A more sustainable and resilient NHS is possible

The pandemic exposed what many had already been pointing out: the vulnerability of our National Health Service. The high level of professional fatigue, the disarticulation and lack of communication between levels of care, funding that fell short of needs, and a weak commitment to prevention were seen as symptoms of a service that was unable to respond effectively, efficiently, and equitably to the needs of the population it was designed to serve.

It was in this context that the PHSSR Portugal study—Partnership for Health System Sustainability and Resilience—emerged, an international initiative developed with the support of a consortium that includes the World Economic Forum, AstraZeneca, and the London School of Economics, among others. In Portugal, the study conducted a literature-based assessment and engaged approximately 40 leading national experts and decision-makers in an innovative and structured policy dialogue process, supported by new participatory and collaborative approaches with scientific robustness.

The result of this dialogue? 43 policy recommendations, consensually recognized as having significant potential to improve the sustainability and resilience of the NHS. These proposals cover seven key areas: Governance, Financing, Human Resources, Medicines and Other Health Technologies, Healthcare Delivery, Population Health, and Environmental Sustainability. For the first time, they provide a structured overview of the various domains that shape health systems, including less commonly discussed areas such as Population Health and Environmental Sustainability.

Among the main areas of policy intervention identified, the need for a profound reform in the system's governance stands out, including better use of strategic planning tools, merit-based appointments to management positions, the adoption of technical competence criteria, and periodic performance assessments. Strengthening institutional autonomy, strengthening mechanisms for collaboration between different types of institutions, and stable and accountable leadership were identified as essential for any lasting transformation.

In terms of financing, the recommendations focus on the transition to value-based models, aligned with the rewarding of health outcomes and efficiency. Experts and decision-makers also recommended the adoption of multi-year budgets for greater predictability in spending, and an urgent review of the financing system and contracting with healthcare providers in the public, private, and social sectors.

In healthcare delivery, a strategic commitment to more decentralized care delivery models, leveraging digital technologies, including investment in full interoperability of electronic medical records, and investment in home care are key recommendations. Technology must be at the service of care integration, ensuring that information accompanies the patient throughout their journey through the system.

Regarding access to medicines and health technologies, the proposed measures include home delivery of hospital medicines or collection from local pharmacies, review of reimbursement systems, promotion of a framework for the adoption of evidence-based technologies, and strengthening of health technology assessment.

In terms of population health, the recommendations focus on promoting literacy, investing in prevention programs, and adapting responses to the specific needs of an aging population. A proactive, community-based approach is advocated, based on the use of health outcome indicators and coordination with programs developed by local authorities, schools, and social structures.

The study does not overlook the environmental dimension. It advocates, among other measures, the introduction of incentives and the pursuit of environmental sustainability in contracting mechanisms, the modernization of hospital equipment, and the adoption of medical device reprocessing practices, within a circular economy framework applied to healthcare.

One of the greatest merits of this work was to demonstrate that these policies cannot be viewed in isolation. There are clear interdependencies: changes in governance are essential for implementing recommendations related to care delivery, human resource management, and financing; and the logic of population health is key to care delivery and access to technologies. The study successfully mapped these connections, highlighting the need for a systemic and coordinated approach.

More than just a new report, the PHSSR Portugal is proof that it is possible to generate consensus among experts and decision-makers with different views and experiences in a system exposed to political turnover and where differences of opinion are sometimes emphasized. It also reminds us that the problem lies neither in the diagnosis nor in a lack of ideas—what is urgent is the implementation of recognized policies. Transforming the NHS requires making choices and ensuring effective policy implementation.

The report is ready. The diagnosis is clear. The recommendations have been identified and are gaining consensus. Now is the time to act. If not now, when?