The NHS is an inalienable moral heritage of our democracy because it is indispensable to citizenship, individual dignity and collective justice.

António Arnaut

In recent decades, much has changed in the health systems of various countries and various challenges and problems have arisen. These include demographic ageing, the management of available resources, the emergence of the knowledge society, the explosion of digital tools and platforms, advances in medical technology, the perspectives, expectations and ambitions of new generations of professionals and the greater awareness and willingness of citizens to manage their own health and participate in the decisions that affect them. Everything has become extremely more complex in recent decades and has intensified during Covid, with ever greater and more centralized financial control.

The National Health Service (NHS) is one of the greatest achievements since April 25, 1974 and one of the main factors in the cohesion of society in democratic Portugal. In order to guarantee its sustainability for the foreseeable future, however, our SNS must undergo strategic transformations.

In general, the existence of an NHS has positive aspects. The first of these is universal access, guaranteeing all citizens, regardless of their financial situation, access to essential healthcare and eliminating financial barriers. No one is left out of the healthcare system due to a lack of resources. Related to the above, an NHS promotes equity in the provision of healthcare, ensuring that people receive treatment based on their clinical needs, rather than their ability to pay, thus reducing health inequalities between socio-economic groups. Another positive aspect has to do with accessibility and the fact that healthcare costs are essentially covered by taxes, making care more affordable for individuals and families, and allowing them not to worry about catastrophic medical expenses. A fourth point relates to the NHS's mission to promote health and prevent illness, which is essential for the safety and well-being of the population. Finally, in an NHS, there is public oversight, and the government and citizens are held accountable and can have a say in what happens.

On the other hand, any NHS is also associated with some problems, which can vary according to how it is implemented and managed in each country. The first is waiting lists due to the large number of people seeking health services, which can result in delays in treatment and frustration for patients. Limited choice can also be perceived as a disadvantage by those who want more healthcare options. Moreover, as the financing of an NHS comes from taxpayers' money, it is associated with limited budgets and financial pressures to contain costs, which can necessarily lead to a lack of resources, a reduction in professionals and limitations in the coverage of medical services. Another aspect that usually coexists in any NHS is political interference and bureaucracy, which can affect decision-making and the allocation of resources in a way that is not entirely based on clinical criteria, as well as the stability and efficiency of services. In addition, private systems may have more resources to invest in the latest medical technologies, leading to possible improvements in treatment and services. Finally, the NHS may face a shortage of doctors, nurses and other health professionals, further increasing waiting lists and pressure on the system.

Faced with these problems, and in order to guarantee sustainability for the foreseeable future, the Portuguese NHS must undergo strategic transformations. It is true that it needs more resources for its development. But that alone is not enough. The necessary transformations need to be made to respond to today's challenges, as strategic vision and action are required, as well as a new model of governance for the health system and the SNS.

In this context, the NHS Health Foundation has identified ten theses for transforming the NHS in a changing world. Among other aspects, these transformations include life journeys, ageing, intergenerational relationships and mental health. In addition, the importance of public health is emphasized, especially local public health. These transformations must aim for people-centeredness, so-called personalized care, ensuring that all health prescriptions and interventions consider how they interfere with people's lives and safety. This also includes the development of new digitalized, people-centered information systems.

We need to invest in adaptive changes in proximity, in local leadership and in the integration of care, because we need decentralized management in proximity, with adequate autonomy, in an adaptive way and according to local circumstances, through entrepreneurial leadership, which responsibly assumes decision-making autonomy in relation to the proposed framework for managing change. In this way, we must once again invest in the concept of the health center, a unit that is closed to citizens. And we need to reactivate the concept of local health systems, bringing together the various local interests, be they public, private or social, along with other sectors such as education.

The new SNS must also be concerned with creating confidence among professionals in the future and in its ability to provide them with attractive and motivating professional careers. This includes remuneration, working conditions, diversity of working arrangements and working hours, as well as effective processes for detecting situations of professional dissatisfaction and suffering and responding in time to correct them.

Technological innovation must be present, encompassing a commitment to people's digital inclusion, strict respect and defense of digital rights and principles, and the establishment of a clear strategy for incorporating technology into the NHS. On the other hand, it is necessary to go beyond budgetary logics focused solely on the creation of gross wealth, regardless of its quality and the underlying inequalities. We need to start funding well-being goals for our population, with concrete short- and medium-term objectives, which requires a different approach when preparing the State Budget. The NHS must be seen not simply as an expense, but above all as an important multi-annual investment to guarantee the economic development and well-being of the population.

Finally, traditional governance models must be overcome, with disjointed, fragmented and sectoral responses. Today, the various levels of care are still organized in "silos" between which users are lost.

Personally, I have high hopes for the medium- and long-term direction that the new NHS Executive Board has in mind. However, the biggest problem is currently the short term and the resolution of the problems that are greatly affecting the people who use health services.

In conclusion to this personal reflection on the situation we are currently experiencing with the NHS, it is possible and urgent to help protect our NHS for the future. For the sake of the health and well-being of the entire population, the country's economy, social cohesion and democracy itself.

The future is at risk. We must join forces and everyone is needed. There is no time for guerrilla warfare motivated by petty interests. Considering the Portuguese reality, I argue that we have no alternative to a strong NHS, which responds to the needs of the people who come to it and in whom they have confidence.