Is Leadership the Root Cause of a Failing NHS?
The NHS is under some of the most severe pressure it has ever faced. This isn’t just because of the COVID-19 pandemic, the cracks were already there. The pandemic simply shoved them into the spotlight. It’s always mentioned, but rarely understood. What does this pressure actually mean?
The Numbers Don’t Lie
In August 2008, the NHS waiting list for consultant-led elective care stood at 2.68 million. By February 2020 — before the pandemic — it had already risen to 4.59 million. As of now, we’re at 7.36 million.
Logically, you’d expect the budget to rise in line with that demand. But for nine years before the pandemic, the proportion of government spending on the NHS began to fall. Despite emergency funding injections during COVID, we’re now looking at a cumulative underspend of around £425 billion. To add to that, healthcare expenditure as a percentage of GDP fell from 11.1% in 2022 to 10.9% in 2023, a small drop, but one that speaks volumes when the system is under this much pressure.
In London, healthcare spending per patient dropped from £4,316 in 2020/21 to £3,946 in 2022/23. In the North West, it fell from £3,946 to £3,489 over the same period.
More patients walking through the doors, with less money available to care for them.
Mental Health: Demand Without Capacity
Mental health services are under enormous pressure too. In 2007, the prevalence of common mental health disorders was 17.6%. By 2023/24, this had risen to 22.6% in adults. Access to services has improved from 23.1% in 2000 to 47.7%. But we’re still not reaching anywhere near enough of the people who need support.
And beds for mental health patients? You’ve probably guessed it — not enough. The workforce is too small, and the funding doesn’t match the growing demand.
Leadership Without Lived Experience
At the head of this struggling system is a Cambridge history graduate. And he’s not the exception, the last five Secretaries of State for Health and Social Care have had backgrounds in:
Law (Cambridge)
History and Law (Cambridge)
Chemistry (UCL)
Economics and Politics (Exeter)
Economics (Cambridge)
This isn’t an attack on Wes Streeting. Far from it, he’s been handed an impossible task and made the face of decades of political neglect. The problem isn’t just who holds the role, it’s what the role is. We need to confront a structural failure in leadership. Clinical medicine and health policy are worlds apart. Even the idea of putting a doctor in sole charge is flawed; not just because doctors don’t represent the whole healthcare workforce, but because no one person can hold the insight or expertise to steer such a complex, interconnected system alone.
The truth is: no single individual, regardless of background, can effectively lead the NHS on their own.
A Four-Pillar Leadership Model
Here’s an idea; a leadership model built on four pillars:
A Public Health Expert
Someone with learned and lived experience of the NHS. You can’t grasp the pressures unless you’ve felt them.A Scientist or Researcher
Science and healthcare need to work together. You can design cutting-edge diagnostic tools in a lab, but what’s the point if the NHS can’t afford to use them? I would know. I’ve been there.A Social Care Leader
Someone who’s worked within the system, understands where the real problems lie, and has seen how poor social care compounds pressure on hospitals.A Financial Strategist
The one who ties it all together, who knows what’s affordable, what isn’t, and how to make resources stretch without sacrificing patient care.
With this structure, the real issues can be prioritised correctly, and funding can be put into action more effectively.
The 10-Year Plan: Policy Without People
Let’s talk about Fit for the Future: The 10-Year Health Plan for England. Catchy title. Bold claims. Reads like something straight out of a management consulting deck lots of slides, not a lot of strategy.
I’m really hoping this isn’t just another set of slick PowerPoint or Canva slides, but something with substance, something that can actually be implemented.
But I have to ask: how much genuine input from frontline workers went into this?
I don’t want “engagement.” I want real involvement. Otherwise, once again, policy is being put in place by people who aren’t expected to live with the consequences, and that’s a recipe for failure.
What About the Kidneys?
Some specialties weren’t even mentioned. Renal medicine — forgotten. Dermatology? Probably not a priority with the UK weather. A paragraph on AI for skin cancer just isn’t enough, especially when that shift has already started? ENT? Oral Health?
You can’t talk about long-term NHS strategy while excluding entire areas of care. That’s not a plan, that’s a spreadsheet exercise.
Digital Dreams Without Infrastructure
There’s a huge push in the plan towards digital solutions. Sounds great! It always does. A classic way for a consulting firm to land a client.
But do we even have the infrastructure? How will any of this actually be implemented? I want to see the route to these goals, not just a flashy document.
Morale, Money, and Missing Voices
We can talk about implementation all we like, but morale in the NHS is at an all-time low. Staff are leaving. Funding is stretched thin. These aren’t side issues. These are the foundations. If you don’t fix them, the whole plan falls apart before it starts. That’s why the people who’ll be impacted by these reforms need to be involved. That’s why we need to question the current structure and leadership. Decision-makers need to come from within or at the very least, have real experience of the system they’re trying to change.
At the bare minimum, they need to be meaningfully engaged, not just consulted for optics.
But Are We Doing Enough?
I don’t think there’s any doubt that the government has reached out to people within the NHS and Social Care. But despite that, there’s still this ongoing discontent from those actually working in these sectors. That tells us something isn’t working. The individuals being brought forward to share their insights with government must be those who are best placed to do so, people with credibility, lived experience, and a true understanding of the system. We need to be intentional and effective in who we put forward, because if we keep engaging the wrong voices, then we’re also part of the problem, and we have to accept some of the blame for the system’s continued failings.
Just a Thought…
This is my personal opinion. I could be completely wrong. But I’d be interested to hear what others think, because maybe it’s time we stopped managing the NHS like a business and started leading it like a service.
Sources:
An NHS Under Pressure – BMA
