Can the ten-year health plan deliver on its promise?

A lot is riding on the government’s ten-year health plan (10YHP) to ensure the public get the best possible care, recover the nation’s health and bolster the economy. Its central promise – to make the health service ‘fit for the future’ – ought to deliver three shifts to address the fundamental issues that led Lord Darzi to describe the NHS as being in a 'critical condition'. 

With the plan just weeks away, and with recent announcements regarding NHS reorganisation, now is a useful time to reflect on whether the 10YHP can deliver on its ambitious promise.

The most radical thing the plan can do is facilitate the shift to a more preventative and empowering model of care

On a mission

The most radical thing the plan can do is facilitate the shift to a more preventative and empowering model of care. This is the only way to put the NHS on a more sustainable footing to avoid healthcare taking up an ever-growing share of national wealth.

If this is the plan’s core aim, several things must follow:

• A clear set of policies that support the health of the nation, not just the NHS. Around 80 per cent of the factors that affect our health are beyond the NHS’s control.
• A clear expectation/commitment to rebalance more NHS funding to primary, community and other settings outside of hospitals.
• A new care model at neighbourhood level, which is community engaged, empowering, personalised and holistic. 
• A more devolved and integrated system operating model, which sits at the heart of the plan. This should provide clarity on overall governance and accountability arrangements, with local flexibility on how change is delivered. 

Achieving these things will require leadership and discipline from a mission-driven government and leaders working in partnership across health and social care and the wider public sector. 

Delivering the promise will be no easy task, but several principles will help guide the approach.

Principles for success

1. Shifting care from acute to community drives better value

Recovery requires real reform, not sticking plasters. With rising patient need due to an ageing population with increasingly complex mental and physical health needs, we must shift from high-cost, reactive, hospital-based services to more sustainable, preventative care that improves people’s access, experiences and outcomes. A model which offers better care to patients and better value to taxpayers.

Shifting care closer to home requires a new operating model that emphasises preventative rather than late-stage interventions. The current model, driven by a national focus on A&E attendances and waiting lists, incentivises hospitals to increase reactive activity, placing a greater burden on system resources while failing to deliver the best outcomes for patients.  

Achieving the shift from acute to community will require:

• An increase in the percentage share of NHS budget allocated to primary and community services by the end of this parliament.
• An increase in out-of-hospital capacity to provide preventative and more cost-effective alternative services. 
• An increase in the proportion of staff working in primary and community health care, equipped with the necessary workforce and leadership skills and capabilities. The NHS Long Term Workforce Plan underscored the need for investment in community nursing and GP staff. Teams must also create a culture where integrated working can thrive at a neighbourhood level, creating more holistic person-centred care.
• Enhancing primary care at scale. Primary care provider collaboratives can unite primary care providers at local and system levels to have a collective voice. These collaboratives should, over time, become legal entities that can hold contracts and pool budgets, allowing them to act as strategic partners within integrated care systems (ICSs).
• Implementing the Mental Health Act reforms, including through improving community provision for people with learning disabilities, autistic people, and those with mental health issues.
• Changes to financial and regulatory incentives. Measurement is a key barrier to shifting care closer to home. There are no significant metrics to track progress, and system leaders are not pressured to prioritise this, unlike elective backlogs and A&E waiting times. This should be addressed by:
  • Improving data quality across primary care, community and mental health sectors, to measure activity.
  • Including a metric in the 10YHP to incentivise shifting NHS spending from hospitals to more preventative community and primary care.

2. Prevention is better than cure

Preventing worsening physical and mental ill health will help people live longer, healthier lives and at better value for the taxpayer. A clinical intervention costs four times as much as a public health intervention to add an extra year of healthy life. 

Yet prevention occupies just 5 per cent of overall NHS spend, and national targets and oversight tend to focus on more immediate operational priorities and highest acuity. This underscores governments’ tendency – as described in the Darzi review – to prioritise short-term solutions over addressing root causes. This explains the lack of national strategy, financial and regulatory incentives to invest in early intervention and preventative services.

Achieving this shift will be difficult in the current financial landscape. Diverting funding currently spent on hospital beds, staff and equipment into prevention – which in most cases will not demonstrate a quick return on investment ¹  – runs counter to the short-term imperative to recover financial and operational performance. Longer waits, poorer access and quality of hospital care will not improve the public’s perceptions of the NHS in the short term. But moving to a preventative model of care will make services more sustainable and requires action on multiple fronts and primary, secondary and tertiary prevention.

Achieving the shift from treatment to prevention will require:

• Strategic commissioning led by integrated care boards (ICBs) to harness the collective power and expertise in the system to design services for outcomes, not activity. 
• Effective partnerships across the public sector, voluntary, community and social enterprise (VCSE) sector and businesses, equipped with the right levers and incentives to focus on helping people keep healthy. 
• Empowering partners across ICSs to direct money towards the most effective interventions, many of which sit, for example, within children and young people’s services, including mental health services.
• Digital tools and data analysis using population health management approaches are crucial for risk stratification and population segmentation, facilitating monitoring progress and ensuring sustained investment.
• Mobilising public health leadership and expertise. The recently announced 3 per cent real-terms increase to the public health grant for 2025/26 is welcome and must be built on.
• Enhancing the role of place and neighbourhood in delivering community-led care, prevention, and action on the wider determinants of health. This means giving neighbourhoods the tools and resources they need to support citizens to take a proactive approach to their own health.
• Reforms to financial flows. This could be approached in several ways: by increasing the proportion of ICS budgets spent on prevention (by at least 1 per cent over five years), a prevention investment standard, ring-fenced budgets (Preventative Departmental Expenditure Limits) and outcomes-based payment mechanisms. As with the shift to community, measurement poses a challenge to changing national financial flows.

3. Digital services and data improve efficiency

Technological advances have seismic potential for how we deliver health and care services. Expanding the use of data, digital and technology will improve efficiency to help address rising demand for services. Supporting citizens to use internet-era based services can also enable and empower them to become self-managers of their own care and ultimately to live healthier lives. 

There have been various national policy initiatives focused on digital innovation and scaling and adopting models. But further work is needed to explore how digital healthcare might build on and change the delivery models used in different sectors and provider types. The ambition should be to digitally transform the NHS where proven benefits in patient care and service quality have been seen, enabling it to effectively and proactively deliver quality health and care services now and in the future. Addressing digital inequalities and patient choice are two important principles that must guide the approach.

Achieving the shift from analogue to digital will require:

• Increased capital funding for digital technology. Currently only 10 per cent of capital is allocated to IT and software. A move towards longer-term funding cycles would support service recovery and transformation and sustained implementation of digital tools and medical technologies, including cost-saving opportunities such as automation and artificial intelligence (AI).
• Improvements in providers’ and systems’ capabilities to unlock the potential of digital technology for enhancing staff efficiency and patient choice. Inconsistent digital infrastructure and maturity across ICSs hinder data sharing, efficiency and effective digital care. 
• Resolution of the complex and fragmented data-sharing arrangements for proactive care, planning, performance and research. To have a system-wide view of data, the plan should create a shared-ownership model for primary and community data that removes the sole data controller responsibility from general practice.
• Increases in the number of digital and data specialists to enable the NHS to fully develop and scale digital care, supported by a specific Data, Digital and Technology Workforce Plan. In addition, the entire health and care workforce must be supported to attain the skills and opportunities needed to oversee this shift. 
• Improved procurement. Many mental health providers are already using AI to aid in diagnosis, delivery of therapy and administrative or clinical decision-making tasks. But navigating the technology market and implementing the most evidence-based solutions remains challenging. This process could be brokered more effectively to ensure the best outcomes.

4. The three shifts are the north star for recovery and reform

The NHS needs to radically improve its productivity to meet existing constitutional standards. This can only be delivered through system working across health and social care. 

But recovery cannot be seen as a prerequisite for beginning work on the three shifts. Recovery and reform are two sides of the same coin. While the government and system leaders should be fully committed to achieving rapid service recovery, they must also address the root causes of ongoing operational and financial pressures – this requires split-screen thinking. The three shifts should provide the north star for both recovery and reform.

Shifting from hospital to community and from illness to prevention, through a neighbourhood health service, can help put the NHS on a more financially sustainable footing by managing demand for more expensive downstream care. Digital and data will also play a critical role in improving efficiency by automating routine tasks, reducing demand for staff, providing virtual appointments and allowing citizens to self-manage their care.

While the three shifts provide the strategic vision, there are also three related immediate-term priorities: 

• neighbourhood development
• reducing waiting lists
• financial balance. 

Discharge and admissions avoidance are the operational links that will drive systems’ progress against these priorities.

5. Investment in physical and digital infrastructure boost productivity

Significant improvements in productivity will be required to recover system performance and enable the left shift. This cannot be achieved without significant capital investment in physical and digital infrastructure. 

UK capital investment has been below peer countries’ averages for decades and Lord Darzi highlighted that the UK spent £37 billion less than similar countries over the past decade. Decades of poor investment have resulted in crumbling buildings, outdated equipment and poorly integrated IT systems across physical and mental health settings, which have significantly reduced staff productivity. 

Our survey of NHS leaders revealed the NHS requires an annual capital funding increase of £6.4 billon each year over the next three years to address the maintenance backlog and boost annual productivity to 2 per cent. But there is a £3.3 billion shortfall between this and the £3.1 billion the government announced in the 2024 Autumn Budget.

Changing national policy and guidance to create new routes for private investment and supporting an attractive investment market can address the productivity challenge and fill the existing gap in capital funding.

As well as increasing the level of investment, there are significant issues with the capital allocation process, which slows down transformation and leads to waste. There are too many layers of approval slowing down projects, insufficient estate management capacity and capability in ICBs, and no routes to allow private investment in capital.

Management capacity will also need to increase to meet the productivity challenge and must be prioritised amid ICB and trust cuts.  Fewer managers means not enough people to make processes better. According to ONS figures, in March 2024, 2.96 per cent of the NHS workforce were managers, down from 3.75 per cent  in September 2009 – a decline of more than a fifth (21.0 per cent). Across the entire UK economy, 11 per cent of staff work in management roles. Fewer effective managers mean it is harder to use scare resource effectively. At the same time, staff are less experienced than they were prior to the pandemic, further highlighting the loss of managers, and the need for more of them. 

A well-functioning health and life sciences sector ensures that patients get access to the most innovative treatments and technologies more quickly. It is estimated that the UK economy would achieve £17.9 billion additional productivity gains through the increased uptake of innovative medicines.

There are opportunities to enhance productivity in mental health and community services. Current contracting arrangements (mainly block contracts) and limited data have hindered the ability to measure activity, cost and productivity as effectively as in acute care. Mental health and community providers are eager to meet NHS England's challenge to better use and analyse data to improve productivity, identify efficiencies, enhance care and benchmark to reduce variation. New productivity metrics are a good start, but accurately measuring activity and outcomes will require time and expert support to ensure their accuracy for commissioning and performance oversight.

6. A devolved operating model delivers reform and encourages innovation

A new government and recent announcements regarding reorganisation within the centre and the system have made a new operating model essential. This must be central to the 10YHP.

In a taxpayer-funded healthcare system, the government and its arm’s-length bodies can improve system performance through strategic oversight and allocation of resource. But as the Hewitt review articulated, the demands of top-down accountability upwards to Whitehall too often draws healthcare leaders’ attention away from outwards accountability to their partners and local communities, as well as laterally to their peers. Performance management and oversight processes are currently too burdensome and distract from delivery. They must be more proportionate and empower leaders to drive change and improvement.

A more devolved and integrated structure in which the NHS, local government, VCSE sector and social care can work together and better engage the public is more likely to drive and deliver sustained reform and encourage innovation. The NHS needs to become a better partner and move beyond a purely medical model.

Since 80 per cent of health outcomes are influenced by factors beyond healthcare, a cross-sector approach is essential to improve population health and address inequalities. The Health and Care Act 2022 established ICBs and integrated care partnerships (ICPs). These structures enable collaborative decision-making among primary care, trusts and local authorities, optimising resource use across 42 areas. 

As the Hewitt review articulated, ICSs were created, but not the conditions in which they can thrive and deliver. In spite of this, the progress made through the new ICS model – including in shifting from hospital to community care and from illness to prevention –  should be recognised and built upon to further enhance multi-organisational partnerships by removing barriers to collaboration.

The 10YHP should outline outcomes that are needed to support change and provide some options for delivery. Local leaders, who are collectively responsible for implementation, should be allowed to choose the best approach for their ICS. Within every model, partnership at place level will be critical to moving towards more integrated, person-centred care and optimising the use of collective resources.

7. The relationship between citizens and public services needs to change

Public satisfaction with the NHS is at an all-time low. The development of the 10YHP has involved one of the ‘biggest national conversations about the future of the NHS since its birth’. Yet to go beyond rhetoric, the 10YHP must include a change model which empowers the public with greater choice. The development of the 10YHP should be seen as the first step towards a more consistent open narrative on the NHS between the public and decision makers. The public must be given an opportunity to influence and support its implementation.

Over the next ten years the health and care system should aim to embed a new model of care at neighbourhood level which is community engaged, empowering, personalised and holistic. Those living with multiple long-term conditions – who account for 70 per cent of need for NHS care – should receive more personalised and continuous care. 

Healthcare leaders are increasingly collaborating with patient organisations and citizens to improve engagement and co-production. They recognise that this approach is essential for improving service quality and safety, as well as for investing in the most cost-effective services. But to enable patients and communities to manage and improve their health, we need to go much further and to flip accountability on its head by moving from ad-hoc consulting towards engrained co-production. The mental health sector has pioneered public co-production of services and should be illustrative for other parts of the system. 

Due to the inverse care law, communities least likely to have their needs met by the system are also the least likely to have their voices heard during consultations or engagements. Systems must proactively engage with these groups to address structural inequalities and meet the needs of their communities.

The way citizens navigate their health will increasingly depend on the readiness and effectiveness of internet-era based services. Digital technologies and access to their personal data can enable and empower people and communities to become self-managers of their own care and ultimately to live healthier lives. 

But digital cannot be seen as a silver bullet – deeper changes are needed to rebuild people’s trust in public services to change the way they relate to and use services. The NHS must realise its potential, alongside partners in local government and the third sector, to work with citizens to improve their health and prosperity. 

8. The government’s health and growth missions are interdependent 

Poor health is primarily driven by factors outside of the NHS’s conventional reach. Improving health requires social and economic measures, such as better access to education, good work, and safe, secure housing. However, the relationship is bi-directional: improved health outcomes lead to improved economic outcomes. The government’s health and growth missions are therefore interdependent. 

The future sustainability of the NHS and wider economy depends on its ability to improve healthy life expectancy – something which straddles the government’s health and growth missions, helping establish a virtuous cycle. Effective partnerships across the public sector and beyond are needed to address the myriad environmental and social factors impacting people’s mental and physical health and wellbeing, which sit far beyond NHS care. The 10YHP should clarify the role of partners in improving healthy life expectancy and contributing to healthier, more prosperous communities. 

Delivery of a broader public sector approach to health must be supported by leadership and discipline from a mission-driven government and leaders working in partnership across health and social care. In this context, the 10YHP is not just a plan for the NHS. It must recognise where the NHS can and does play a role in socio-economic development. While it cannot boil the ocean, it must align with wider public sector policies and reforms to social care, local government and devolution. The 10YHP provides an opportunity to renew the government’s commitment to a mission-driven approach. 

The 10YP should reinforce the crucial role of ICSs in collaborating with other local partners to create a more inclusive economy and healthier communities, for example through outcomes-focused funding for work and health, such as the ICS health and growth accelerators.

Our local public service delivery model needs transformation, especially for those with the highest needs. This should be achieved through a biopsychosocial model of care delivered at neighbourhood level and supported by place. Delivering this will require a new relationship between citizens and public services, whereby health and care and broader public sector partners work in partnership with communities to design local models of delivery that respond to their needs.  The 10YHP must therefore align with the government’s work on wider public service reform.

9. Neighbourhood health responds to communities

Neighbourhood working is a place-based, community-centred approach that brings together all partners to improve health and wellbeing and reduce inequalities. It aims to address systemic pressures in health and care, declining public satisfaction with the NHS and growing health inequalities. It emphasises community-based, psychosocial models of delivery, that focus on outcomes and local leadership. The goal is to build on existing efforts rather than restart or restructure, protecting and scaling successful initiatives. 

Neighbourhood working involves:

1. Wrap-around care: Providing comprehensive support for high-intensity users, addressing clinical, social, emotional and environmental factors.
2. Promoting health and wellbeing: Building stronger relationships with communities to respond meaningfully to population needs.
3. Increasing community resilience: Strengthening trusted local organisations and improving access to services.

For neighbourhood health to thrive it must have three core components. Firstly, it should be truly community led. For example, the geographical boundaries of these services should be led by communities rather than statutory services, which should instead focus on ‘thinking neighbourhood’ in all they do and using larger infrastructure to provide resilience and expertise. The boundaries must have meaning to residents.

Secondly, infrastructure will be integrated across a wide range of partners to enable aligned commissioning and contracting, shared data, digital capabilities, population health-informed risk stratification and leadership strategies that connect neighbourhoods to system priorities. This should be driven by ICS and place integrators. This may involve, for instance, improving and developing places to convene teams and community-based services like local neighbourhood health hubs, bringing out-of-hospital health services together with local government and Job Centre Plus under one roof.

Thirdly, there should be a focus on fostering team-based care by harnessing the (clinical and non-clinical) expertise and intrinsic motivation to do the right thing on the frontline. Ultimately, integrated care requires care staff to work together towards a common goal.

The 10YHP should clearly articulate the core principles, intended outcomes and essential functions of neighbourhood models nationally. The detailed design and local delivery arrangements are best determined by each area based on its context and relationships. Various delivery models such as place-based partnerships and lead provider models may be chosen – each with their merits and drawbacks. Effective models combine local leadership with system-level support.

10. A clear plan for implementation is mission critical

The 10YHP must also be accompanied by a robust implementation plan, including metrics to support monitoring and evaluation. The failure of previous long-term plans to do so led to delays and even failures to implement the proposed changes. The implementation framework and specific steps to achieve the 2000 NHS Plan reforms were developed over subsequent months and years. This delay in providing a clear and actionable implementation plan contributed to the slow materialisation of improvements in the health and care system. 

In contrast, the mental health implementation plan for the 2019 Long Term Plan provided a clear roadmap, with clear accountability and funding lines which was integral to successful implementation of the vast majority of the plan.

As a result of the recent announcements on NHS reorganisation, it is now unclear who will be leading the implementation of 10YHP reforms. A lot of work is currently happening within ICBs, and cuts have created uncertainty and risk aversion when bold change and leadership is needed most. The 10YHP must provide clarity on this, including how local leaders will be supported to deliver change. 

The plan should set out the expectation of partnership working to deliver a set of outcomes and a clear articulation of a journey to a better destination. But local autonomy over implementation will enable change most effectively.

And unlike the 2000 Plan, the 10YHP cannot rely on significant additional investment beyond the funding awarded at the Autumn Budget, or significantly more staff, meaning that locally-led reform will have to do more of the heavy lifting.

The beginning, not the end

Publication of the 10YHP will not be the end of the journey. Several sequels will follow, including a digital strategy and updated Long Term Workforce Plan. Ensuring join-up between these plans will be crucial.

A lot is riding on the plan to create an NHS ‘fit for the future’, improve population health outcomes and bolster the economy. The government’s three shifts are crucial and need robust policy proposals. For example, rebalancing more funding towards increasing out-of-hospital capacity is essential to delivering the left shift.

Boosting productivity and supporting the workforce will be key enablers

There are several other things the plan must do to deliver on this promise. Above all, it must facilitate a shift towards a preventative and empowering model of care to ensure sustainability and prevent healthcare from consuming an increasingly larger portion of national resources. 

It must also include a devolved, more integrated system operating model, a new relationship between citizens and public services through a neighbourhood model and align with wider public sector reforms to improve national prosperity. Boosting productivity and supporting the workforce will be key enablers, and recovery and reform must be treated as two sides of the same coin. 

The government should heed lessons from previous reform efforts by developing a clear plan for implementation, with scope for local delivery.