Heritage, hierarchy and hubris as observed by an ex-NHS strategist
I returned last week after a holiday in Berlin. An excellently timed break to reflect and gain perspective 7 months after leaving my NHS Head of Strategy role. Structurally the NHS is back in the British media again, a new temporary regional structure, separate to DHSC, now being set up in the wake of a new PM and devolution agenda. The revolving door never stops spinning. But its shape, materials and people passing through are inherently variable.
A few weeks ago, I explored the synergies between the people and culture of health, politics and fashion. This week, the practices, which feels perfectly apt given recent creative director shake-ups, Q3 results and the endless NHS political football match.
Mission-oriented (or disoriented)
Defining the macro-challenges of a national health system should in theory be a fairly simple exercise. An exhaustive amount of data. Occam’s razor put to work. And defining the problems in a rigorous, evidence-based approach is in fact simple. Where the challenge falls in in having senior executives and ministers agreeing them, prioritising their urgency, and communicating them back to staff.
Diagnosing problems is so critical in any competent strategic practice. In healthcare where the stakes are so high, it’s a non-negotiable. And without the diagnosis, i.e. the root cause defined as well as the material and perverse symptoms which happen as a result, a clear goal and steps to achieve that goal can’t be designed.
Where I’ve had the best experience of a mission-oriented culture and practice, where people coalesced around a problem, ran a proper dual diagnostic, agreed a solution, and designed and delivered the path to get there inclusively, was during Covid. The mission was so clear, its urgency and criticality clearly defined and communicated.
Covid actually drove a large culture shift at the national level where structural limitations, team boundaries and lowercase ‘p’ politics were in essence ripped up. We coalesced around the problem, the goal and collaborated effectively, maximising efficiency, productivity and a sense of belonging, a sense of pride.
I have repeatedly tried to bottle or broker the conditions for success the NHS sustained during Covid (a global pandemic aside), and from my experience, the winning formula was always a mission. Not projects or programmes, reports or team legacies. Create and drive a mission. Do so collaboratively and inclusively. Be unequivocally clear on the problems you’re solving for, the goals you’re driving towards and the individual roles required to get there. Intellectually of course this makes perfect sense but doesn’t take into account human behaviour: politicking, ego, communication, accountability. And when the operating context lacks a mission-oriented culture, and big bureaucracy places impetus on the wrong practices, this is where disorientation happens ad nauseam.
I’m currently seeing in the luxury fashion industry the same sorts of behaviours playing out in a different way: structural misalignment causing multiple solutions to run in parallel without an effective problem diagnosis, or at least willingness to accept and agree what the problems genuinely and inherently are. The industry knows there is an aspirational client gap, which, according to the BoF and McKinsey State of Fashion report, represents upwards of $90 billion sitting with underserved luxury clients1. But instead of acknowledging and strategically addressing the reasons the aspirational client has stopped purchasing, there’s an over-indexing and reliance on digital solutions: AI discovery and agentic shopping.
As with health, it’s not either/or, but both/and. No single solutions, no silver bullets. Instead, to meet the conditions for success, you need a coherent diagnosis of the problems you’re solving and their root causes, agreement on the goals you’re aiming for, and then define and design the solutions, strategically aligning the people, structures and systems to get there.
Foresight and culture-scanning
Perversely and likely against better judgement, what I loved most about working in healthcare was its complexity. Our personal health can be volatile. The NHS as an anchor institution is constant, for which I am grateful, but it’s also in constant need of investment, review, improvement and transformation. The needs are sometimes incremental, sometimes a quantum leap. None of it can be driven without competent people, an evidence-base and a mission (see above).
The NHS does have an uncanny ability to horizon-scan and arguably against many schools of thought, forecast the health needs (and therefore the system needs) for the population in two, five, and ten years’ time. This is where complexity sits: the longitudinal health data we already hold as a nation (and globally for that matter) defines fairly rigidly the health requirements, while also intersecting with industry and healthcare innovations (see: GLP-1s for example. Absolute potential to be a game-changer for preventative health management, with new use cases being explored). Tech of course is accelerating at a huge pace, and the opportunities and innovations for ten years’ time might not have even been conceptualised yet.
That was what I also found so exciting about healthcare: it is emergent, complex and critical. The NHS needs to be long-term future-proofed, not just for the service it provides and the future needs of patients and citizens, but the funding required to do so, and the value proposition it provides to taxpayers. And overlay that all with our expectations.
Societally, most of us expect tech to be driving impactful, realtime benefits to our everyday lives. So not only does forecasting healthcare needs require longitudinal health data and other important broader social determinants of health to design population health services and products, but also societal behaviours, cultural expectations.
And what can health influence in that space? Innovative medicines and med tech (wearables for example) are part of that foresight but also, culturally, are important players in the wellness movement. Optimising your health and wellness is having a direct influence currently in everyday British culture. How pervasive and sustainable is this trend, a passing fad or a culture shift embedded into the British psyche?
I read something really interesting recently about e-commerce. There’s currently a debate about agentic shopping, and will e-commerce as we know exist in 10 years’ time. Prada recently launched a plug-in pilot with ChatGPT (currently only available in the UK, USA and Italy) to directly connect into the AI model and reach a new potential client base. I’ve tested it and it’s actually quite fun. You can explore the brand history, have intelligent conversations about design, your ideal products, seek recommendations and explore specific products, asking hyper-specific questions with decent responses. I haven’t tried transacting through it but from my user experience and journey, it was entirely frictionless.
Do I think this will entirely replace a brand’s owned e-commerce? No. And the reason I say this is because of the question I would have previously asked in healthcare. Instead of focusing on what we predict will change, focus on the constant. What do we know will not change in purchasing online?
The experience will no doubt transform from end to end, but specific touch-points along that journey won’t. And culturally, the evidence exists to show the fast adoption of agentic shopping from McKinsey’s recent report: the share of US AI users buying directly within an AI tool rose from 10% to 17% between December 2025 and June 2026, a 70% increase2.
But there’s still a trust gap between trusting AI to recommend and trusting it to buy. McKinsey finds 74% of US AI users trust AI chat and search tools, yet only 21-30% would let AI complete a purchase in the top categories3. And that trust is unequivocally the constant.
The human requirement of trust to make a purchase will never change irrespective of the journey. And whether the trust is aligned with a human being, a heritage brand or an AI model is simply a structural question, because it must coexist across each of those axes.
As we move through the next two, five and ten years of huge advances at accelerated pace across tech innovation and use cases, the constant culture-scanning will be a critical piece of analysis to drive towards delivering a future-vision based on customer needs and earned trust, the art of the possible, exponential growth and value.
Adaptability and endurance
Historically, when I’ve recruited into my teams, whether during my time in central government or the NHS, I would deliberately seek out the candidate’s ability to adapt. For better or for worse, there is a lot of volatility, uncertainty and unpredictable change in the public sector. Personally, I’m a highly adaptable person, the uncertainty and ambiguity hardly faze me (especially now). I am a highly empirical person too, much preferring the lived experience and knowledge to feel confident and comfortable.
So it’s complementary to also be highly adaptable, with an uncanny ability to review the evidence and context and course correct if/when required. And to have the resilience and endurance to do that many, many many times over. Those are soft skills fundamentally required to work in UK public service. If you’re entering the workforce assuming it’s a cushy job for life, those days have long since ceased. As mentioned in Part 1, leadership is entirely precarious, both politically and executively at the top of the NHS. The NHS itself, a heritage institution is also constantly adapting to societal, health, market, labour and political needs, wants and expectations. Change fatigue is very real, so as the individual operating in the system, you need to devise other coping mechanisms and psychological safety nets to endure. But as a strategist, of course this is where excitement and opportunity can sit, where a quantum leap could take off.
Even more so in fashion, there are micro-movements, seasonal trends, creative people and their IP constantly shifting. Where I think luxury heritage brands get it right far more than the NHS is accepting that driving towards the vision is going to take time, and leadership providing that time and capacity to actually get there. And when that time and capacity isn’t provided, see Kering’s current creative director shake-up, with Piccioli leaving Balenciaga after just 16 months in post, the industry insiders are seeking answers. That’s telling about an industry culture where long-term change and growth are understood to take time, and the removal of a creative director after 16 months is incongruent with that culture.
Importantly, of course the business of luxury fashion is not simply to produce beautiful, artisanal craft but to be commercially viable. And the requirement to translate a first collection and a point of view into sales six months later, then repeatedly, is an endurance challenge. And this endurance challenge plays out in a landscape of many micro-movements, seasonal trends and cultural moments, where adaptation might be a sign of a wavering point of view. Where the adaptability strength needs to sit is in the response to the economic and market forces: where can greater value be eked out incrementally or when is a course correction intervention needed.
Diagnose before you design. Align around a mission, not a programme. Define the value, for the customer and for the business. Scan for the constant, not just the change. And give the people doing the work the time to deliver it. None of this is complicated. All of it is tough, because every one of these practices depends on human behaviour: ego, communication, accountability and agreement. The NHS taught me that. A fashion house in the middle of a reset is teaching it again.
But that’s health, politics and fashion right? The strategy is rarely the problem. The evidence exists, the horizon is visible, the mission fits on a single page. What breaks is the alignment, the patience and the nerve to see it through. They’re each playing a long game against short cycles, in public, with constant discourse and existential dread. As I said in Part 1, health, politics and fashion are in the business of people, possibilities and progress. This week I see they’re held together by purpose, patterns and perseverance.
References
1 The State of Fashion: Face to Face with Luxury Clients, The Business of Fashion and McKinsey & Company, June 2026.
2, 3 Who wins when AI does the shopping? New Evidence on Agentic Commerce, McKinsey & Company, October 2026.
