Dazed and confused? Policy ideas behind the 10-Year Health Plan

The government published its 10-year plan for the NHS earlier this month. The plan promises to ‘reimagine’ NHS care and includes a dizzying array of proposals across more than 150 pages – spanning NHS structures, services, staffing, technology and more. 

Analysis of the plan so far has largely focused on its overall ambitions (broadly OK) and whether they can be delivered (unlikely, at best). But less has been said about the policy ideas underpinning the plan and what they tell us about its potential impact. 

Policies are guided by ideas or theories about how change happens. NHS reforms in the 1990s and 2000s, for example, were guided by the idea that market-style mechanisms – such as splitting the roles of purchasers and providers – would improve public services. More recently, policymakers have prioritised collaboration as the main route to improving care.

We identify five policy ideas that seem to guide key proposals in the 10-year plan, draw on evidence about their potential impact and stand back to see what it all adds up to for the NHS.

Five ideas behind the plan

1. ‘Strategic commissioners’ and Foundation Trusts ‘reinvent[ed]’ 

The plan marks a return to the use of market-style mechanisms to improve NHS services – similar to those adopted in New Labour’s NHS reforms from 2002. Competition and collaboration co-exist in the NHS, alongside other approaches like top-down control. But the dial is shifting away from collaboration as the organising principle for managing the health service.

Commissioning is back: NHS providers will be removed from the NHS’s integrated care boards (ICBs), and ICBs will be asked to focus on ‘strategic commissioning’ instead. This includes responsibilities to ‘actively shape’ provider markets and use ‘competitive processes where helpful’, alongside ‘clear contracting and contract management to drive change’. 

Meantime, providers will be given more power and autonomy. Revamped Foundation Trusts will be given new freedoms to retain and reinvest surpluses and borrow for capital investment. A package of other measures aims to stimulate competition between providers – for instance, with greater ‘diversity’ of providers and league tables ranking them – and use financial incentives to improve performance – for instance, through new contracting models. The logic seems to be that competition, greater freedom for providers, sharper financial incentives and clearer rules are needed to improve quality of services and value for money.

Evidence tells us previous forms of NHS commissioning have struggled to have an impact on patient care or outcomes. The same is true internationally, with purchasing organisations held back by asymmetries in information, political power and resources (for example, with hospitals having more power and resources than commissioners). There is little in the plan to suggest things will be different this time. While New Labour’s market reforms in the 2000s coincided with big improvements in NHS care, the main ingredient was likely the substantial cash injection into the system – around 6.8% real-terms growth in spending each year – that will not be available this time.

2. ‘Transparency and choice will drive performance’

A linked idea is that more information about the performance and quality of services, along with greater choice for patients, will boost performance – for instance, by making care more responsive to people’s needs. Proposals in the plan involve assessing providers and commissioners, ranking them in league tables and publishing information to make ‘performance more open to public scrutiny’ and enable people to choose between providers.

Publishing information about health care performance can contribute to improvements in care – for example, with providers wanting to engage in improvement efforts to avoid doing worse than their peers. But there is less good evidence on the impact of publishing aggregate ratings and league tables linked to overall organisational performance. Past experience in the NHS shows that ratings can improve performance in the areas measured, but can also have negative effects, such as gaming or distortion of local priorities. They are complex to design and risk concealing more than they reveal – and their impact ultimately depends on the wider context and policies used to improve performance based on the data.  

Evidence on previous policies to boost patient choice in the NHS is also mixed. In the 2000s, government mandated that patients be given choices about where they are referred for hospital treatment. Evaluation suggested patients valued being offered choice, but relatively few chose to attend a non-local provider. There were equity issues, and comparative information on performance seemed to have a relatively limited influence on decisions. Many relied instead on personal experience, loyalty to local providers or advice from their GP. 

Patient choice is already embedded in policy and vast amounts of information is already on offer to the public. It is not clear what more the new government will offer in practice. Patients may become more aware of their right to choose and equipped with better data to inform decisions. But more choice alone will not be enough to deliver the benefits claimed by government, like reducing inequalities in care. For example, more information via the NHS app will not tackle the structural issues that shape these inequalities, like some patients being unable to afford to travel for treatment or facing discrimination in their care. 

3. ‘Shift to provide continuous, accessible and integrated care’

Collaboration is not out of fashion completely. Alongside competition and choice, the plan emphasises the need for much better integration of local services around people’s needs. The idea is that this will improve care, help prevent ill health and reduce use of hospitals. 

The big proposal is for new ‘neighbourhood health services’ to join up care in the community – for example, with GPs working together alongside nurses, social care workers and other staff, as well as social support like debt advisors. Neighbourhood health centres will become ‘one-stop shops’ for care in every community. And some NHS trusts will become ‘integrated health organisations’, with responsibility for managing all health services in their area. 

These ideas build on a long history of policies designed to integrate health and care services in the NHS. This includes initiatives like ‘new care model vanguards’, ‘pioneers’, Darzi polyclinics and more. Integrated health organisations seem to draw inspiration from accountable care organizations (ACOs) in the United States – a recurring source of interest for NHS leaders.

Overall, evidence suggests more integrated care can improve patient satisfaction, access to services and perceived quality of care, but does not lead to big financial savings or reductions in hospital use. Potential benefits are modest and take time to be realised. And a mix of ingredients are needed to make it happen, including resources and policy stability. 

Research into previous versions of neighbourhood health centres in the NHS suggests that, in theory, combining general practice and other services in one organisation might lead to more coordinated care. But implementation in practice has been limited and varied, with services cut back due to issues with duplication, equity and cost-effectiveness. It is also not clear how more integrated health and social care in the community is supposed to work effectively without meaningful reform and investment in adult social care services.

Past attempts to develop ACO-style models in the NHS have fallen flat, partly because of the complexity of the procurement and contracting processes to make it happen – and partly because the context is so different between health care in the US and UK. In the US, overall evidence on the impact of ACOs is mixed, but evidence from more than a decade of ACOs in the federal Medicare programme suggest physician-led ACOs and those with a larger proportion of primary care providers tend to do better than hospital-led models. Given the plan’s penchant for policy ideas from the past, it is surprising that some version of GP fundholding – where GP groups purchase health care services, including hospital care, for their patients – has not been revitalised given its potential for exerting power on hospitals.

Collaboration will also continue in how services are planned across geographical areas – though exactly who is collaborating and what their role is will change. ICBs remain, but they now look much more like traditional NHS commissioners than system leaders responsible for bringing together organisations to improve care and manage resources (idea one). Another reorganisation of their governance and boundaries will be a distraction – particularly when local government is being reorganised at the same time – and disrupt the local relationships needed to collaborate effectively that take time and energy to develop. 

4. ‘Pushing power out to patients and the public’

A fourth idea running through the plan is to give people more hands-on control of their health and care – for example, to help people manage their health and improve how services are designed. A raft of measures is proposed including better care planning; greater use of personal health budgets (where people help direct funding to meet their care needs); giving people access to a single patient record; self-referral to more diagnostic services; and a renewed emphasis on patient feedback and use of patient-reported outcome measures. 

Some of these measures would be good for patients and staff. Personalised care planning, for example, can improve care for people with long-term conditions. But others would not. A scheme where patients will be asked to rate their care and decide whether the provider gets reimbursed in full is likely to result in already struggling NHS hospitals being penalised for issues beyond their control, like crumbling buildings or staff gaps. And many of the proposals in the plan are existing policy or the prior subject of planned expansions. 

The plan – read alongside the Dash review of patient safety – also includes changes that could erode patient voice. Governors will be removed from provider boards – a policy originally introduced to boost accountability of NHS trusts to local communities. And Healthwatch will be abolished, marking a 50-year end of attempts to give patients and communities a clear and independent route to having a greater say in how the health and care system works. Local Healthwatch organisations vary in their setup and have had to walk a tightrope between their roles as ‘strategic partner’ with a seat at the table and ‘critic’ holding NHS organisations to account. But scrapping these organisations and bringing their functions into the NHS means patients are losing an institutionally independent voice. NHS organisations have a distinctly mixed record of listening to patients and the public. It is not clear that ICBs will have the information, skills and legitimacy to play this role effectively.   

5. A ‘more devolved’ NHS?

The plan commits to ‘meaningful devolution’ in the NHS to drive improvements in care. The idea is for ‘earned autonomy’ and additional freedoms for NHS organisations deemed high-performers, accompanied by a smaller centre, fewer targets and a ‘reduction in the burden that central bodies place on systems and providers’. NHS bodies will have more flexibility to tailor policies to fit local contexts – for instance, in designing new neighbourhood health services. This mirrors broader public policy, where government has made devolution a flagship policy and is moving fast towards greater coverage of strategic authorities.

Deja vu? The NHS in England is – by design – a highly centralised health system with a strong degree of political control and national oversight. Throughout its history, national policymakers have embraced rhetoric on devolution and localism. For example, Working for patients in 1989 promised that ‘as much power as possible will be delegated to the local level’. Yet central grip appears to have strengthened over recent decades – not diminished. Policies to encourage decentralisation of decision making have been limited and local leaders have often struggled to make use of them (partly because the NHS and government’s centralising tendencies contribute to an unwillingness to exercise autonomy locally). There is little good evidence on the impact of decentralisation in health systems internationally – though data point to the potential for negative as well as positive effects.

Will NHS policymakers be able to let go this time around? Scrapping NHS England will bring the day-to-day running of the health system under closer political control. A reformed national quality board and new national service frameworks will increase central oversight. And top-down performance management is unlikely to disappear as government bears down on the health system to meet high-profile waiting times targets and restore financial balance.

Do the ideas add up?

The 10-year plan is based on a mix of ideas about how the health service might improve. Many of these ideas still need to be fleshed out – for instance, how power will really be devolved from central government to local NHS organisations and communities. And others are unlikely to deliver the benefits policymakers expect. For example, more integrated care would be better for patients, but is unlikely to save money or radically reduce hospital use.

A bigger issue is that these ideas pull the health system in different directions. A mix of measures rely on competition and choice to stimulate improvements – for instance, by encouraging a ‘plurality’ of providers, ranking them in league tables and asking patients to shop around to get the best care. Yet the plan also suggests that large integrated providers running services across whole areas of the country will become the norm in future. Or is it ICBs that are supposed to be the ‘strategic’ leaders of the system? Meantime, various proposals focus on devolving power and putting it in the hands of patients, yet the plan also includes measures that erode patient power and centralise NHS decision making. Standing back, the plan has lots of ideas, but lacks an overarching theory about how the NHS should work.

Faith in new technology might be the closest thing to it. Better data and new technology, including artificial intelligence (AI), is seen as a route to achieve almost all the big ideas in the plan – for example, putting more power in the hands of patients and helping deliver new neighbourhood health services. New technology offers hope – for instance, in reducing administration for clinical teams – and the plan is right that government should play a central role in steering new technology to benefit patients and the NHS. But the plan risks techno-optimism. AI cannot fix underlying structural issues, like constrained resources for the NHS. And new technologies can widen inequalities if wealthier groups make better use of them.

The experience of past long-term plans in the NHS suggests that the plans themselves have been the starting point for reform, not the final word. The detail comes later – in planning documents, guidance and the way national NHS leaders manage the system in practice – and changes in direction are common. A clearer guiding theory for how change will happen is now needed to translate the plan’s ideas into tangible improvements in care. Guidance for how the NHS is expected to implement the plan will need to help local leaders navigate the trade-offs between the varied objectives and policy approaches within it.