Imagining a new Health System for a thriving health workforce

Structural, cultural, and mindset shifts

In 2024, three visionary social entrepreneurs and Ashoka Fellow Karolien van den Brekel-Dijkstra, Positive Health, Mark Swift, Wellbeing Enterprises, and Guillaume Alsac, Soignons Humains, brought together diverse health stakeholders from their respective countries: France, the UK, and the Netherlands. Their goal was to create a space for deep listening, open sharing, and, most importantly, collective dreaming of what the health system for a thriving health workforce should look like. This article delves into the analytical findings and shared visions that emerged from the three groups, building upon quotes and reflections from participants. 
 

1. Overcoming structural and cultural barriers in Health 

Across health systems, professionals often encounter systemic constraints that make it difficult to initiate or sustain change. These challenges are not only structural but also shaped by long-standing cultural norms and assumptions within the system. Healthcare workers, policymakers, and communities must reclaim their agency and recognize that collective actions, even small ones, can drive meaningful change.  As one participant in the multi-stakeholder process reflected, “I used to think we had no power to change things. But through this work, I realized that even small changes can make a big difference."

A key challenge identified in the discussions was the significant administrative burden faced by health professionals. Many clinicians report spending substantial time on bureaucratic processes, reducing opportunities for direct care. Policies intended to enhance accountability can result in extensive paperwork, which may take time away from patient interaction and preventative initiatives. In France, for example, participants explored the idea of moving toward more trust-based governance models, approaches that streamline oversight and reduce unnecessary reporting requirements, helping ensure that administrative structures support, rather than hinder, patient-centred care. 

The emotional toll of working within rigid, high-pressure healthcare environments has also led to burnout and disillusionment among professionals. Indeed, many feel disconnected from the purpose that initially drove them to enter the field. To counteract this, some researchers such as Ruth A Levitas, look at utopia as a method inviting health researchers and practitioners to use imagination as a legitimate and rigorous form of inquiry. This approach encourages moving beyond the constraints of existing policy frameworks and evidence hierarchies, envisioning the social conditions under which genuine health equity might be possible. Through this lens, utopian thinking becomes a practical tool for critiquing the present and constructing alternative futures, ones that foreground care, justice, and collective wellbeing as the foundation for transformative action on health inequalities.  

2. Redefining the role of health professionals: from saviours to co-creators   

Research indicates that only 20% of health outcomes are directly linked to medical care, while the remaining 80% are shaped by social and economic factors such as income, education, employment, environmental conditions, and community support. Given this reality, the role of healthcare professionals needs to evolve from being seen primarily as expert decision-makers to becoming partners in health. This involves working alongside patients, families, and communities to build sustainable solutions that emphasize patients’ agency and mutual support.  

This shift in professional roles also needs a transformation in the doctor-patient relationship. Rather than treating diseases in isolation, medical practitioners must consider the broader lifestyle factors influencing health. This approach is particularly relevant for chronic conditions such as diabetes, where the best course of action may not be increasing medication but rather supporting patients in making sustainable lifestyle changes. Health coaching, nutrition guidance, and mental health resources become as critical as medical interventions, underscoring the need for a more integrated, holistic approach.  

Many health professionals receive training primarily focused on clinical care and disease management, which reflects the traditional structure of medical education. However, health is influenced by a wide range of social and economic conditions, including access to stable housing, education, employment, and strong community networks. Because these factors play such a significant role in shaping health, effective approaches increasingly rely on collaboration across sectors, bringing together local governments, businesses, educators, community organizations, and healthcare providers. Working collectively can help create environments and communities that support good health and reduce the need for medical intervention related to preventable conditions. 

3. Shifting healthcare financing: from treatment-based to preventive and community models   

The way healthcare is financed significantly influences whether systems prioritise treatment or prevention. For example, in France many physicians are remunerated through a model driven by the volume of treatments and procedures they perform, rather than being rewarded for maintaining population health or reducing the incidence of chronic disease. This structure can reinforce a cycle in which conditions such as diabetes and cardiovascular disease continue to grow, while preventive care remains under-resourced. 

In contrast, in the Netherlands, there is growing interest in population-based funding models. These shift payment away from individual services and instead allocate resources based on community health outcomes. For instance, the Dutch government has moved toward payments linked to outcomes and value, beyond traditional fee-for-service, to encourage prevention and long-term wellbeing. Such models aim to direct financial incentives toward upstream health and community-centred care, rather than primarily funding short-term clinical interventions. 

4. Imagination and innovation for Health Systems: the role of social entrepreneurs 

Social entrepreneurs play a crucial role in reshaping health systems by introducing innovative solutions, yet they remain underutilized in mainstream systems. Many struggle to secure funding because traditional medical research models prioritize evidence from large-scale clinical trials, which do not always apply to innovative, community-driven solutions. To bridge this gap, the UK government is launching its first Social Investment Vehicle, a fund designed to bring together the National Health Service (NHS), social enterprises, and philanthropic investors to finance large-scale health innovations. If implemented effectively, this initiative could represent the most significant shift in UK healthcare funding in 75 years, providing critical support for preventive and community-based health initiatives.  

Another major barrier to innovation is the insistence on traditional forms of evidence, such as large randomized controlled trials, long-term longitudinal studies, and strict biomedical outcome measures. Many promising health approaches struggle to gain support simply because they do not yet have this type of large-scale data, even when they show clear benefits in smaller community settings. This creates what some call the “tyranny of proof,” where the absence of conventional evidence is assumed to mean something does not work. 

For example, social prescribing programs in the UK and Housing First initiatives internationally both faced early resistance because they could not initially demonstrate results through traditional clinical metrics. Pilot studies later revealed improvements in wellbeing, reduced emergency care use, and lower system costs, an evidence that only became visible once space for experimentation was created. 

Rather than rejecting new models because they lack large-scale precedent, governments and institutions can support pilot programs that generate the evidence needed to evaluate and refine innovative approaches. 

5. Balancing individual and public health: ethical and systemic considerations   

One of the most challenging tensions in healthcare is balancing the needs of individual patients with broader public health priorities. Some medical interventions can require substantial financial, human, and environmental resources, while offering only limited extensions of life. At the same time, investment in preventive and community health services has the potential to improve outcomes for a much larger number of people. During the discussion, a participant shared a real-world example of a hospital facing a difficult decision: significant resources were dedicated to extending one patient’s life by only a short period, while others, especially in lower-income communities, were struggling to access basic care. Situations like this highlight complex ethical questions that health systems everywhere must grapple with: How do we weigh individual needs against collective wellbeing? What principles should guide decisions when resources are limited? 

These dilemmas do not have simple answers, but they point to the importance of integrating ethical reflection into organisational policies and decision-making processes. Creating spaces where health professionals, patients, and communities can openly discuss may support more transparent and equitable choices, helping balance compassion for individuals with a commitment to broader health equity. 

6. Seeing health creation as everyone's business 

The concept of "Health creation as everyone's business" emphasizes that health is not the sole responsibility of the healthcare system or medical professionals but rather a shared endeavour that involves individuals, communities, and broader societal structures. Instead of focusing solely on treating illness, this approach advocates for a shift toward a system that actively creates the conditions for good health by addressing social, economic, and environmental determinants. 

A key aspect of this vision is the recognition that health outcomes are shaped by far more than medical interventions. Factors such as stable housing, education, employment opportunities, and social connections play a crucial role in determining wellbeing. As a result, health creation requires collaboration across multiple sectors, including local governments, businesses, educators, and social organizations, to ensure that communities are supported in maintaining good health rather than relying on healthcare services to manage preventable illnesses. 

Recognising health professionals as changemakers highlights the essential role they play in enabling patients and communities to build confidence, capacity, and agency in shaping their own health. Health professionals should be encouraged to innovate and develop imaginative pathways for improving health, stepping beyond clinical treatment to engage with other sectors such as social services, education, and urban planning. 

By working in partnership with these fields, they can help create environments that make healthy choices easier and more accessible. At the same time, the idea of shared responsibility must be carefully framed to avoid the risk of shifting too much burden onto individuals. One concern raised in the discussion was the way certain narratives around self-responsibility have been misused in the past. In the UK, for example, the concept of "asset-based working" was originally intended to focus on community strengths rather than deficits. However, policymakers later co-opted it to suggest that individuals should simply "use their strengths" to overcome health challenges, effectively ignoring the systemic inequalities that limit people’s ability to do so. This misuse of a narrative that blames individuals for their health struggles continues to allow structural issues, such as poverty and lack of access to resources, to remain unaddressed. 

True health creation requires a balance between individual agency and systemic responsibility. While it is important to support people in making healthier choices, it is equally critical to ensure that communities are not doing so in a system that sets them up for failure. Governments and institutions must continue to play a role in addressing the root causes of health inequalities rather than using narratives of personal responsibility as an excuse to withdraw support. 

Going further 

If you are interested in the methodology used to unleash collective imagination in a multi-stakeholder process, Karolien Van den Brekel and the Positive Health team designed a toolbox to organize your own “Dream Session”.  

If you want to learn more about Social Imagination, its importance, and how to nurture it, specifically for policy development, Mark Swift has written a series of articles, published by the Liverpool University, that you can access here. 

"The skills required for collaboration are not technical, they are relational. We must learn how to trust, to share, and to listen deeply. Systems change requires not just new ideas, but the courage and willingness to work together in ways that challenge old patterns." Margaret J. Wheatley 

Guillaume Alsac will be remembered for his inspiring vision, profound kindness, and lasting impact through the innovative French community nursing social enterprise, Soignons Humain.