Intended for healthcare professionals


The NHS in England should use horizontal networks rather than vertical structures to improve health and care

BMJ 2022; 377 doi: (Published 24 May 2022) Cite this as: BMJ 2022;377:o1310
  1. Chris Ham, co-chair
  1. NHS Assembly

The NHS passed a landmark on 19 May 2022 when its national leaders in England announced a reduction from a level 4 (national) incident to a level 3 (regional) incident in the covid-19 response.1

840 days have passed since a national incident was first declared at the beginning of the pandemic. In that time the NHS has treated 730 000 patients with covid-19 in hospitals and delivered 123 million vaccines. Staff in all parts of the NHS have contributed with support from volunteers, the military, other public sector organisations, the private sector, and voluntary and community sector organisations.

In announcing the change, national leaders emphasised the importance of learning lessons from the pandemic response in tackling the backlog of need that has built up and ensuring continued vigilance on covid-19. These lessons include the value of working in partnership within the NHS and with other agencies and of empowering staff to find solutions to the challenges they face. Equally important has been the contribution made by people and communities in providing mutual aid and adjusting their behaviour in line with requirements laid down by the government.

The challenge is how to act on these lessons in an organisation which by default uses national targets and performance management to bring about change. Targets do of course have a part to play in a national health service, but over reliance on improving health and care from the top down risks demotivating local leaders and staff and constraining innovation. Too strong a focus on the role of NHS organisations and other public sector agencies may also crowd out the vital contribution of people and communities themselves as the NHS confronts the biggest challenges in its history.

The starting point in learning lessons from the pandemic response must be recognition that the NHS is a complex adaptive system in which there are inherent limits to bringing about change through command and control. National leaders should be willing to devolve more responsibility for decision making and support NHS organisations to work with and learn from each other. The power of peer learning and peer challenge is beginning to be recognised and needs more emphasis if aspirations to rely less on achieving change through the hierarchy are to be realised.2

Making a reality of devolution and peer learning requires a willingness to limit the role of national and regional agencies in the NHS in England. The number of staff in these agencies increased substantially during the pandemic and their activities take up time and energies that could be better spent tackling issues that matter to patients and those who care for them. Work already underway to reduce the number of national agencies is a welcome first step in reducing the burden of regulation and performance management and associated overhead costs, but much more remains to be done.

Harnessing the power of people and communities is essential if commitments to improve health and tackle inequalities are to be delivered. The Healthier Wigan Partnership is an example of what can be achieved when councils and their partners listen to the people they serve and act on what they hear. In Wigan’s case this included increasing spending on voluntary and community sector organisations who were able to find more effective ways of meeting people’s needs than those offered by statutory services—and in so doing they improved health outcomes on a number of metrics.3

The relevance of these considerations is underlined by the unlikely example of the war in Ukraine. A recent commentary suggested that Ukraine’s use of horizontal peer-to-peer networks is proving superior to Russia’s reliance on vertical institutional structures.4 This assessment echoes the changes that occurred in the United States army in response to new terrorist threats in which silos were broken down, lines of communication shortened, and teams established spanning different sources of expertise.5

The “team of teams” in the United States army approach was consciously adopted in the vaccination programme, arguably the most successful element in the NHS’s response to covid-19. The experience of the programme demonstrates that the NHS and its partners are capable of working differently when faced with an existential threat. This offers hope that new ways of working based on collaboration and using all available assets can now become more widely established in work on recovery from covid-19.

Integrated care systems in England take on their statutory responsibilities on 1 July and need to work with national leaders to ensure that the opportunity is not lost.


  • Competing interests: none declared.

  • Chris Ham writes here in a personal capacity.

  • Provenance and peer review: not commissioned, not peer reviewed.

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