Alastair Mitchell-Baker


The NHS at 70: making sense of a mess

As the NHS celebrates 70 years, I recently found a video in my office I made with regional colleagues in Anglia and Oxford in 1998 on the 50th anniversary of the NHS! It was called ‘Sustaining the NHS.’ Three thoughts immediately came to me:

  • ‘Plus ca change’ – the challenge persists – but so does the service, the concept, the ideal. As a nation we seem to believe in the NHS more than ever.
  • ‘So much change’ – we’ve had many a reorganisation since then; remember PBCs, PCTs, CCGs, STPs, ACOs and now ICSs etc. We’ve been through various middle tier geographical shapes – even back to Anglia and Oxford, aka Midlands and East, and now another change.
  • ‘What’s really changed?’ – we spend twice as much but still not enough. We’ve more staff but still not enough. We’ve adopted amazing new technologies and transformed care for many patients with cancer and stroke for instance. Yet we are still slow at disseminating new technologies. People live longer yet still die prematurely compared to our aspirations.

A fourth soon popped up – why had I kept that for 20 years as I don’t even have a video player anymore! A metaphor for the NHS surrounded by change and yet so recognisably the same as when I started over 30 years ago as a very enthusiastic and naive management trainee.

And yet we have the most complicated and fragmented service I have ever known. The words of Jim Mackey at the NHS Confederation Conference in 2017 still resound in my ears. “Eventually it will all make sense again.”


What is it about the NHS that will ‘make sense’? How will that happen? Is it to be a clever top down policy repositioning to show us it really was coherent after all? Will the planned organisational juxta positioning of NHSE and NHSI resolve things, as if the regulated market was after all, just a myth? Will the PM and Chancellors Damascus road funding moment and promises be enough? Will a new Secretary of State and a wave of new technology be enough? The NHS barely survived the last winter without the Daily Mail quite landing a knockout blow but can it continue to just muddle through and survive?

In short, my reflection is none of the above.

I believe one of the key things local health and care systems can do is to ‘talk’ themselves out of the current mess, confusion, and frustration. Of course, this is easier if there is money and staff (and a central hands off approach) – but the last 20 years teaches me that these alone are not enough. Local clinicians, council leaders, frontline staff, and organisational leaders must come together to dialogue and shape a shared story about their local health and care ‘ecosystem’. Forget the labels for now of ACOs, ACSs, ACPs, STPs, LDSs, LHEs, ICSs, and the like. Tell the story for our Place, for our Staff, our Patients, our Citizens, and our Communities.

‘Ecosystem’ is being increasingly used to describe these health and care collaborations: is this just fashion? I would propose there is real value in thinking about the complexities of biological ecosystems as a metaphor for what’s needed. Ecology is the study of interactions between and within species and their environment. Considering the behaviour and characteristics of healthcare organisations, councils, and local communities in this way, can give different insights to prompt us both to think and potentially act differently. Furthermore, the combination of new (and old) insights emerging from the sciences of ecology, neuroscience, and applied behavioural science provide valid foundations for new approaches to designing and transforming value in health and care systems.

Up and down the country local systems are coming together to develop a narrative that focusses on local needs, local opportunities, and how local resources can best for used for local people. These stories frame a different way of thinking about the challenges of health and care. They can shift the focus from my organisation and my patients to our system and our communities. They provide a compelling ‘why’ for local staff and representatives to work together.

To be more than words, however local systems need to articulate their shared principles which describe ‘how’ they can create a common ethos and ways of working to guide local staff and leaders. I did various pieces of work in Salford some years ago. What struck me was that co-working and collaboration within and between the NHS, council, and voluntary and community services, was the default. It didn’t matter what national policy demanded – whether joint commissioning, Section 75, BCF or whatever. Things were done in an integrated ‘One Salford’ way –the external requirements were complied with, but they were secondary, not primary.   It’s no surprise to me to see the spread of integrated and collaborative working across local providers and the whole GM Devo region.


But principles need to be enacted so everyone is clear ‘what’ they must do. Key processes can be approached from the local health and care ecosystem perspective, to develop and ‘feed’ it. These might include:

  • Population health perspective: understanding and addressing the key issues which will enable people to live long and healthy lives.
  • Person-centred pathways for people with similar conditions/needs focussed on supporting well stay well in their normal place of residence.
  • How do we measure and manage the performance of the whole ecosystem and not the individual organisational components alone? How are incentives and rewards used? Colleagues at a recent EODF conference told me how Shell had deliberately and successfully introduced performance management for senior managers at the ‘ecosystem’ level to encourage people to work collaboratively and beyond their ‘narrow’ personal accountabilities.
  • How do we allocate work and resources across the ecosystem to achieve our overall goals and support ecosystem health and sustainability?
  • How do we develop and enhance relationships across the ecosystem especially at key interfaces and points of pressure? These will typically be where different sub-systems meet such as hospital discharge. How can integrated and shared teams be developed to manage these tensions, rather than degenerate into blame.
  • How can we embed feedback lops and learning about ourselves and our ecosystem?   When we have worked with local health and social care teams we have known there is real breakthrough when real time information from all parties is openly shared and used to make decisions.
  • How does authority get used? Developing ways of making decisions that work for the whole ecosystem and naturally draw from a distributed and collective leadership approach. How do we make our governance structures and processes align with and serve the ecosystem? The current tension is real of a strongly vertically regulated system with NHSI and NHSE driven to manage providers and commissioners at times as if they don’t share the same space, drink the same water and breathe the same air. How can the local ecosystem embrace the regulatory dysfunction and still decide what’s best for the local services and local people?
  • And perhaps most importantly, how do we keep building the identity of the ecosystem? How can we develop communications, leadership, and workforce development and employment practices which reinforce the ecosystem above individual organisations.? What feeds the energy and passion of local staff?

Sense cannot be made for you. It will not be created top down. The opportunity is there, like never before, for local health and care clinicians and leaders to come together to create together a shared narrative around their local ecosystem, underpinned by their shared principles and enacted through a series of collaborative practices. Together a more enduring and meaningful sense can be made to guide the development and sustaining of local services. Biology tells us that healthy ecosystems survive and adapt through tough times, catastrophe and even changes of climate. Local development of health and care ecosystems might not just create more sense but develop greater resilience.

Is it time for a conversation with your colleagues across whatever divide holds you back from developing the local ecosystem?

To explore an ecosystem perspective on your local challenges please contact Alastair Mitchell-Baker at