The NHS risk crisis: The failure of risk in a complex healthcare system


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The shocking crimes of serial killer and neonatal nurse, Lucy Letby, who was sentenced recently have reinforced that the NHS is in a state of crisis.

Public trust and satisfaction are declining, there are long waits for care, and staff are exhausted and demoralised.

In addition, the NHS continues to feel the impact of the pandemic three years on, and this is still resulting in a significant number of threats and problems for the sector, including the greatest workforce crisis in the NHS’ history.

A survey of 451 NHS leaders in England finds the health service is already at “tipping point”. The results of the poll, conducted by the NHS Confederation, which represents the healthcare system in England, Wales, and Northern Ireland, show that 88% of leaders think the demands on their organisation are unsustainable. Meanwhile, 87% believe a lack of staffing in the NHS is putting patient safety and care at risk.

Staff shortages

NHS staff shortages have been growing for some time. New research suggests the health service in England is short of 12,000 hospital doctors and more than 50,000 nurses and midwives. In addition, The Observer revealed nearly 170,000 workers left their jobs in the NHS in England last year, in a record exodus of staff struggling to cope with some of the worst pressures ever seen in the country’s health system.

Shortages of staff are widespread and exist across all disciplines. There are too few nurses, midwives, GPs, hospital doctors, and mental health workers. This is driven by inadequate workforce planning and lack of government accountability, not to mention insufficient funding and lack of infrastructure to train enough new staff.

Workers are leaving the service due to low pay, work-related stress, and reduced job satisfaction, while recruitment and retention continues to be a growing problem. This persistent understaffing poses serious threats to employee and patient safety in routine and emergency care.

Appropriate and adequate monitoring of staff is not being carried out. This is resulting in an avoidable reputational taint on the NHS, due to the behaviour of a minority of doctors and nurses who breach their Hypocritic Oath and professional duty to provide patient safety.

This lack of due diligence, the increasing population and the burgeoning demands made on the NHS, mean staff are working with ever-decreasing levels of supervision, sadly leading to breaches in patient care, as seen horrifically in the Lucy Letby case.

Furthermore, inpatient units with too few staff are struggling to monitor patients sufficiently, which can lead patients to come to harm.

Lack of funding

Financial pressures on the NHS are severe and show no sign of easing.

As demand for health services continues to rise, NHS budget figures paint a bleak picture: increasing deficits, missed efficiency targets, short-term borrowing, and suspension of capital investment.

85% of physicians believe current health funding is insufficient to meet rising demand for services1. In addition, a new report by the Health Foundation concludes that a short-term approach has resulted in years of declining and inadequate capital spending for the NHS in England, risking patient care and staff productivity.

A new report titled ‘No more sticking plasters: repairing and transforming the NHS estate, NHS Providers’, which represents every NHS hospital, mental health, and community service in England, says major capital investment is crucial to enable trusts to improve productivity, operational performance, and patient care across all sectors. However, under-investment has already had serious knock-on effects across the system, including a significant deterioration in NHS infrastructure, presenting major risks to patient safety, quality of care, and efforts to bear down on waiting lists.

Clearly, leadership and staff issues, coupled with underfunding and no risk framework, is causing negligence to happen and, in the healthcare sector, the safety of patients and anyone involved in medical procedures must be a priority.

Defining risk in healthcare

While in other industries threats may pose a business challenge rather than a physical one, the consequences can be severe if a patient’s health and wellbeing are compromised.

The term ‘risk’ refers to all situations and conditions that are changeable, both negative (threats) and positive (opportunities).

Risk needs to be operated interchangeably and dynamically to create benefits that align with the purpose of the healthcare sector and particularly the NHS. However, given the NHS’ complexity and size, it is unsurprising that this is something it has so far failed to incorporate.

‘Risk management’ is the process of identifying, analysing, and either reducing or eliminating things that may jeopardise the purpose of an organisation.

For the NHS, it is about preparing for the uncertain and unpredictable threats, and anything that may negatively impact patients, staff, and/or the NHS’ purpose, financial disposition, operational resilience, or reputation.

‘Risk exploitation’, on the other hand, is the process of identifying opportunities that will enhance the value of the NHS’ purpose, which is primarily centred around five core clinical risk factors: Governance & Strategy, Management & Organisational Structure, People & Work Environment, Process & Procedures, and Patient Care.

Maximising opportunities to minimise adverse threats and problems

In the world of risk, ‘10Xing’ risk exploitation is a concept that delivers continuous growth, operational efficiency, and customer or client satisfaction (patient satisfaction when applied to healthcare). This operational approach, which minimises adverse events and their consequences, is lacking within the NHS.

For example, in the NHS there is currently an absence of technological innovation to manage resources and processes that are still based on outdated methods. The failed NHS National Programme for IT [NPfIT], valued at around £6.2billion, was the world’s largest ever IT programme for any government organisation. However, it did not deliver the benefits it was meant to and, since then, there has not been any other significant initiative to move the NHS out of its woes.

The UK healthcare system is also largely fund-driven. This means it operates as a publicly funded and publicly provided healthcare system, and its services are generally free at the point of use for UK residents. While this could be seen as a blessing, it means the NHS does not generate a large proportion of its own revenue to operate efficiently and achieve its ultimate purpose, and this has been a big curse for the organisation and its people.

If the NHS is to transform to a fully efficient organisation that delivers exceptional patient care, manages and satisfies its staff by paying them well and optimises both its clinical and non-clinical infrastructure, it needs to exploit its many risk opportunities, cut or limit the apron strings of its sole reliance on government funding, which politicises it, and take a business approach to its leadership and governance.

The way forwards

Risk, risk exploitation, and risk management need to be incorporated across all pillars of the NHS, including both its delivery model (how it makes money to operate and deliver its purpose) and its operating model (how it maintains and supports the levers on which it functions).

‘To privatise or not to privatise’ has been a long-running debate in the political arms. The truth is that, if the NHS remains a funded organisation in its current vein, the same problems we see today will persist.

A new model of operating the establishment is needed and it simply will not come from the NHS running solely as a government entity. It needs to transform to a model with a for-profit approach, using profit-making organisations like Tesla, Apple, and the big banking institutions as an example.

There are multiple ways the NHS can bring in the revenue that matches its risk appetite but, currently, its value at risk surpasses its risk appetite.

Of course, I am not advocating for eliminating funds that come from the government, but other sources must be exploited. Some considerations might be introducing medical tourism for foreigners and utilising digital technology to provide telemedicine and other e-health services that can also be accessed by people in other countries for a fee.

An even more ‘outside the box’ approach might be to open the NHS and its organisations up for investment.

The opportunities abound but, without genuine appetite for real transformation, the current state of the NHS will only continue to decline, with poor service, extreme waiting times, and low pay at its core.

Final thoughts

While the Lucy Letby case is an extreme example of NHS failings, every day brings new horror stories from the frontlines of a healthcare system on its knees begging for rescue from drowning.

The NHS’ survival now depends on urgent and decisive action and the change must be radical. A leadership of steel needs to be handed the task of rescuing the institution and transforming it into a world organisation.

Only going that big and broad gives us any chance of getting a grip on the crisis and avoiding the NHS’ ultimate collapse.


1. Underfunded. Underdoctored. Overstretched. 2016.

Chizubel Egwudo
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Chizubel Egwudo