The National Health Service is in a precarious state and may not reach the end of this decade intact. The current model, as envisioned by Sir William Beveridge and Aneurin Bevan, is no longer viable. Even with additional funding, health outcomes are unlikely to improve without significant transformation. 

The most fundamental shift required is to balance sickness and preventative care more effectively. Today, we have the means to increasingly prevent or anticipate ill health as a result of technological and scientific advances. We also know that true and effective health care needs a much deeper and continuous relationship between patient and carer to address the complexity of need.  

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Progress towards modern health care has been slow because of the very DNA of the original NHS model: a highly centralised system with an overreliance on top-down performance management as the main system of accountability. 

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Many have recognised the challenges posed by the NHS’s command-and-control approach and the need to unleash transformation. But previous attempts at change have failed because of an inability to resolve the apparent conflict between greater autonomy to innovate and the need for robust accountability in a tax-funded national system. 

But now we have the tools to square the circle. Autonomy to innovate without loss of accountability is possible. The very same advances in technology, data and participatory levers that inform tomorrow’s health care also now make it possible to replace top-down accountability with a new “accountability network” that involves patients, clinician peers, citizens and local government – and which puts a different vision at the heart of a refounded NHS.
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As this paper shows, Whitehall should focus on activities that demonstrably benefit from centralisation, including providing data and digital infrastructure at a national scale. But instead of relying predominantly on top-down command and control, a smart public-service model should make greater use of horizontal accountability through peer-to-peer, citizen-to-carer and participatory-democracy levers.  

Some of these are relatively easy and inexpensive while others will require structural, cultural and legislative changes. All of them are practical examples of how we can transition into a future where the NHS is able to meet the growing expectations placed upon it.  

With the NHS having celebrated its 74th year on 5 July, it is time to reboot the way in which we bring about change, to move away from one-size-fits-all health-care provision and to create a modern public-service model that helps to bridge the gap between the many opportunities for innovation and the urgent need to reform the NHS.