In his first of two blogs, Diarmaid Crean, Ethical Expert and former Chief Digital and Technology Officer, shares the reasons for his love/hate relationship with the 10 Year Health Plan. Starting with the ‘love’ – due to the emphasis on systems thinking – he explains why the nurse will become the most powerful person in the system

In a reshaped NHS, leadership doesn’t begin at the top. It starts in a living room. A warm, familiar space where a community nurse is sitting beside an 81-year-old woman. She’s managing frailty, persistent pain from musculoskeletal damage caused many years ago when giving birth her 6th child, early-stage diabetes, and mild mental health concerns. 

The nurse isn’t just offering care – they are enabling the system to learn, adapt, and respond. They are the NHS. 

“We will reinvent the NHS through 3 radical shifts – hospital to community, analogue to digital and sickness to prevention.” (Fit for the Future: 10 Year Health Plan)

System 1: The Patient and the Nurse – Real-Time Health Management 

In this reshaped NHS, everything starts with the frontline connection. The nurse notices that her patient’s mood is dipping. She’s in pain. Her sleep is disturbed. She hasn’t seen her friends in over a week. The nurse checks blood sugar using a small remote monitor on the table and reviews her notes on a tablet. 

This is not passive monitoring. It is active, adaptive care—what systems thinking calls self-regulation. The nurse is already making micro-decisions: Does this need escalation? Can this wait? Is the current treatment plan working? 

This is where the system does its most important work—not in reports or dashboards, but in dialogue and trust. 

“People with complex needs will be offered a care plan and supported to personalise their care.”(Fit for the Future: 10 Year Health Plan)

System 2: Coordinating Local Activity 

The nurse leaves the house and accesses the local universal care plan (shared care record). She writes a brief note and flags an alert for the Integrated Neighbourhood Team (INT). 

She asks for a multi-disciplinary team (MDT) discussion and requests input from a consultant physiotherapist. The goal: to revisit the patient’s MSK treatment plan and help her regain enough mobility to reconnect with her local walking group—a key source of wellbeing and social support. 

This is coordination in action. Shared Care Records aren’t just view-only repositories—they are connectors. They allow distributed teams to move as one. 

“As first steps to deliver the neighbourhood health service, we will restore GP access and ensure a far better experience of arranging care.” (Fit for the Future: 10 Year Health Plan)

System 3: Operational Oversight – The Integrated Neighbourhood Team 

At the INT level, coordinators and clinical leads look across hundreds of similar patients. They review flagged cases like this one and check which services are under pressure. The MDT sees that community physio is at capacity, but consultant support is available. 

The team accepts the nurse’s request and arranges a remote consultation. They log what service was offered—and critically, they track whether it worked. Did the patient improve? Did she regain mobility? Was she able to reconnect with her social group? 

This is not control for its own sake. It’s oversight that responds to real needs—and adjusts dynamically. 

System 4: Learning from the Frontline 

Over time, patterns emerge. The INT notices that similar patients—older, frail, isolated—respond well when MSK pain management includes social reactivation. A new local protocol begins to take shape. A GP practice trial includes walking-group referrals alongside physio support. 

This is strategy generated from the edge, not imposed from the centre. It’s the system learning from itself. 

“This Plan will put the NHS at the front of the global genomics revolution and make the NHS the most artificial‑intelligence‑enabled care system in the world.” (Fit for the Future: 10 Year Health Plan)

System 5: Identity and Purpose 

Why does the NHS exist? In this reshaped vision, it exists to produce health, not activity. Its identity is grounded not in command structures or targets, but in the quality of relationships—in the connection between a nurse and a patient. 

I think I love the NHS 10-Year Plan, even though it does not use the language of systems thinking— but because of its emphasis on devolved decision-making, integrated neighbourhoods, and population-level care is, perhaps unintentionally, a radical alignment with it. 

“To create an NHS fit for the future, we need leaders at every level who are bold, relational and capable of leading system change aligned to the 3 shifts.” (Fit for the Future: 10 Year Health Plan)

What This Patient Needed — And What the System Must Provide 

– Joined-up referrals to mental health, physio, and pain services 

– Outcome tracking—did each service help the patient feel better, move better, live better? 

– Diagnostic support in the community—blood glucose, pain assessment, frailty scoring 

– Remote monitoring—a low-friction way to track key indicators between visits 

– Consultant input at the right time, without hospitalisation 

– Social connection as a care outcome, not a luxury 

The New Architecture That Makes It All Work

So much of what is described—adaptive care, trust, responsiveness, agency—is blocked not by people, but by systems. Not by clinicians’ will, but by the architecture they’re forced to operate within. 

Now imagine a New NHS Architecture—one that has been quietly, carefully reshaped around the real work of care. 

It doesn’t interrupt. It supports. It doesn’t extract. It shares. It doesn’t assume control. It distributes trust. 

Let’s return to the patient. Six months later, her life is different—not because of a dramatic intervention, but because the system finally worked as it should. 

  • She knows what’s happening 

The shared notes from her nurse visits are written in her language—not just clinical shorthand. Her care plan is clear. Her progress is visible, not just to her team, but to her. She feels seen. She feels involved. 

  • She’s no longer just receiving care—she’s co-managing it 

When the physiotherapist adjusts her exercises, she’s notified immediately. Her local walking group is integrated into her care goals. Small wins are acknowledged. Missed connections are flagged early. 

She has a sense of direction—not just treatment. 

Her team feels connected, not fragmented 

The GP sees her most recent nursing visit. The pharmacist knows her pain medication was reviewed last week. The community mental health worker notices a pattern in her sleep and asks the right question. 

Because the architecture underneath them is joined up, they can be too. 

She trusts the system—because it trusts her.

She can see who accessed her information, and why. Nothing is hidden or done behind her back. She consents once—intelligently—and sees the benefit immediately. Her information helps her, not just the institution. 

For the first time in years, she doesn’t feel like she’s navigating “the system.” She feels like the system is working with her. 

And the system learns from her story.

Her journey becomes part of the local learning fabric. It helps shape future care models for other patients like her. The decisions made in her living room ripple upwards—not as anecdotes, but as evidence. 

A Reshaped NHS Must Be Built Around This Kind of Life

The New NHS Architecture doesn’t need fanfare. It just needs to quietly, dependably enable what matters most: human connection, timely response, and trusted coordination. 

It must be designed from the edge inward, not from the centre downward. 

And when it is, the nurse becomes the most powerful person in the system—not because she controls anything, but because she listens, acts, and learns. 

This is what reshaped care looks like. Not a revolution of tools, but a re-commitment to relationships – at every level of the system. 

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Diarmaid Crean is an Ethical Expert and highly experienced digital health leader with a strong track record of delivering national-scale innovation across health and care. Formerly Deputy Director for Digital Health at Public Health England and Chief Digital and Technology Officer at Sussex Community NHS Foundation Trust, Diarmaid now advises both public and private sector clients on large-scale digital transformation through Ethical Healthcare Consulting.