The 10 Year Health Plan: our recommendations

Our health and care system is in crisis and at risk of becoming financially and operationally unsustainable. The King’s Fund supports the need for transformational shifts in how health and care services are planned, delivered and accessed.

The government has a mission to improve health, and as part of that is working to produce a 10 Year Health Plan for health in order to reform the health system, structured around three shifts: from a service treating sickness to one focused on preventing illness occurring in the first place; from delivering care in hospitals to delivering care closer to home, in communities and in primary care; and digital transformation of service delivery.

In this long read, we set out the key recommendations The King’s Fund is making to the government to support the development of the 10 Year Health Plan and realise these shifts. It is based on our formal submission to the government’s Change NHS listening exercise.

Lay the fundamental building blocks of change

A clear vision

The aim of the three shifts should be to deliver improved care, outcomes and experience for the public across mental and physical health, while ensuring our health and care system is compassionate, equitable and sustainable. Change is imperative and the 10 Year Health Plan needs to set out a clear vision of the specific policy choices the government will make and the trade-offs these require.

We believe the shift from treating sickness to prevention is the ultimate prize as it will enable a truly transformational approach. This focus on prevention also clearly connects the 10 Year Health Plan with the government’s mission to build a service fit for the future. Our central message is that the bold choices needed to transform the health service into a prevention-focused service by 2035 must now be taken, with the other important shifts working in aid of this overarching goal (for example, expanding preventive community services such as vaccination programmes, and developing and promoting technologies that help people manage their own health).

This fundamental transformation will require ensuring measurement and accountability at national and local level are oriented towards the shifts needed, a managed rebalancing of resources, and a focus on leadership and management to ensure the system capabilities to deliver the shifts. Underpinning all transformation, the health system should build on the approach in the development of the plan to work differently with people (patients, staff and communities), meeting people where they are to ensure services are co-designed to meet needs and care is truly patient-centred.

Prioritisation, measurement and funding

Given fiscal constraints and the incredibly challenging state of services that staff and patients experience every day, it is vital that the government holds its nerve and continues with the current approach of having honest conversations with the public and staff about the trade-offs that will have to be made.

Some trade-offs will need to be made on the sequence of policy actions. For example, within each shift, some early priorities should be identified to build momentum, such as expanding existing screening and health check programmes to support a shift to prevention.

Trade-offs will also be made between current priorities. For example, The King’s Fund believes the government should review its ambition to meet all constitutional standards within the parliamentary term. There is a risk that the existing commitments will pull in different directions to the three shifts, by reasserting a focus on hospitals rather than community and by underestimating how a renewed focus on preventive and community services might uncover unmet need that will add to waiting lists.

The plan must clearly define what outcomes leaders are expected to achieve to deliver the three shifts – elevating existing datasets where they exist (eg, on community health care waiting lists) and developing others where they do not (eg, developing a measure of prevention spending, which integrated care boards (ICBs) can use to track their prevention spending). Once the vision is clear and the ambitions for the health system over the next 10 years have been set, the plan must set out details of how the system will be transformed to meet the shifts, including how financial resources and people can be mobilized. This must include a strategy to achieve a managed shift in resources and power away from the acute sector towards primary, community and preventive services.

And there are some clear existing long-term strategies that could be reviewed urgently to signal this intent: including the New Hospitals Programme and NHS Long Term Workforce Plan.

Embedding transformation and planning for successful implementation

The plan can only be achieved if staff feel ownership of the work required and leaders can enable the necessary cultural conditions to implement the changes set out. The current workforce crisis in the NHS means staff are under significant pressure, struggling to deliver existing targets and requirements, rather than feeling enabled to improve productivity, lead and implement significant change.

The King’s Fund has developed a framework on the core needs of staff at work: autonomy, belonging and contribution. It is vital for the plan to set clear expectations about working differently with systems and teams to centre staff development, health and wellbeing, and equity, diversity and inclusion – as well as equipping staff with the skills to deliver change at all levels. The King’s Fund believes collaborative leadership is crucial to embedding this, and as part of the plan the government should look at using existing vehicles and regulatory frameworks such as the ‘well-led’ framework to set out what good collaborative leadership would look like for staff.

The plan must also build in mechanisms to continue the dialogue with staff and the public opened up through the initial engagement process. Transparency on how engagement has informed decision-making is an important first step. The plan should also consider mechanisms to build on this engagement to form genuine partnerships with people and communities, so that listening to and working with people and communities is built in throughout all future stages of the plan implementation and delivery. There needs to be a significant shift from ‘doing to’ to ‘working with’ people and communities, recognising the strengths and assets that already exist in communities themselves. Partnership working with local communities represents a huge opportunity to genuinely transform how services are set up in line with the three shifts. But this transformation is only possible if health and care systems are allowed to prioritise and act on what they learn.

Much of the change we are calling for in the 10 Year Health Plan will not happen quickly. In the meantime, it is important to rebuild public trust in the NHS and improve people’s experience of services. The King’s Fund believes that patient experience is a core component of the quality of care, and one interface that needs particular attention is patient-facing admin. Too many people find it hard to form basic interactions with the health service, such as receiving test results or booking, amending, or cancelling an appointment. Embracing a user perspective, seeking and harnessing patient feedback, and working with patients and staff to co-design processes will be essential to developing truly high-quality admin in the NHS.

Beyond the 10 Year Health Plan – social care and the health mission

It is near impossible to see how any 10 Year Health Plan could be delivered successfully without similar attention and support for adult social care. There are multiple dependent touch points between the health and social care systems. The health plan should indicate where its success is dependent on social care reform. Alongside the health plan, a long-term plan for social care is essential, or pressures on the system will continue to jeopardise any ambition for transformation.

The 10 Year Health Plan must also support the government’s overall health mission. This includes placing prevention at the heart of the new health care system, retaining a strong focus on the role of the NHS as an anchor institution and in tackling health inequalities, and supporting more co-ordinated action across the public sector and beyond to tackle the root causes of inequalities.

The plan also sits alongside other missions, and there is an opportunity for reciprocity – considering how the health mission can support other government goals. For example, making better use of technology and delivering care closer to people’s homes will help the NHS play its part in the government’s efforts to address climate change – and clarifying the benefits of the shifts beyond health as part of the vision will also help illustrate the case for change.

Spotting illnesses earlier and tackling the causes of ill health

Preventive health care should be the core business and main focus of the future health care system. But prevention is currently not prioritised or incentivised systematically or at scale throughout the health system, and prevention is not hard-wired into the health and care system’s core accountability structures. The system doesn’t spend enough, reward or support change enough, or hold to account enough when it comes to prevention. This is despite a huge amount of evidence showing that prevention is cost-effective in delivering health gain in the long run. Prevention is therefore set a higher bar to cross than treatment, which is inequitable, short sighted and a poor use of taxpayer’s money.

Beyond the core delivery of its own preventive services, the health system has a huge role to play in improving the health of the nation more widely. The role of the health and care organisations as anchor institutions needs to be developed much further and faster, and the NHS must work more cohesively with partners in other sectors – for example, in housing and employment – to help improve health and wider outcomes, including economic productivity. This means government recommitting to the principles underlying integrated care systems (ICSs) – on health inequalities, population health and the wider economic and social contribution of ICSs – and requires strong signals from the government that this activity is valued as highly as reducing waiting lists and increasing treatment activity. We support the government’s intention to introduce a statutory duty for mayoral combined authorities to work with local authority partners and ICSs to take action on these principles.

Scale up existing interventions that are working

A failure to shift resource into prevention has been a barrier to preventing ill health. The health service has a key role to play in the short-term shift towards required improvements in basic work on prevention; for example, better roll-out of health behaviours advice, enhancing preventive measures across primary, secondary and tertiary care, and increasing availability and uptake of health checks and appropriate follow-on care. Current data shows that the majority (around 60%) of people invited to an NHS Health Check did not complete one.

The shift from treating sickness to prevention presents an opportunity to prioritise babies, children and young people – as good health in childhood and the early years are strongly linked to health outcomes in adulthood. The health service has a role to play in facilitating cultural change on prevention, through empowering people to take control of their health, and through education on health behaviours and self-management of conditions. We know this is much harder for some groups than others, and interventions need to be co-designed and tailored for different populations. The NHS can also help through improving its communication with patients, for example through ensuring all communication is checked for health literacy and in supporting good administration.

Shift resources to enable preventive health care as core business

Prevention budgets and activity tend to face cuts first, and unless this changes the government’s shift to prevention will remain rhetoric not reality.

We need better and consistent measurement of spending on prevention (to benchmark and challenge); a shift from prevention being seen as an instrument to reduce demand, to being a goal in its own right; clearer accountability for preventive activity and uptake of cost-effective interventions; and investment in capability.

A commitment to shifting resources towards prevention and the introduction of an accounting framework to measure investment would help ensure that funding is directed towards initiatives with the greatest impact.

Up-skilling staff and growing the public health workforce  

All staff across the health service should be incentivised to play a role in the shift from treating sickness to prevention. However, a barrier to shifting to prevention is the supply-and-demand challenges facing the public health workforce. Despite the vital role they play in improving population health and reducing the use of higher acuity health services, public health professionals currently represents a very small proportion of the wider health and social care workforce.

The NHS Long Term Workforce Plan should be reviewed with an aim to having more ambitious and long-term commitments around increasing training places for the public health workforce, and to support all staff across the health service to have the confidence and skills to bring a preventive focus to their practice.

Move more care from hospitals to communities

The King’s Fund’s report, Making care closer to home a reality, highlights the barriers to moving care from hospitals to communities. These include short-term approaches to return on investment, financial architecture that does not support a focus on primary and community care, lack of aligned metrics and performance management priorities, and policies and strategies that centre acute care.

To deliver this shift, therefore, there must be a focus on restructuring financial architecture, rebalancing the metrics and accountability, workforce redesign (including improvements to training to deal with the complexity of people’s needs), investment in infrastructure, and enabling locally driven, co-produced change. The King’s Fund are publishing further insight on this in early 2025.

Restructuring financial architecture

The NHS’s financial architecture does not currently support a focus on primary and community care. Primary and community care have seen less funding growth than acute hospital services, and programmes to increase productivity in secondary care can mean more and sicker patients are being cared for outside of hospital without commensurate funding.

In the short term, the plan should incorporate changes to the approach to commissioning and contracting primary care to give greater flexibility over how existing funding is best spent, by moving money from micro financial incentives (small pots of funding tied to required activities) to core funding (the global sum payment) and investing in local commissioning so this can be targeted to local population need and strategy.

In the longer term, funding growth in community and preventive services must increase at a higher rate. The government must be honest with the public that this funding shift cannot be accomplished without trade-offs, and that improvements to the access and quality of hospital care cannot happen as quickly alongside – particularly in our health care system that is already relatively under-bedded and under-staffed.

Rebalancing metrics and accountability

There is comparatively little community-level data compared to the mandated data collection on activity in hospital. While some progress has been made, existing metrics, accountability and performance management priorities still maintain a focus on hospitals. And this data is often limited to the number of contacts with services, with relatively little data on demand, patient and staff experience, patient outcomes, and quality of care.

The focus in the short term should also be on ensuring that community-level data is comprehensive and of better quality, increasing the meaningful data available to local commissioners. In parallel, there needs to be engagement across the system to develop new ways of measuring patient experience and outcomes across care pathways as a way of better reflecting the role of primary and community care. Additionally, accountability structures and support offers should be rebalanced to reflect ICBs’ role as strategic commissioners for the three shifts, for example by intentionally rebalancing representation on ICB boards to better reflect the role of primary and community care services.

Workforce redesign

The growth of the health and care workforce has not been aligned to delivering care closer to home, with larger growth in acute hospital sectors and worrying trends of some community workforce numbers decreasing. Culturally, working in acute settings has perceived higher status compared to primary and community services, with the career backgrounds of many senior NHS leaders concentrated in hospitals.

Delivering the shift will mean rebalancing the clinical and managerial workforce to primary and community settings. This might entail re-examining the assumptions and plans in the Long Term Workforce plan, ensuring roles in primary and community care settings are attractive and valued enough to build the management and development capability that is currently lacking.

Enabling locally driven change

Primary care and community providers are already working collaboratively to join up services and deliver more care in community settings, including through integrated neighbourhood teams. The challenge is how to go further and move from pockets of innovation to widespread change.

There is a need for more trust and devolved decision-making from national bodies so that local systems including ICBs have the ability to listen to and work with the communities they serve to reflect local needs and priorities and ensure care is truly patient-centred. This means moving away from, for example, a nationally set specification for an integrated neighbourhood team to thinking of the constitution of these teams being driven by local population need. It also means empowering existing structures, like primary care networks (PCNs) and improving their capability to do this work – working in an integrated way requires different working practices and a change in organisational culture.

Decentralisation of decision-making should be accompanied by appropriate support and training of local leadership to ensure quality and consistency.

Make better use of technology in health and care

The 10-year vision for a digitally enabled and transformed NHS is one where all areas of the health system in each part of the country is digitally mature, able to share health and non-health data, and using technology to improve patient outcomes.

The barriers preventing the move from analogue to digital include a lack of local investment in core capabilities (people, skills and technologies), a lack of interoperability between systems and services, a reliance on legacy systems, and a lack of public trust in digital services.

To realise the potential of technology, the short-term focus must be on getting foundations right and reducing variation across different parts of the system. In the longer term, the focus should be to manage the uncertainty inherent in innovation by setting a vision for the types of technologies local leaders should focus on and building capabilities and enabling structures at the national, ICB and provider level to embed innovation. The analogue to digital shift can amplify the other shifts, and new technologies that help with prevention or for people to self-manage their health in the community should be prioritised.

Reducing variation in the basics will build staff and patient trust in digital capabilities 

The basic technology capabilities for staff are not being met. For example, research shows that three-quarters of district nurses struggle with connectivity issues, heavy laptops and poor battery life. A focus on the basics could improve buy in from staff for innovation as their experience of trying to work with technology would not be one of frustration. Improving interoperability and data sharing between services will also help build patient trust in digital services – as they are required to frequently repeat themselves when records are often not shareable between services.

There is significant variation in digital maturity, both geographically but also in different parts of the health system. The variation enables those further ahead – who often have buy-in from leadership – to be able to go further, faster by accessing pots of funding that are available. This leaves many others behind.

There is also significant fragmentation, with organisations using different software and hardware with different capabilities. This limits how much staff across organisations can work together and share medical data to improve care. It also creates inefficiencies with staff needing to replicate work across multiple systems.

The focus in the short term must also be on reducing the variation between places and services, with a focus on the basics, data sharing, and improving existing patient-facing technologies – rather than implementing new technologies.

Improve digital skills and confidence of staff and leaders

Technology funding has largely focused on funding the technology itself through capital spending, rather than the revenue funding needed to develop the skills and time for the workforce to best use it. This has led, for example, to significant variation in self-reported usability of the same electronic patient record system in different NHS organisations.

Strategic communication from NHS England that focuses on a ‘how to’ approach to technology complemented by increased peer support would help address variation. A peer support offer could take the form of networks but could also be further formalised into fellowships.

In the medium term, the NHS needs to invest in digital leaders by reviewing the remuneration packages available and ensuring it is more competitive with the private sector. Leaders must be held accountable for and given support to deliver increased digitalisation of services, but also improvements in staff skills and confidence in using digital tools.

Provide a national vision and procurement standards to enable local choice

The 10 Year Health Plan should provide greater clarity on roles and responsibilities at different levels of the system. Where possible groups of technologies should be procured at a national level to leverage NHS buying power and enforce interoperability and standards. However, this should also enable choice at a local level where possible: ICBs and local providers should be supported to select the capabilities and personalisation they need to provide optimum functionality.

Data sharing should be a priority for the plan – existing legislation sets out a duty to share but providers should be encouraged to use technologies that share a curated subset of information by default.

There is currently no particular prominent body or person with responsibility for developing standards and strategic procurement at a national level.

Plan for the future through focusing on the capabilities the system needs to harness innovation

The impact of policy changes facilitated by technology, such as increased patient access to medical records results, has not always been thought through; for example, what an increase in patient queries about medical records might mean for staff workload or liabilities. Planning for innovation is challenging – not least because the exact technologies that might deliver it are often still in development. The plan should set out technology areas that should be a focus such as new technologies that help enable prevention to help signal to and shape the digital provider market, as well as signalling to local leaders where they should be focusing.

To enable choice and personalisation locally, the plan should set a vision of technology that moves from big integrated system architecture towards modular architecture. Currently big systems seek to meet diverse needs across different services and settings but without the ability to personalise and optimise functions. This leads to a generic offer which means that to have the functionality they really need to deliver care, services have to procure additional add-ons. In a modular approach, the basic capability of the system capability is supplemented by the ability to have additional modules depending on need. However, for this to work there needs to be clear standards for digital providers to ensure they are able to build technologies with these capabilities.

The recommendations set out here are not easy; prioritisation inevitably involves difficult choices. But the alternative is to continue on the current trajectory, with too many people unwell and unable to access the services they need when they need them. This moment represents a significant opportunity to reimagine the health and care system – the government should set out a bold plan for a compassionate, equitable, sustainable system that supports mental and physical wellbeing.