For most of its history, the NHS has been viewed as the central, almost singular, pillar of healthcare in England. It is a powerful brand and a national institution. But according to Alan Milburn, a former Health Secretary and now a senior government advisor, that view is no longer sufficient. The NHS, he argues, should be seen not as a standalone system, but as one part of a much broader health ecosystem.
Milburn played a central role in drafting the 10-Year Health Plan, which embeds this idea into government strategy. The plan’s aim is to shift thinking away from healthcare as something delivered solely by the NHS, towards a model where public and private providers work alongside each other. In this vision, the NHS remains vital, but it operates as part of a wider network that includes independent companies, voluntary organisations, and other public services.
As lead non-executive director at the Department of Health and Social Care, Milburn believes the department’s role should also evolve. Instead of directing or running the NHS, he argues it should act as a convener, bringing together the full range of providers that make up the healthcare system. The department would set the conditions for collaboration, oversee performance, and ensure that different parts of the system work effectively together.
This approach inevitably invites debate. For some, introducing a greater role for private providers risks fragmenting services or eroding the principle of universal access. For others, it represents a pragmatic way to expand capacity, improve choice, and bring in innovation from outside the NHS. Milburn acknowledges that the tension between collaboration and competition is unavoidable. His position is that both have a place in a large, complex health ecosystem, and that the challenge lies in striking the right balance.
This view is shared by the current Health Secretary, Wes Streeting, who has also described the NHS as part of a broader system rather than a self-contained entity. Writing in The BMJ, he pointed to the benefits of creating a “market” that allows for a wide range of providers to contribute to healthcare delivery. The aim is not to diminish the NHS but to situate it within a more flexible and adaptive structure.
Milburn is realistic about the scale of change required to make this vision work. Integrated Care Boards, the local bodies tasked with planning and commissioning services, are still in the early stages of developing the analytical and managerial capabilities needed to oversee such a diverse set of providers. He describes them as being in “the absolute foothills” of this journey. Managing a complex health ecosystem will demand not only new skills but also a cultural shift towards partnership working across organisational boundaries.
The concept of a health ecosystem challenges the NHS’s traditional self-image. It asks whether the goal should be to protect the NHS as an institution in its current form, or to protect the principle of high-quality, accessible care; even if that means delivering it through a wider mix of providers. That is not a comfortable question, but it is one that policymakers will need to answer if they are to create a system capable of meeting rising demand, integrating care more effectively, and embracing new technologies.
Whether this approach succeeds will depend on how well it is implemented. A health ecosystem can only work if the different parts are connected, accountable, and committed to shared goals. Without that, it risks becoming a patchwork of services that confuses patients and wastes resources. Done well, it could allow the NHS to remain a cornerstone of care while drawing on the strengths of other sectors to build a more resilient and responsive system.
