosperity of the country. Patients and the public The 2002 Wanless report, commissioned by the Treasury to look at the long term sustainability of the NHS, recommended that this could only be achieved through the full engagement of patients in their own health and healthcare. 27 Relatively little progress has been made since, with a focus on immediate service provision rather than upstream on human behaviours, illness and injury prevention, and health creation. This needs to be reversed, with patients and the public (as voters and future patients) engaged not only in maintaining and improving their own health but also in maintaining and improving the system. Patients and the public can play a greater role in the design and evaluation of NHS services. Patients are experts in what it is like to experience NHS care, to live with specific conditions, or to care for loved ones experiencing ill health. They often know better than researchers and analysts the most important research questions, the most vital services needed, the right outcomes to measure, and the best ways to ensure that the NHS delivers on its ultimate goal of patient and public benefit. Patients and the public also have important roles in improving and creating health, and make an important contribution to the future success of the NHS. Organisations within local communities and in every sector are already dealing with some of the most difficult health issues and creating health for themselves and others, with or without the assistance of the health system and health professionals. 28 We therefore recommend that the government develops better ways to connect patients, the public, and community groups with the NHS, particularly at local level. We propose that the NHS needs to embrace these roles by: • Placing community assets and efforts at the centre of health creation and long term conditions management. • Recognising that measures that strengthen community connection, voluntary sector activity, citizen voice, and health democracy strengthen the NHS ’ s ability to do its job properly and create the conditions for people to be healthy. • Learning from community health improvement in environments where resources are more constrained: focusing on the essentials, looking upstream, majoring on inclusion, and advocating for rights.
the bmj | BMJ 2024;384:e078903 | doi: 10.1136/bmj-2023-078903
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