The 10-Year Health Plan: Will It Work?

Labour campaigned on a promise to improve the NHS and it was a big winner in the spending review. After a year of formulating its reforms, the government has at last unveiled its blueprint: the 10-Year Health Plan for England. Here, three of the country’s leading health policy experts review the contents.

Mark Dayan of the Nuffield Trust assesses whether Keir Starmer can repeat Tony Blair’s success in driving up satisfaction rates with less money, Siva Anandaciva of the King’s Fund gives the context of the plan’s predecessors, while the Health Foundation’s David Finch finds words louder than actions on the shift from treatment to prevention.

Satisfaction not guaranteed

The NHS Plan the New Labour government introduced in 2000, and updated in 2002, marked the dawn of the most remarkable period of improvement, expansion and public affection that the English health service has ever seen. It is the triumph of plummeting waiting times that most people remember, but this was also a time of rapid improvement in infection control and clinical outcomes. Public satisfaction rose from 38 per cent in 2001 to 70 per cent in 2010, hitting the highest level in the 40-year history of the British Social Attitudes survey.

Last week’s 10-Year Plan sets its sights on a similar transformation at a time when public satisfaction is at an all-time low – just 21 per cent. The political importance is similar, if not even greater, with the party again elected by voters who wanted a better health service above all else, but this time languishing, not leading, in the polls.

The headline target is the same: less than 18 weeks for planned care. Many of the tools are similar. The plan anticipates the return of competition between trusts vying for autonomous foundation status, with a huge array of financial incentives bribing and cajoling them to deliver its commitments. It revives the faith in the choice of patients as consumers to drive up standards which was such a well-worn theme for Tony Blair’s governments.

But can Labour really earn such a dramatic rise in public confidence again?

There are reasons for optimism. The British Social Attitudes survey suggests hospital waiting times, getting a GP appointment, and increasing the number of staff are the main priorities of the British public. Improvements should be possible in all three.

New Labour inherited an NHS whose workforce was barely growing – the number of nurses and midwives grew by only a fraction of a per cent, equivalent to just 415 extra full-time workers in the three years up to 1998. The government today inherits a workforce boom driven by international recruitment. In the three years up to March this year, the number of nurses and midwives grew by 15 per cent, equivalent to 50,000 full-time workers.

A slump in productivity, possibly partly due to the sheer number of brand new NHS staff, meant this had limited effect in taking people off the waiting list or out of A&E departments faster. But there are signs this is recovering. If that continues, people should see the reality of an NHS which actually does have more staff, delivering more.

Even before Labour took office, the waiting list had begun to stabilise, and the “median” wait – the man or woman exactly in the middle of the queue – had begun to fall.

General practice is more complicated. Its workforce has grown, and appointment numbers have increased, but perhaps because many appointments are virtual and many new staff are not doctors, this has yet to deliver improvements in satisfaction.

But this is one of the areas where the plan is relatively strong, with aspirations on funding and access that come alongside a pledge to look at the formula that distributes money – possibly tackling the long-standing NHS shame that the UK’s poorest areas on average receive a worse service.

The number of trainee GPs has risen quickly in recent years. If the plan follows through on its promises to shift funding to general practice and offer a range of business models, the potential is there to turn around a long-term fall in full-time, fully qualified family doctors, the missing piece in an otherwise growing workforce.

So far, so good. But the government is facing two powerful new headwinds. The first is the changed financial climate. With a growing economy in an age of overbearing western military power, the governments of the early 2000s splurged on healthcare. In the three years from April 2000, the English NHS budget rose by 37 per cent. In the three years set out in the recent Spending Review, the health budget will increase by less than 10 per cent – and the service started out already financially underwater.

The government’s MPs have blocked welfare cuts, while its own promises block most tax rises. Those pledges may not hold, but the British Social Attitudes survey shows the public are divided about whether taxes should be raised to fund the NHS. And while most people agree that the NHS needs more money, most people disagree that it spends the money it has efficiently. A government focused on wooing voters away from Reform UK’s poll surge will note that their supporters tend to be the most suspicious about NHS inefficiency, and the least enthused about spending more.

Without enough money to pad out the hard edges, reform and change is much more difficult.

The pledge to reform general practice funding so that it goes to more deprived areas is long overdue. The government will deserve the political credit for helping “working-class areas” if it finally tackles it. But taking funding and therefore staff away from wealthier areas is political poison. Extra money is the only possible tool.

The same issue applies to deploying the plan’s battery of new financial incentives for the NHS. These are meant to come alongside a crackdown on NHS trusts’ regular habit of overspending their budget. The logic is that they will be driven to compete for money – and therefore pushed to deliver the goals to earn it, from caring efficiently for people across a year to delivering a good experience so that patients, effectively, choose to tip them.

But this is a race that can have no losers. No town or region is going to accept a bankrupt hospital trust. The prize money will be severely limited by the political need for everyone to finish the race.

For the NHS, funding above all means staffing; the pay bill accounts for easily the majority of the budget. While numbers overall have grown healthily, this workforce is not the one required for the plan’s pledges to scale up work outside hospitals, or for under-served clinical areas. The number of district nurses has plummeted.

The first resort of the NHS when it needs more of some type of staff suddenly, while spending as little as possible, has always been immigration. Wave after wave of shortages have been resolved by doctors, nurses and others moving to the UK. This was invaluable to New Labour’s expansion of services, as it was at so many times in NHS history, but is ruled out in the new plan, which doubles down on a pledge to greatly cut the proportion of international joiners.

The second problem is the state of public health and the public realm. New Labour neglected serious social care reform, and the current government is at best slow-pedalling. The sector is in a grim position, unlikely to be able to do much more to keep people well or receive them faster from hospital. The same is true of much else that supports health, from housing to transport.

The public health budget, not the NHS, covers the services which tackle ill health most directly, such as drug and alcohol treatment. It recently received a small increase in real terms funding for one year, after a decade of austerity. But the plan carefully avoids promising even a penny more than that.

Some mixture of weakened public support and the global pandemic has caused a shocking recent drop in “healthy life expectancy”: people are, on average, unwell for longer than they were a decade ago. Yet even as people have grown sicker, the UK’s post-war baby boom means that the number in older age groups continues to climb, just as it has for several decades.

A third problem is one that the government has created for itself: the weight of expectations.

We are promised that the dramatic improvement in waiting times seen in the 2000s, which previously took years to build up to, will be repeated – with a closer deadline. This alone may be deliverable with focused effort.

However, the plan promises it alongside an explosion of pledges on digital access and choice, and a shift from hospital to community services encapsulated in “neighbourhood health centres”. This, too, has echoes of New Labour and its policy of “polyclinics”, which similarly aimed to turn the abstract vision of connected care keeping people well into tangible buildings, full of different health professionals. But New Labour only began to attempt this in 2007 – a decade into its mostly well-funded rule.

The 10-year duration of the plan is no protection. Many of the key commitments pile up at the start. There is a commitment that shifting money away from hospital care will happen within three to four years – mostly to neighbourhood health services providing general practice, ongoing care for long-term conditions, and preventive support. But well within that timeframe, the government has also committed to shorter waiting times at A&E and for planned care. These depend on a significant increase in the availability of hospital care.

In several places in the plan, there is a hope that more care in the community will mean the people who receive it – often with several serious long-term illnesses – get better so quickly that very soon fewer will need treatment in hospital. But robust evaluations often struggle to find any such effect in the short term. These changes are very difficult, and better care outside hospital can just as easily uncover new problems to treat.

One important question is how brave ministers will be in identifying the things the NHS cannot do. In the 2000 Plan, the role of the new National Institute for Health & Care Excellence (NICE) in blocking less efficient new treatments was emphasised.

That commitment to tough and sometimes unpopular decisions is revived in NICE’s expanded role, set out in the plan: to go back through medicines approved over the last 25 years to withdraw its seal of approval from the least efficient.

But this will not always be popular – with patients or with politically powerful bodies. Ministers are locked in difficult negotiations with the pharmaceutical industry over the general ‘VPAG’ cap on branded medicines spending. The entire government faces pressure from Donald Trump to spend more on medicines on multiple fronts, politely negotiated and otherwise. Both the pharmaceutical industry and the United States government have powerful tools to strike back, from investment ebbing away to tariffs. The political pleasure of promising more has been drawn out first, with much of the pain of doing less still to come.

There are reasons to expect this Labour government to oversee an improving NHS, as its predecessor did 20 years ago. But the promises have got bigger while the pocketbook has got smaller – and the results may be uncomfortable to explain.

Mark Dayan is head of public affairs at the Nuffield Trust

Everybody has a plan...

So, here it is. A year after taking office, and after months of focus groups with the public and NHS staff, the government has published its 10-Year Plan to reform the health service in England. As a colleague of mine said, the NHS tends to get a new 10-year plan every five years. So, let’s take a quick detour through previous plans to help us understand what makes this latest plan any different.

If we exclude the national response to Covid-19, there have been five or six major attempts to reboot, reset and revamp the English NHS over the past 25 years:

• The NHS Plan under New Labour (2000)

• High-Quality Care for All: The Next Stage Review, aka the Darzi Review (2008)

• Equity and Excellence: Liberating the NHS, aka the Lansley reforms (2010)

• The Five-Year Forward View (2014)

• The NHS Long Term Plan (2019)

Let’s start by going back to the 2000s. During the ‘most expensive breakfast in history’, then-prime minister Tony Blair promised to raise UK health spending up to the EU average by 2005. New hospitals were built with private finance, market-style reforms were introduced, new staff were hired, and new performance targets were introduced. And over time, waiting times fell and public satisfaction with the NHS hit new highs.

Roll on a few years, and the eminent surgeon Lord Darzi was brought in to review the NHS and propose the ‘next stage’ of its journey as a health system. His review tried to put quality of care at the heart of everything the NHS does. So, for example, some payments to hospitals would be conditional on hitting quality targets and there would be far more transparent data on how the NHS was performing. Polyclinics would be introduced to offer a wide range of out-of-hospital services under one roof. And Fit to Work services would try to get people back into work after periods of ill health.

The Darzi plans would be hit in 2010 with the double whammy of the Great Financial Crisis and a change in government. And then came a political curveball in the shape of Andrew Lansley’s plans to ‘liberate’ the NHS. A raft of new legislation would extend the New Labour market-style reforms, abolish swathes of national and local NHS bodies, and create a swathe of new ones to replace them.

But just one year after becoming law in 2013, Lansley’s reforms would be reversed. The new chief executive of NHS England, Simon Stevens, published the Five-year Forward View for the NHS, which would put collaboration – not competition – at the heart of how services should operate. Rather than competing for patients and income, NHS hospitals would be encouraged to partner with neighbours to share resources and improve patient care. The NHS Five-Year Forward View was a fundamental reset in how the NHS was organised, to the extent that the succeeding NHS Long-term plan in 2019 was basically a continuation of the same strategy.

And now, just six years after the last 10-year NHS plan, we have the Labour government’s 10-Year Health Plan. There is lots in this plan that astute use of ‘Ctrl+F’ would find in its predecessors. And perhaps even more than that, there are parts of this plan that have the feel of the unfinished revolution – not least because many of the people who had a hand in writing it were ministers or civil servants in the Department of Health 25 years ago, who saw their plans only half-delivered.

So, in the new plan we see a greater focus on keeping people healthy, rather than treating them when they’re ill. We see a push to tackle the obesity crisis across the UK. We see a desire to boost patient choice and put more power in patients’ hands. We see a push to get more people out of ill-health and back into work – because a strong economy requires a strong NHS (and vice versa). And we see, once more, a commitment to a paperless NHS.

The same things that were missing from previous health plans are missing still. The plan nods to the need for a strong adult social care system without providing any detail on how that will be achieved. And it focuses on a new strategy for the NHS, when the health services we receive in reality are delivered by a panoply that includes pharmacies and opticians, independent hospitals, community groups and social enterprises.

But if there is much in the plan that feels like it came from healthcare policy Vinted, there are also three ways in which this plan feels different from its predecessors.

First, this is the first NHS plan where science and technology are more than a subplot. The government is betting the farm on technology being the game-changer that means staff can work more efficiently, with AI scribes taking notes for them; patients can use the NHS app for clinical advice and real-time information on which services are available to us; an offer of universal genetic testing for newborns; and through all these actions a hope that the NHS can become far more productive and effective at maintaining our health.

Second, this is another plan that wants to shift the balance of care away from hospitals, but maybe this time with some teeth. Over the coming years, the government plans for the share of spending on hospital care to fall as a new Neighbourhood Health Service is steadily constructed. Though the government has declined to say just how much less will be spent in hospitals, or by when, or what the impact will be – teeth then, but milk teeth rather than adult canines.

Put those two things together and you get the final striking thing about this plan: it is an NHS plan that doesn’t obviously come with a promise of more money and more staff to deliver it. The subtext of today’s plan is of tough choices and trade-offs. The government wants to invest in neighbourhood health centres, which means fewer hospitals can be built or refurbished. The government wants to prioritise waiting times for knee and hip operations, which means other areas of hospital care like A&E departments will improve at a far-slower pace. And the current long-term plan to grow the NHS workforce from 1.4 million now to 2.3 million by 2036 will be pared back. This plan then is an altogether different proposition to previous promises of milk and honey.

Take a step back and look at NHS plans, both past and present, and you can see just how much they are a creature of the political beliefs at the time – from new public management to deliverology, to systems thinking and then mission-led government. You see how they are often politically fragile things, where even a change of secretary of state, let alone a change in government, can mean that ‘hardwired’ proposals can be dropped like a bad habit (and conversely, some of the best proposals from previous plans can stay evergreen). And you see just how often even the best-laid plans can be derailed by a volatile world filled with industrial action, cyber-attacks and global pandemics.

The 10-Year Health Plan paints a picture of a health service in 2035 that is prevention-focused, community-based and technologically enabled. It meets a system in 2025 riven by industrial action and staffing shortages, paper-based systems and endemic financial deficits. That surely wasn’t in anyone’s plan.

Siva Anandaciva is director of policy, events and partnerships at the King’s Fund

Missing in action

The 10-Year Health Plan promises a shift from sickness to prevention. In doing so, it provides some promising hints and continued gradual progress in tackling risk factors – smoking, poor diet, alcohol misuse and lack of exercise – that can help to improve health. But it is ultimately a plan for the NHS, not a plan for improving the health of the nation through a more fundamental preventative shift. Its focus is on mitigating the consequences of sickness, rather than tackling the underlying drivers and introducing enabling structures and mechanisms to prevent ill health.

A recommitment to tackling the UK’s deep and entrenched health inequalities and the target to reduce the gap in healthy life expectancy between regions is welcome, but the plan lacks the cross-government commitments needed to make sustained progress towards these goals. That’s a problem when life expectancy improvements have stalled, and life expectancy is now around three years lower than it would have been if pre-pandemic trends had continued. The health mission was a potential vehicle for such an approach, but it has gone missing in action. With only two explicit mentions of the health mission, there is an increasing question about what has happened to the mission-driven approach to government.

A reference to developing a suite of delivery indicators to track progress on improving the nation’s health, working with the Office for National Statistics, is a positive sign that there will be some focus on addressing more upstream outcomes that shape our health, such as having a suitable home to live in, decent employment and an adequate income. The concern is how and when the broader action needed to improve health will happen. The Spending Review did commit to significant investment in housing, but the fiscal picture looks increasingly tight, and we are yet to see meaningful action to reduce child poverty, which has such an impact on health.

The plan’s ambitions on prevention are made clear by the proposed action on risk factors – a mix of policies already underway, gradual progress in some areas, but ducking the big ambitious calls that would really make a difference. There was the very welcome commitment to progressing the Tobacco and Vapes Bill, along with support to stop smoking and the strengthening of the ban on smoking in public places. But these reflected existing plans.

With obesity, there were more signs of progress – if gradual. Plans for advertising restrictions, banning under-16s from buying energy drinks and updates to the national planning framework and soft drinks levy were welcome and important restatements of existing policy. A new healthy food standard, applying to major food businesses, like supermarkets, aims to shift sales towards healthier options for consumers is a sign of progress. It must be ambitious in the speed and scale of a shift towards healthier food purchases, and enforcement will be key – past reliance on industry self-regulation has been largely unsuccessful.

But this needed to be part of a much wider package of measures to tackle obesity across the population, including: investment in local public health services, further advertising restrictions on junk food in public places, bolder use of tax and regulation, learning from the successful example of the soft drinks industry levy, and, of course, reducing poverty so that people can afford to eat well. What we got instead was a commitment to increasing access to obesity jabs.

A planned physical activity strategy, with increased investment in sports facilities, will help and is an important part of encouraging healthier lifestyles, but again the bolder vision would have included explicit plans to ensure that the built environment supports people to be more active. The opportunity for doing so is there, with £15.6bn committed to city region transport settlements at the recent Spending Review.

Where action on risk factors is particularly lacking is in relation to harmful alcohol consumption. Alcohol-related death rates have increased by 50 per cent over the last decade, but we still don’t have a strategy. A commitment to better health labelling and encouraging consumption of low or no alcohol products represents a failure to bring forward the action we know works. Minimum-unit pricing in particular was omitted – a policy that has been shown to reduce alcohol deaths and reduce inequalities.

The public health grant, which provides local authorities in England with £3.9bn a year to provide health supporting services such as sexual health clinics, drug and alcohol support and health visitors, was at least referenced, though this is small consolation after a 26 per cent per capita cut to the grant over the last decade. There is no commitment to a further boost beyond the small real terms boost for 2025-26.

With NHS England’s budget set to increase by an average of three per cent a year in real terms until 2028-29, holding the public health grant at its current real-term level will mean its value expressed as a share of the NHSE budget will continue to fall – a symbolic shift away from prioritising prevention.

Local government plays an important role in shaping and supporting the health of its population, which goes well beyond the public health grant. Neighbourhood health centres – which aim to shift care to the community and away from hospitals – are at the heart of the plan. On the face of it, these are an opportunity to start joining up some of these services with the mention of including debt and employment services alongside healthcare provision. But these are similar to “Darzi centres” from the 2000s, which faced significant challenges to effective implementation.

Missing was a formal reference to the health duty for Strategic Authorities that has been proposed in the English Devolution White Paper – another missed opportunity to tie in and recognise the cross-sector action needed to improve health. There could also have been consideration of mechanisms to start tracking preventative spend, to ensure resources across the health and local government systems are being used effectively.

Employment support and efforts to tackle numbers of people out of work due to their health are a prime example of where success will come from local government and health services aligning and working together to deliver interventions. What we get from the plan is a reference to a number of existing pilots and schemes, all doing something slightly different in this space and at a small scale. While the continued funding of them, and the recognition of their importance, is welcome, this is far from a step change. The multi-billion cost of ill health to the economy dwarfs the resources being allocated to preventing it.

The preventative shift that the 10-Year Plan is meant to herald feels more like gradual progress on what is already in place. Much of that is positive and moving in the right direction. But the plan lacks the overall ambition, commitments to systemic change and funding commitments to enable a true shift to prevention that can keep people in good health in the first place and reduce inequalities.

David Finch is assistant director at The Health Foundation