Why Your Strategy Isn’t the Issue

The NHS doesn’t have a strategy deficit. It has an execution problem

Spencer Humphrys, Founder, Nexus Consulting

If culture hasn't eaten your strategy for breakfast already, the general NHS approach to execution is about to kill it.

Let's start with the obvious.

Walk into almost any NHS organisation right now, and you’ll find a 10 Year Plan response, a Medium Term Planning Framework submission, a clinical strategy, and a handful of improvement programmes. Probably all running simultaneously.

If we printed them all out, we’d solve the country’s flood-defence gaps. But that’s about all they’d solve.

Because millions of people are still on waiting lists. Thousands are stuck in hospital beds every day, clinically ready to leave. Only 65% of resident doctors expect to still be in the NHS in five years (RCP, 2025). Adult Social Care are hundreds of millions off budget. And the NHSE even admits there's a difficult gap to bridge between what the NHS does now and what it’s capable of.

The strategies are often sound. Many are excellent. So why doesn’t the change stick?

The answer is almost never about the what. It’s about the how. And until we’re honest about that, no amount of strategic planning will close the gap between ambition and reality.

The pattern I see

I’ve worked in health for nearly two decades (I don’t look that old, right?). The pattern is so consistent I’m tempted to write a book.

A trust identifies a problem. Workshops are held. Slide decks are produced. Action plans get milestones, owners, and RAG ratings. Governance structures wrap around it. And then… not much changes. Things improve for a few weeks, then drift back.

This isn’t because NHS leaders lack capability. It’s because the system chronically underinvests in the hardest part of improvement: the disciplined, unglamorous work of turning a plan into embedded, sustained operational change. That takes a different skill and mindset than managing operations or being a great clinician.

The MTPF is now asking systems to deliver a 2% annual productivity improvement, pursue Neighbourhood Health models, recover performance in elective, cancer, and emergency care, and achieve financial balance. That’s an execution challenge of historic proportions. If we approach it the way we’ve done most NHS improvement — strategy-heavy, delivery-light — the next ten years won’t look rosy.

Why good strategies fail

When we start working with partners, we look at what’s come before. Almost without exception, the strategy was sound. The execution failed for avoidable reasons:

The presenting problem isn’t the real problem. “Our ED can’t hit four hours” usually means exit block and inpatient flow — the ED itself is often fine. “We need more beds” almost always means occupancy is too high due to slow internal processes. And my favourite: “We’ve got loads of plans, but nothing’s really working.” That’s not a strategy failure. That’s an execution failure.

Process change without structural change. Teams redesign handover protocols and discharge checklists, only to find that things revert within weeks. Process change rarely sticks without structural change beneath it: new team configurations, changed governance, physical redesign. The organisations making sustained progress aren’t just running better processes — they’re making structural changes. Changes that impact the environment, working patterns, governance structures, and, most importantly, decisions that make the right thing the easy thing to do.

Improvement without development. We wouldn’t expect a junior doctor to perform a procedure they’d only read about. Yet we routinely expect operational leaders to deliver complex transformation with minimal coaching, support, or protected time. When it doesn’t work, accountability erodes. People become defensive. They look for data that justifies why things haven’t improved. The failure isn’t the person — it’s the infrastructure around them.

Three questions to test your execution infrastructure

Implementation science has studied why change sticks (or doesn’t) for decades. Successful implementation rests on three pillars: Competency, Organisation, and Leadership. Miss any one, and your strategy will stay on paper.

If you can’t confidently answer “yes” to all three, you don’t have a strategy problem. You have an execution problem.

1. Competency: Can your people actually do the improvement work?

Not “do they have the intention” or “have they been on a course.” Can they actually do it? Do they have a structured method for identifying root causes, testing changes, and measuring impact? Are they being coached through it by someone experienced, with regular feedback?

Improvement is a skill. And like any skill, it requires deliberate practice with expert feedback — what Mike Rother calls the “Improvement Kata.” Most NHS improvement asks people to learn by doing, without the coaching infrastructure to make that learning effective. The result is a well-intentioned activity that doesn’t reliably produce results.

Feel like you're always doing improvement programmes on the same problem? That might be a sign to stop and reflect.

2. Organisation: Does your infrastructure make the right thing easy?

Are your governance structures, data systems, team configurations, and physical spaces set up to support the new way of working? Or are you asking people to operate a new process within an old structure?

This is the structural change question. If you want discharge to work differently, it’s not enough to change the checklist. You need to change the artefacts. You need co-located MDTs, real-time NCTR data visible at the point of care, and governance that connects acute and community decision-making daily — not monthly.

3. Leadership: Are your leaders solving the right problems at the point of delivery?

Reviewing performance data three weeks after the fact in a board meeting isn't this. Being present at the gemba — on the wards, in the A&E, at board rounds — seeing how the system actually operates and where it breaks down.

The RCP found that 72% of resident doctors cited staffing gaps as the biggest impact on their wellbeing. You don’t understand that from a boardroom. You understand it by being present. And when leaders are present, they see opportunities to remove barriers, coach their teams, and make decisions at pace. And they see the impact on patients and their staff of the problems everyone knows about, but no one really wants to face up to.

If your answer to any of these three is “no” or “sort of,” the good news is that the problem is identifiable and fixable. The bad news is that no strategy, however brilliant, will compensate for the gap.

What this means for 2026 and beyond

The MTPF asks systems to deliver three simultaneous shifts — hospital to community, analogue to digital, sickness to prevention — within a tight financial envelope.

The King's Fund asks where leaders will find the bandwidth.

I’d frame it differently. The question isn’t just bandwidth. It’s whether we’re prepared to change the way we approach improvement itself. Fewer strategies, executed with rigour. Honest diagnosis before action. Structural change alongside process change. Sustained coaching through implementation. And data that drives daily decisions, not monthly reports.

It's easy to blame 'people above you' for not being able to work like that. But everyone has agency and the ability to make some decisions, whether you're on the front line or in the boardroom. The climate you work in is influenced by outside factors and people, but you also have more control than you think you do.

Putting it bluntly

Strategies, plans, and slide decks make no difference to patients or the front line.

A great plan without execution is wasted effort.

A focused plan, executed brilliantly, that shifts behaviours, upskills leaders, and builds execution infrastructure, is the start of a new chapter.

The NHS wasn’t designed for the demands of modern healthcare. We all know that. But redesigning it doesn’t require another strategy. It requires the courage, discipline, and infrastructure to execute the ones we already have.