Priorities, trade-offs and power: where will the 10-year health plan land?

The NHS has a long history of producing long-term plans. The government’s three shifts – moving care from hospitals to communities, making better use of technology, and focusing on preventing sickness, not just treating it – are positive statements of intent. But they are not new, and the impact of past national plans with similar ambitions has been limited. The government faces challenging decisions about how to transform health care delivery with the NHS under severe pressure. Here we outline six questions that those drawing up the NHS 10-Year Health Plan will need to tackle:

1. How will the plan connect with the overall vision for health?
2. What key trade-offs will the plan make?
3. How will the plan aim to make change happen in practice?
4. Where will the power lie?
5. Can the plan balance the need for quick progress without detracting from long-term change?
6. How will the plan secure the future of the NHS in a time of scarce resource?

1. How will the plan connect with the overall vision for health? 

Despite positioning their mission-driven government as a radical change, Labour’s overall vision of a ‘reinvented’ health system appears to have been supplanted by more traditional priorities. With the 10-year health plan focusing on the NHS, where does that leave the government’s overall vision for health? 

The government has established several policy processes that will have major implications for the NHS and will need to demonstrate how these pull together to offer a comprehensive vision. Most immediate is the upcoming Spending Review, expected in June. Others are working to longer timeframes, including the Casey commission into adult social care, plans for mayoral devolution, the refreshed NHS workforce plan and a ‘Life Sciences Industrial Strategy’. Then there are all the existing plans, including targets for the NHS to reach net zero by 2040, where delivery needs to happen within the decade. 

How will the government ensure these changes work together to achieve overall ambitions for the NHS as well as wider health?

2. What key trade-offs will the plan make?

Past plans have often floundered by seeking to improve everything, everywhere, all at once. 

The top political priority is elective care, but this appears out of step with ambitions to shift care from hospital to community and do more on prevention. Achieving the 18-week standard for elective care will require substantial resources, with trade-offs likely to include slower progress on improving services like general practice and emergency care. 

Improving primary care is a the public’s top priority, and although the NHS’s current model of general practice is well-designed to offer high-quality care, under-resourcing and staff gaps have contributed to worsening access and poorer continuity of care for patients. Priorities for policy include recruiting and retaining more GPs, better integrating GPs and the growing number of other staff working in primary care, fixing pervasive ‘operational failures’, and more.

Given current pressures and funding constraints on the NHS and public sector more generally, where will the plan land on setting clear headline priorities?

3. How will the plan aim to make change happen in practice?

Another common flaw in previous plans was to focus on the ‘what’ without paying sufficient attention to the ‘how’.

Unlocking the benefits of reform and investment will require a clear approach to building improvement capability (enabling staff to develop and deploy the skills and knowledge necessary to improve the quality and safety of care, such as change management or data analysis). Buying new technologies is of little use without this. The government will also need to ensure national policy levers align behind ambitions. For instance, current national NHS performance targets are skewed towards hospitals, which runs against two out of the three shifts.

Although the government’s approach to making change happen in the NHS is still emerging, there have been mixed signals. Some positive signs include establishment of a working group on ‘mobilising change’ to inform development of the plan, a clinically-led quality strategy in development, the launch of NHS IMPACT, and stripping back national targets in the planning guidance and general practice incentive scheme. But these feel at odds with other decisions: the return of league tables, threats of sackings for NHS managers, not to mention a focus on structural change with the scrapping of NHS England. 

Will the plan offer consensus and detail on the ‘how’? 

4. Where will the power lie? 

Changes to national bodies and local organisations will fundamentally reshape how decisions are made in the NHS. The sudden abolition of NHS England has created uncertainty over who is responsible for its long list of functions and what the new regional tier of the NHS will look like. Halving the combined staff of NHS England and the DHSC will cause disruption and jeopardises institutional memory. Other arms-length bodies may also be at risk, and ICBs have been told to cut their costs by 50%, likely leading to mergers. 

Will ministers choose to take back control of NHS England’s functions, delegate them to a different set of national or regional bodies, or use this as an opportunity to transfer power and resource to local leaders? And what will the future hold for ICBs? Newly empowered to set local priorities, commission more strategically and shape how they implement the plan’s vision of the future? Or stripped back, merged and left undermanaged and undermined?

5. Can the plan balance the need for quick progress without detracting from long-term reform? 

Alongside ambitions for longer term improvements to health services and ultimately population health, the government has a political imperative to deliver rapid improvements that the electorate will notice before the next election. 

History tells us that short-term targets often trump longer term ambitions. For example, despite a legislative mandate and strong motivation from NHS leaders to reduce health inequalities, short-term political priorities have dominated, with targets for improving hospital performance crowding out work to tackle health inequalities. Past integrated care initiatives tell a similar story. 

How will the plan reconcile competing timelines for reform?

6. How will the plan secure the future of the NHS in a time of scarce resource?

Keir Starmer has spoken of ‘great forces buffeting and impacting on the lives of working people’, positioning the NHS as ‘fundamental to our security’ at a time of global uncertainty. This chaotic backdrop of growing political polarisation, a stagnant UK economy, and pressures to increase defence spending will make delivering on a long-term plan for the NHS harder than ever.

Labour’s NHS reforms of the 2000s were backed by real-terms funding growth of almost 7% a year and a large increase in the NHS workforce. How will the government secure the necessary – and substantial – resources needed to make reform possible?

Join the conversation

Answering these questions will be difficult, but the 10-year health plan is an opportunity to build on the NHS’s strengths to deliver enduring change. Catch up on our recent webinar when we explored some of these challenging questions further and discussed the top priorities for the plan’s success.