Lord Nigel Crisp: How to rebuild the NHS

Former NHS boss Nigel Crisp on how to fix the ailing system to build a health service that’s fighting fit for the next generation

We have all seen the television pictures of queuing ambulances and patients waiting in A&E, and listened to the interviews with hard-pressed staff. Some Big Issue readers, of course, will have been caught up in it – the NHS winter pressures – as patients or as health and care workers.

The immediate response from many of us will be that the NHS and social services need more money, more people and more hospital beds. More money is needed but that’s only part of the answer. The underlying problem is that we have health and care services that are too reliant on hospitals, and we don’t have enough services in the community or in people’s homes.

We need a big increase in services in communities and homes to look after people with long-term conditions

The diseases that we suffer from have changed over recent decades. There are, happily, far fewer accidents, fewer heart attacks and fewer acute illnesses that may strike people down suddenly. Instead, the British public have more long-term conditions like diabetes and dementia, and other problems associated with ageing. Thanks to improved treatments, most cancers now have become chronic diseases that we can live with for years.

The truth is that we have got the wrong model for service delivery. We need a big increase in services in communities and homes to look after people with long-term conditions, and we need to invest far more in helping people to be healthy and to live normal lives despite their illnesses. The pressure in the system always ends up in hospitals – the place of last resort.

We will still need hospitals and emergency services, of course, but the health and care system needs to change, from being a largely hospital and illness-based service to become a far more community- and health-based one. Advances in medicine, as well as IT and better communications systems, make it possible to do far more outside hospitals – monitoring people at home, offering advice and support remotely and even delivering quite complex treatments in health clinics and homes.

This change is very well understood within the health and care system, and there are brilliant examples around the country where it is already happening thanks to the efforts of far-sighted clinicians, social workers and organisations. However, in many parts of the country this change has gone into reverse. Cuts in community health and social care services have led to more people having to go into hospital because there wasn’t an alternative – or because the service that helped them to keep healthy or head off an acute episode has disappeared.

I saw this myself recently when I led a review of acute mental health services for adults on behalf of the Royal College of Psychiatrists. There are difficulties throughout the country in admitting patients who desperately need acute mental health care, with the result that some patients travel long distances for urgent admissions. The problem here is that about a quarter of mental health beds are occupied by people who would be better looked after in the community, if only there were services available.


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Health is made at home, hospitals are for repairs. We need good community services if our hospitals are to function well. This is not the only problem. The NHS and social care can’t do everything for us: we also need to do more to prevent disease and promote health. Part of this is in our own hands: we all have responsibility for our own health. All the joggers, cyclists, dieters and gym-users know this very well, and so do all of us still hanging on to our new year resolutions about smoking, drinking or sugar. However, responsibility doesn’t just stop there.

Common sense tells us that schools and employers as well as food manufacturers and architects, designers and planners all affect our health. Interestingly, research is catching up and providing the evidence that this common sense view is right. Our life at work or our time being unemployed affect our health; our education is also important and so are our surroundings and our communities.

What would it be like if our society actively marketed healthy lifestyles?

Loneliness is a very sad feature of modern life where people often lives miles from their families and become isolated as they grow older, and this in turn affects their health. Recent research tells us that loneliness has the equivalent health risk of smoking 15 cigarettes a day. The NHS can’t do anything about this but planners and architects can in how they design homes and communities – and so can those communities themselves.

A World Health Organisation report sums it up memorably in saying that “modern societies actively market unhealthy lifestyles”. Stress, poor diet, lone-liness and lack of exercise are all part of modern life.

What would it be like if our society actively marketed healthy lifestyles? If schools, workplaces and the places we lived in all contributed to improving health and not, as sometimes happens, damaged it? Everyone, and every sector of society, has a responsibility and a role to play in improving and maintaining mental and physical health.

There are some great examples around the country of businesses, schools and others working together to both prevent ill health and to help create strong and healthy communities and individuals. Some are business-led like the City Mental Health Alliance, which “aims to create a culture of good mental health for City workers”.

The St Paul’s Way Transformation Project, also in London, is an even wider partnership of businesses, schools, universities, faith organisations and local health services. The lessons learned there are being transferred to 10 towns and cities in the north of the country by Well North, a new partnership set up by Public Health England, Manchester University and Manchester Academic Health Sciences Centre.

What all these organisations are doing is creating the circumstances in which we as individuals can thrive. In my view this is not just about promoting health and wellness or preventing diseases but is about creating health, making us strong and capable. The New NHS Alliance sees its mission as “to infect the health service with wellness” and help people to take control of their lives.

These developments remind me that there is a great African saying: “Health is made at home, hospitals are for repairs.” I want to add to it and say: “Health is made at home and in communities, schools and workplaces.”

The health and care services are not just a cost to society – they also make a big economic contribution

The health and care services are not just a cost to society – they also make a big economic contribution. They support a healthy workforce and therefore help to improve the UK’s productivity and competitiveness in the world. A recent report by ERS Research and Consultancy brought together the evidence about how illness affects productivity, noting that, among other things, an average London firm of 250 employees loses an estimated £250,000 a year due to ill health, and the productivity loss to the UK from cardiovascular disease alone is £8bn per year.

Moreover, the NHS provides a platform for the extraordinary science, research and education that makes the UK a world leader in health. Already we have 4,800 bio-medical enterprises contributing £55bn to the economy and there is enormous potential for growth. It is encouraging to see that the new industrial strategy announced by the Prime Minister last week will promote these sectors.


Last October a group of leading clinicians, scientists, social entrepreneurs – including Big Issue founder John Bird – published a manifesto in The Lancet that brought these ideas together. It set out four strategies for the future:

  • The bio-medical and life sciences should be central to the country’s future industrial policy.
  • The transition from a hospital and illness-based health service to a community and health-based one needs to be accelerated.
  • Every sector must contribute to a health-creating society.
  • The health and science sectors with their emphasis on knowledge, openness, integrity and collaboration should make their own contribution towards building a better society.

It looks to me like a no-brainer. Let’s get on with it.

Lord Nigel Crisp is a crossbench member of the House of Lords. He was chief executive of the NHS and permanent secretary for the Department of Health from 2000-2006

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