We often measure the success of the NHS by how much it does; more activity, more access, more spending.
But what if true success isn’t about doing more, but about helping people live well within the limits of both their lives and the system’s resources?
In this episode, Dr Johnny Marshall explores how the idea of doughnut economics offers a different lens for the NHS. One that balances social need with sustainable use of resources, and reframes what it really means for people and communities to thrive.
Transcript
Introduction
Welcome back to Neighbourhood Health Conversations, the place where we explore how health and care can feel more human, more connected, and more effective. Today, I want to talk about something a little unexpected. Something that’s been on my mind recently. Donuts. Yes, doughnuts. My first encounter with donuts, like most people, was simple. They were tasty. When I started working as a GP, I used to take doughnuts into the practice on Saturday mornings as a bit of a treat for the team. It was part of that shared ritual of getting through a busy weekend surgery together. Over time, the habit faded, in part because Saturday surgeries moved to an out-of-hours collaborative, but also because my own awareness of metabolic health changed. The older I got, the more I realised how something that feels comforting can in excess become part of a problem. And that realisation resurfaced recently when I came across something called doughnut economics.
What Is Doughnut Economics?
This time, the donut wasn’t about the sugar, it was about society. I started reading more from Kate Raworth, who originated the theory of doughnut economics, and the London Donut Economy Coalition. And whilst I am absolutely no economist, the more I read, the more it struck me just how relevant this thinking could be for the NHS.
If you’ve not come across it before, donut economics is beautifully simple. Start by imagining a ring donut. The inner aspect of the ring is the social foundation. It’s the basic conditions everyone needs to live well. Food, housing, education, income, safety, community. The outer ring is the ecological ceiling, the limits of our planet’s resources. Between the two rings is the sweet spot, the place where humans thrive without overshooting resources.
The NHS and Its Inner and Outer Rings
And it made me realise something important. The NHS has its own inner and outer rings too. At the inner ring, we have people who are falling through the gaps. Loneliness is a powerful example. We know how damaging loneliness can be for our health. In fact, its effects are comparable to major risk factors we talk about all the time. And yet our response often isn’t relational or community-based or even preventative. Instead, if detected, people risk ending up on antidepressants long before they end up with regular companionship.
Then there’s the outer ring, the places where we overshoot and use more resources than we need to. Al Mulley’s work on clinical decision quality captures this so well. We often provide interventions because the system is designed around biomedical answers, not because those interventions are what matter most to the person.
If doughnut economics teaches us anything, it’s that thriving isn’t about endless expansion. It’s about finding the balance point where needs are met without waste. Let me give you two examples of perhaps how this has looked in my practice.
A Story from Practice: Helping Someone Into the Inner Ring
The first is a woman called, well I’m going to call her Anna, whom I saw many years ago and who wasn’t taking her antidepressant medication regularly. It took me slowing down and properly listening to understand why. Taking time to listen and make better decisions is such a precious gift that supersedes the prevailing short-termism of what verges on an NHS obsession with more GP access. Anna could barely afford the prescription charge. She was working part-time, proud of holding onto that job, but the math simply didn’t add up. Once I understood the reality, we found a way forward. I increased the number of tablets on her prescription and connected her to the local food bank.
This eased the pressure on her household budget just enough that she could afford her prescription and stay in work, which was the thing that gave her dignity and purpose. It clearly wasn’t the perfect solution, but it was within my control. I could do something, however small, and it enabled Anna to take one step into the inner ring. Imagine what more could be achieved if this was how the whole health and care system and beyond were to operate.
Staying Within the Outer Ring: Digital Health Coaching
The second example is digital health coaching for people with type 2 diabetes or at risk of type 2 diabetes. It’s simple, relational and human. Connection, support, healthier habits and building confidence are at the heart.
Early evidence of digital coaching suggests that people with type 2 diabetes can improve their HbA1C and metabolic markers significantly above and beyond current routine general practice support. Meaning it could be one of those approaches that helps shift the system from its biomedical default and helps us to remain within the available resources. When we create the right conditions, people flourish. That’s the sweet spot of the ring donut. It’s no longer jam in the middle for the few.
What Would an NHS Within the Doughnut Look Like?
As a result of my growing understanding, I began to wonder why do we celebrate record above inflation growth in NHS spending as if it’s a triumph? Shouldn’t the real measure of success be fewer people falling into poor health and inequity and fewer resources wasted on things that don’t add value?
An NHS within the donut would be one where people have enough social foundation, connection, meaning, stability. The system uses its finite resources carefully and purposefully. We prioritise health creation and not just disease treatment. And professionals have the time and tools to listen and understand what matters most. So how are we doing against those success factors? It’s not about a bigger NHS, it’s about a smarter, more human one.
Conclusion
So here’s a thought to take into your day. What part of your work helps lift people into the inner ring of the doughnut?
And where in your own service might we be overshooting at the outer edge? No judgment, just curiosity. Small changes ripple in neighbourhoods, and neighbourhoods when they shift change the whole system. Thank you for listening to Neighbourhood Health Conversations. If this has sparked ideas, questions or reflections, I’d love to hear from you. Join the conversation, because this change will only happen if we work it out together.
