Labour’s 10-year plan for the NHS in England: what should it look like?

The UK government is producing a 10-year plan for the NHS in England.¹ The health service is in crisis after a decade of austerity, the COVID-19 pandemic and political failures since 2010.² Public finances are constrained.³ And the NHS, like health systems across Europe, is facing twin pressures from labour shortages and a population ageing in poor health.⁴ The cracks are evident – for instance, in long waiting times for hospital care – and patients are suffering.^5,6 

The new government has promised to recover services and ‘transform’ the NHS to make it ‘fit for the future’.¹ The 10-year plan aims to tell us how, including reforms to achieve three shifts in NHS services towards more community-based care, prevention of ill health and use of digital technology.

The NHS has a long history of producing long-term plans. A national 10-year hospital plan for the NHS was developed in 1962, for example, alongside plans for community care.⁷ The government’s objectives – such as shifting more care out of hospitals – are nothing new. We analyse previous NHS long-term plans, draw on relevant evidence on NHS reform, and consider the context facing health services in England to identify priorities for the latest NHS plan due in spring 2025.

The experience of three major long-term plans since 2000 (Table 1) – the NHS Plan in 2000, the Five Year Forward View in 2014 and the NHS Long Term Plan in 2019 – provide some pointers for policy today. 

The plans feature familiar themes including tackling long waiting times, strengthening prevention, coordinating care for people with chronic conditions, and how the NHS is organised to do it. 

But the context for the plans matters almost as much the content. The NHS Plan in 2000 came after Tony Blair’s first Labour government had committed to substantial increases in NHS resources, designed to bring spending up to the EU average. The plan showed how the money would be spent to boost capacity – more doctors, nurses, equipment, appointments – and the standards of care people could expect. It went alongside a wider strategy to reduce health inequalities in England,^14,15,16 including public spending and new social programmes, and was introduced off the back of a growing economy. 

No such luck in the 2010s. The financial crisis in 2008 and new Coalition government in 2010 changed the weather for the NHS. A major structural reorganisation in 2012 – the ‘Lansley reforms’ – distracted and fragmented the health service while public spending slowed¹⁷ The Five Year Forward View in 2014 was developed at arm’s-length from government, by NHS England, to paint a picture of how the health service could change – more integrated, preventive, efficient – if politicians provided additional investment. Extra money followed. But a decade of austerity meant growth in NHS spending still fell below the long-run average¹⁸ and investment in wider public services was weak.¹⁹ The focus on developing new care models quickly shifted to dealing with financial pressures,²⁰ and funding earmarked for redesigning care was used to fill provider deficits.²¹

Evolving plans and patchy implementation

Plans have been a starting point for reform, not the final word. Major components of New Labour’s reforms, such as payment by results, came after the NHS Plan. The NHS Long Term Plan in 2019, meanwhile, built on the NHS Five Year Forward View before it and set the stage for major changes to NHS legislation – including the formal introduction of integrated care systems – in 2022.

The prevailing ideas guiding reform have shifted too. Labour’s NHS reforms in the 2000s were fuelled by faith in market-style incentives, such as provider competition and patient choice, combined with a heavy dose of hierarchy through top-down targets and performance management.²² Lansley’s reforms in 2012 strengthened these market mechanisms on paper, but – in reality – NHS leaders emphasised collaboration between organisations to improve care and manage resources instead.²³

Implementation and impact have varied. Labour’s NHS reform programme in the 2000s contributed to major improvements in the health service, including bringing down long waiting lists.²⁴ But Labour’s planned reforms, such as to expand patient choice, were only partially implemented²²and progress was constrained by repeated organisational restructuring and persistent weaknesses in NHS commissioning.²⁵ The Five Year Forward View in 2014 led to 50 local programmes testing ‘new care models’ – including to join up general practices, hospitals and social care. But impact was mixed²⁶ and spreading new models of care proved challenging.²¹ Indeed, better integration of health and social care services has been a consistent and elusive objective of national NHS plans since at least the 1970s.²⁷ The NHS Long Term Plan led to some changes in NHS structures but was largely overtaken by events – COVID-19 – from which the NHS is still recovering.²⁸

The context for the latest plan combines a little of the 2000s and 2010s. Like the 2000s, a Labour government inherits long waiting lists and promises to rebuild the NHS. But like the 2010s, resources are constrained and the economy sluggish. The 2020s bring their own challenges too: rapid growth in data and technology, such as generative AI, present risk and opportunity. So what should the plan do?

Provide clarity and hope

Government needs to provide hope that things will get better. Labour’s political narrative on the NHS so far has emphasised the depth of the problems facing the health service. The health secretary has declared the NHS ‘broken’.²⁹ The story now needs to turn to the strengths of the NHS and a clear direction for change. Labour’s three shifts1 are vague and could be filled with almost anything. 

Public satisfaction with the NHS is at an all-time low³⁰ and NHS staff are experiencing high levels of stress and burnout.³¹ Any vision for the future needs to be combined with confidence it can happen. Recent deliberative research with the public suggests a mix of approaches could help build confidence in government’s plans for the NHS – including greater devolution of decision making and using public engagement to inform decisions.³² The government’s programme of public engagement on the plan³³ may therefore help. But Streeting’s ‘targets and terror’-style interventions, such as league tables and threats of sacking NHS managers, risk undermining the support needed within the health service for implementing trickier changes.³⁴

Set actual priorities

The tendency for NHS plans is to say that everything will get better, everywhere, all at once. But if everything is a priority then nothing is a priority. And there’s not enough money to do it all anyway. Health spending is set to increase at around the long-run average to 2026, but growing pressures – for instance, from population changes and pay increases – will eat up a large chunk of extra spending.18

Improving primary care should be high on the list. General practice is the foundation of the NHS and changes in the burden of illness will increase pressures on primary care in future.³⁵ Yet more people are struggling to get GP appointments and continuity of care appears to be declining.³⁶ These problems are worse in more deprived areas.³⁷ Priorities should include recruiting and retaining more GPs, better integrating GPs and the growing number of other professionals working in primary care, improving systems and processes to reduce the ‘operational failures’ holding back GPs,³⁸ ensuring financial incentives for GPs promote high-quality care and more. This will take investment. Like many before it, the new government has pledged to shift resources from hospitals to services in the community. Yet the natural flow of resources in the NHS since 2000 has gone in the other direction.³⁹

Improving care in NHS hospitals risks remaining the overriding policy priority. Keir Starmer’s six pledges for change by the end of the parliament include one target on the NHS: for 92% of patients to wait no longer than 18 weeks for routine hospital treatment.⁴⁰ The NHS has not hit this target since 2016 and making it happen will require substantial resources. The trade-offs will likely include slower progress on improving care elsewhere, such as in primary care and hospital emergency departments.

Focus on how, not just what 

Recent NHS plans have been weak on how care will improve.⁴¹ What the NHS should look like in future is important – for instance, people better supported to manage their health and patients’ time not wasted navigating confusing services and telling their story over and over.^42,43 But changes in how care is delivered depend on changes in how the system works. This includes how resources are allocated, services are paid for, care providers are regulated and more. Otherwise, a gap emerges between rhetoric and reality – for instance, in policy to shift care out of hospitals.³⁹

Making change happen in practice is not simple. The NHS is a complex system with multiple parts (like hospitals, general practices and all the people in them), which interact with each other and their wider context (like other public services and communities), often in unpredictable ways.⁴⁴ One pull on a policy ‘lever’, like new targets for treatment, will have a knock-on effect elsewhere.⁴⁵ So policy changes need to work in concert to guide the system in the desired direction.⁴⁶

Some NHS policy levers are ripe for reform. National NHS performance targets shape what gets done but are skewed towards hospitals.⁴⁷ The NHS payment system is a complex mess of conflicting incentives. Quality regulation is publicly collapsing and needs rethinking alongside evidence from other countries and sectors.⁴⁸ But none of this will make much difference unless policymakers strengthen the NHS’s capacity to improve in response – for instance, by developing the capabilities to identify, implement, test and spread promising service changes in different contexts.⁴⁹ This includes dedicated time and resources, skilled managers, data and data analytics, peer support and more.

A stronger national approach is needed to shape the development of new technology to benefit the NHS – not just to ‘shift’ towards using it. For example, AI can be used to help diagnose disease but risks widening inequalities.⁵⁰ As a national health service with a single payer structure, the NHS could fund and evaluate totemic innovations in a coordinated and systematic way. One priority should be how new technology can free up clinicians’ time to care for patients – for instance, by automating some admin tasks.⁵¹

Back it up with investment 

Labour has emphasised the role of policy change – ‘reform’ – over investment in its NHS plans.⁵² Disentangling the effect of overlapping reform approaches, like new targets and money, is difficult. But there is no escaping that investment is often a major driver of NHS improvement. Labour’s last round of NHS reforms in the 2000s was backed by real-terms funding growth of almost 7% a year and big growth of the NHS workforce.^53,54 Policy change – like targets and performance management – helped make better use of extra spending.⁵⁵ But the story makes little sense without the investment.⁵⁴

Capital investment – in buildings, equipment and IT – will be essential this time around. Improving care and productivity is hard in crumbling buildings with weak capacity and outdated equipment.^56,57 Yet the NHS’s maintenance backlog – including urgent repairs to avoid serious injury or major disruption – stands at £13.8bn.⁵⁸ UK health care capital investment has been below comparable countries for decades.^59,60

Combine with wider policy change 

Improving health and the NHS depends on broader policy changes outside the health service. The adult social care system in England is a threadbare safety net in need of investment and reform.⁶¹ Many people go without care they need and levels of poverty among staff are high.⁶² These problems affect the NHS – for instance, by increasing pressure on hospitals.⁶³ Government has promised a plan for reform after an independent review,⁶⁴ which may take several years. This increases the likelihood – already high based on experience since the 1990s – that reform is delayed or ducked again.⁶⁵

A cross-government strategy for reducing England’s vast health inequalities is also needed. Health and inequalities are shaped by social, economic, environmental and other factors, which are influenced, in turn, by policy changes across sectors.⁶⁶ Evidence suggests that England’s last cross-government strategy to reduce health inequalities in the 2000s contributed to reductions in health inequalities over time.^67,68

The problems in the NHS are so deep that a single parliament is not enough to fix them. In the short-term, improving access to care – not just in hospitals – is essential to maintain public confidence in the health service and stem avoidable harm. This will be hard enough. But the bigger challenge will be doing so while making progress on the more fundamental changes needed to improve health longer term – for instance, by investing in primary care and strengthening public health policies. 

Standing back, the new government’s approach to driving improvement in the NHS is yet to emerge. Streeting’s focus on league tables⁶⁹ and capital investment for higher performing trusts,70 for example, sits oddly with the current NHS structure based on organisational collaboration.²³ How the government’s devolution agenda⁷¹ fits alongside a highly centralised NHS is unclear. Without a guiding theory for how change will happen, reform risks being incoherent and blown off course. And the wave of new technology that could transform the health care system in future risks steering rather than following the NHS’s agenda.

Whatever the guiding ideas, a persistent part of the political approach to managing the NHS has been organisational restructuring.⁷² The latest round in 2022 created 42 area-based integrated care systems, and gave them responsibility to improve care and manage resources. However tempting tinkering with these structures may seem to ministers, it will cost time and money.⁷³ The NHS has neither to waste.