Intended for healthcare professionals


What would a sustainable health and care system look like?

BMJ 2017; 358 doi: (Published 04 September 2017) Cite this as: BMJ 2017;358:j3895
  1. Nigel Crisp, independent member of the House of Lords
  1. London
  1. nigel.crisp{at}

Making health and care systems fit for the future requires a strategy involving all sectors of society and maximises the contribution the system makes to the economy, writes Nigel Crisp

Key messages

  • Sustainability of the health and care system depends on internal and external factors and public and political acceptability and support

  • The system’s contribution to the economy—through supporting a healthy workforce and providing a platform for the UK’s world leading health research and development—is generally overlooked and should be maximised

  • Cross-sectoral partnerships of private and public organisations have crucial roles in building healthy and health creating communities, towns, and cities

  • A new strategy and narrative are needed to embrace these wider issues

Current problems in the NHS and social care raise questions about the long term sustainability of the whole system. Sustainability is not just about finance and affordability, important as they are; nor is it purely about the efficiency and effectiveness of the system. It also depends on factors outside the control of the health and care sector.

Here I argue that sustainability depends on seven factors, all of which need to be tackled, and that new emphasis should be given in particular to cross-sectoral partnerships that help create healthy and resilient people and communities and to understanding and increasing the health and care sector’s contribution to the economy.

Changing context for sustainability

Sustainability is a moving target in a system that is changing rapidly. A transition is under way around the world from hospital and illness based systems to person and health based ones, where, aided by technology, more services are provided in communities and homes. This is a long and difficult transition dating back at least to the Alma Ata Declaration of 19781 and most recently represented in England in the Five Year Forward View and related policies.2

Much of the pressure on hospitals can be attributed to this transition being incomplete or, in some areas, going into reverse. The greatest burden of disease (and associated cost) worldwide now comes from long term chronic conditions and increased numbers of very frail elderly people, both of which require community based models of care. But the UK health and care system, like all others in the West, is still largely using a 20th century acute care model of service delivery to meet 21st century needs.

This approach is ineffective, wasteful, and leads to suboptimal care and perverse decision making. A mismatch exists between the needs of patients and the services available, with the result that, for example, many patients with mental illness are unnecessarily admitted to hospital and kept there longer than necessary owing to a lack of community support.3 This puts enormous operational and financial pressures on hospitals.4

The transition needs to be accelerated,5 but financial pressures are leading to further reductions in social and community services, in part because cutting these is easier than closing hospital services. NHS England has tried to promote this transition by requiring NHS and local authorities to cooperate in producing local sustainability and transformation plans. These were designed to tackle three factors: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. But in many places they are seen as purely finance led hospital and service closure programmes.678 I would argue that these need to take account of other factors and aren’t radical enough in tackling sustainability.

Seven factors involved in sustainability

A recent commission on the Portuguese health system, which I chaired, identified seven factors that needed tackling in the pursuit of sustainability.9 Its main recommendations have since been accepted as policy by the Portuguese government. Box 1, adapted from the commission report, shows that sustainability is dependent on three factors internal to the system and three external ones.

Box 1: Sustainability of a health and care system depends on seven factors

Internal factors
  • Efficiency and effectiveness of health and care provision

  • Availability of well trained health and care workers

  • Costs and economic benefits

External factors
  • Health and resilience of the population

  • Contribution of carers and informal networks of care

  • Integration of policy and practice with other sectors and building healthy and health creating communities

  • Public and political acceptability and support

Underpinning all factors is the need for any health and social care system to have public and political acceptability and support. No system, however expertly designed, will be sustainable without the commitment of its staff and the support of the public.

These factors are interdependent and interconnected and need to be tackled both separately and together. Here I highlight only the central problems and suggest ways forward. Each of these topics needs to be examined and understood in detail.

Efficiency and effectiveness of health and care provision

This is a health problem, and not a financial one. Economic and financial measures are important, but the greatest gains will come from improving the way diseases (particularly chronic diseases, which account for about 70% of budgets)10 are managed and health and disease prevention are promoted. Community and home based models of care already exist and can be enhanced with technology, new scientific discovery, and the engagement of patients, families, and communities.

Availability of well trained health and care workers

Staffing is the greatest cost and the greatest vulnerability of the healthcare system. Health workers are lacking globally, with an international market for their skills,11 and Brexit has dramatically increased risks for the UK system. Roles must be developed to meet changing needs, with some demarcations between professions being broken down and a greater use of technology. This requires vision, leadership, and a determined programme of training and development.

Costs and economic benefits

The affordability of a health and care system depends on a country’s resources, on how effective and efficient the system is, and on political choices. A country’s health expenditure generally rises as its economy grows,12 although expenditures differ between countries. The UK, for example, spends 20-50% less than similar countries such as Australia, France, Germany, and the Netherlands.13 These differences can partly be explained by differences in the efficiency of the system, on which the UK scores well,14 but also by political choices.

Recent thinking in health has emphasised the importance of measuring the value of procedures and services and of doing, in effect, cost-benefit analyses that compare outcomes with inputs. This approach needs to be extended to the whole system, yet the contribution to the national economy is often overlooked. Health and care are not just costs.

The NHS, as the largest and most integrated health system in the world, is an invaluable platform for research and development. The UK is a world leader in health, with top rated universities, and leads G7 countries in citations in peer reviewed journals. This brings economic benefits, with around 4800 biomedical companies turning over £55bn (€60bn; $71bn) annually.15 In addition, the NHS contributes to productivity by helping support a healthy workforce and by supporting education and skill development in this important sector of the economy. An average London firm of 250 employees loses an estimated £250 000 a year owing to ill health, and the productivity loss to the UK from cardiovascular disease alone is £8bn a year.16

Health and resilience of the population

Population health is of obvious importance to sustainability, with the compression of morbidity into as few years as possible before death having a large effect on quality of life, demands on the health and care system, and costs. Health status is markedly different around the country, largely related to economic and social factors. Children’s health and wellbeing in particular have long term effects on the health and care system and its sustainability. Legislation on areas such as food and air quality as well as programmes to tackle inequalities have an important role here.

Contribution of carers and informal networks of care

Carers and voluntary and community organisations provided care with an estimated value of £132bn in 2015, compared with UK spending on health of £134bn.17 Any reduction in the contribution of the informal system increases pressure on the formal system, whereas strengthening takes pressure off health and social care.

Integration of policy and practice with other sectors and building healthy and health creating communities

Pilots and demonstrations have been set up between the NHS and local authorities to link health and social scare. Others, such as in Greater Manchester, bring a wider range of services together with a focus on “health, wealth, and wellbeing” to create new types of holistic services (

Employers, educators, designers, planners, and others also determine health status and have responsibilities for protecting and promoting health. Some employers run health programmes for their staff, while organisations in the arts, horticulture, and design and individual schools are establishing new programmes in the absence of national policy. In St Paul’s Way in London, employers, the NHS, schools, local businesses, and the local authority are combining to build a health creating society ( This area needs further development.

Public and political acceptability and support

Maintaining and increasing support will depend not only on the quality of services but also on the political and media narratives that are developed to support the necessary changes in service models and facilities. The major changes stemming from the 2000 NHS plan led to an almost doubling of public support for the NHS thanks to service improvements and to active marketing of the changes and promotion by clinical and other champions.18

Conclusions—the way forward

Some of the seven factors that contribute towards sustainability receive a great deal of attention, while two need far more emphasis: the economic benefits derived from the health and care system and the potential for multisectoral partnerships to provide the environment to improve health and health services. The seven factors and how they apply to health and care in the UK will be explored in greater detail in a new series on the future of the NHS coming soon to The BMJ.

The health and care system can provide a wonderful service, but it can’t do everything by itself. It needs to be strengthened as an underpinning for the economy, and people from all sectors need to be brought together in creative partnerships to establish health in our communities, towns, and cities. These ideas are not new but the timing is right for the creation of a new strategy and a new narrative that will help bring the public and politicians on the journey alongside today’s many pioneers.


  • Contributors and sources: NC was chief executive of the NHS in England and permanent secretary of the UK Department of Health from 2000 to 2006. He has subsequently worked in health outside the UK, primarily in Africa, where his understanding of health and health systems has developed considerably. He has written extensively on global health, health partnerships, health creation, and health worker training and development. This article was written after the author chaired the Gulbenkian Commission on the Future of Health in Portugal between 2013 and 2014 and after subsequent discussions with many people about the NHS in England and the health system in Portugal.

  • Conflicts of interest: The author has completed the Unified Competing Interest form and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; externally peer reviewed.


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