Truly fit for the future? The 10 Year Health Plan Explained

On 3 July 2025, the government published its 10 Year Health Plan for England, setting out ambitions for the NHS over the next 10 years.

At 168 pages, the plan includes a significant number of different policy proposals, including everything from ‘golden handcuffs’ for newly qualified dentists to a shift in the overall pattern of health care spending. Here we set out the main policy ideas and analyse what the plan will mean for patients, and for staff and leaders working in the system, as well as highlighting opportunities and challenges as people start putting the plan into action.

This 10 Year Health Plan has a lot riding on it. The government has been saying for the past year that the NHS is broken, backed by an investigation in 2024 by Lord Darzi that comprehensively highlighted a wide range of problems, and public satisfaction with the NHS at an all-time low. The plan leans into that rhetoric – stating that ‘the choice for the NHS is stark: reform or die’.

If you accept the government’s diagnosis that the NHS is broken, then this new plan needs to provide the public and those working in the health system with hope that it can be ‘fixed’, by setting out a strong and positive vision as well as a credible roadmap for how it could happen. The King’s Fund believes that the government’s overarching vision of the well-rehearsed three shifts is the right one – shifting care into the community, shifting from analogue to digital, and shifting from treating sickness to prevention.

There is a lot in the new plan that will feel familiar. Familiar because it builds on commitments in the government’s manifesto, and familiar because it echoes what NHS reform plans have been saying for much of the past 25 years.

So, after 8 months of engagement with patients and staff and wider stakeholders, this plan needs to go beyond that high-level vision and set out the detail on how the NHS will evolve over the next 10 years, and what will help deliver the ambitions of this plan when so many of its predecessors have failed.

Unsurprisingly, the backbone of the plan is the three shifts, accompanied by sections on structures and operating models, workforce, finances and care quality. But the plan will leave some asking questions about deliverability, as there’s certainly more space given to detailing what will be different in future as opposed to explaining how proposals will be put into practice.

There is a lot in these 168 pages. It is certainly ambitious and there are lots of ideas – it touches on the majority of aspects of the NHS. And there are good intentions. So, what cuts through the most when we step back and look at the plan?

The plan majors on patient experience, technology and shifting care into the community

What comes through strongly is a clear understanding of the frustrations people have with accessing and interacting with the existing health system and what needs to change. There is no doubt that the plan focuses on the issues that patients say matter to them. It addresses head on the issues that have driven public satisfaction with the NHS to historically low levels over the past few years. Lack of access to services, poorly co-ordinated care, poor admin that means appointment letters arrive after the appointment was meant to happen, and fears of staff burnout have led many to ask the most fundamental question of the NHS: ‘Will it be there for me when I need it?’

Much is made in the plan of putting choice and control back in the hands of patients – echoing a theme from previous NHS plans. If the ambitions of the 10 Year Plan for Health are realised, then by 2035 people will have access to better information, will find it easier to manage their appointments, and will have more opportunity to feedback on their experiences.

The shift that perhaps comes through most strongly is ‘analogue to digital’. Technology is expected to change the way people access and interact with services, take over many administrative tasks to free up staff time, and even prevent ill health occurring by allowing for predictive and personalised care based on genetic sequencing. Coming a close second is the shift from ‘hospital to community’, with a new neighbourhood health service sitting at the centre of a new offer to the public of how we can access care in the future.

And so, it is the shift from ‘treatment to prevention’ where it feels like the government has not been as bold or radical as we hoped. England is an international outlier, with stagnating life expectancy and increasing numbers of years lived in poor health. Although there are some welcome measures outlined to reduce obesity rates, attempts to reduce alcohol harms feel very weak, and the package as a whole does not meet the scale of the health challenges we face as a country.

Given the cross-government action that is required to get anywhere near close to the government’s stated goal of reducing the healthy life expectancy gap between the richest and poorest regions, this feels far too much like an NHS plan – not a health plan – and the government must go much further on its original health mission if it is truly to ‘bend the curve’ and fix the nation’s population health crisis.

The plan could have gone further on fixing the basics

Over the past eight months, significant time and money have been spent engaging the public and staff in what it describes as the largest national conversation in the history of the NHS. One of the key issues that came from that engagement was a plea from staff and patients to ‘get the basics right’. AI scribes can only transform the productivity of the NHS if staff don’t need to spend 30 minutes every morning logging into multiple out-of-date IT systems.

The plan does try to chart a course between getting the basics right and transforming our model of care delivery, but it is not always clear about how its ambitions for the future will emerge from the realities of the present. For example, the plan calls for genomic testing to be incorporated in the NHS Health Check programme for people over 40, with no acknowledgement that current uptake of health checks is low and well below targets.

Meanwhile, social care still waits for its moment of reform

Another obvious concern is social care. Because of years without reform, many people are unable to access the care they need – and this has a huge impact on the NHS as well. Although the Casey Commission is the vehicle for social care reform, reporting back in 2028, it feels strange that the interface between social care and health care is not more acknowledged. The plan does say that the Better Care Fund will be reformed from next year, but there is no detail on what that might mean. And no mention of reform to NHS Continuing Healthcare – one of the ways people with long-term complex health needs access packages of health and social care. Health care cannot be fixed without also fixing social care so it must be hoped that thinking about how the two can best work together happens sooner than 2028.

Mental health is an example of a new approach to specific conditions

Previous NHS reform plans of this type have looked very different. Where once there would have been entire chapters on disease areas such as cancer, this plan instead describes how the three strategic shifts will change care across a range of conditions.

So, for example, there are a range of proposals for mental health services across the shifts, many of which are relatively discreet and reflect development or extending of existing initiatives, such as dedicated mental health emergency departments, expansion of assertive outreach and mental health support teams.

However, there remain bigger questions around the details of how mental health will be reflected within wider policy ambitions, including neighbourhood teams, development of a modern service framework and changes to funding and payment processes for mental health care.  

There are opportunities to learn lessons from the past

In many ways, this plan is a ‘greatest hits’ of many of the 2000s Labour plans. Foundation trusts are back, as are polyclinics in the form of neighbourhood health centres, and the National Quality Board is being revamped. Meanwhile, it repeats long-held ambitions to bring together patient data into a ‘single patient record’ and shift more funding out of acute care. Just because ideas are not new, it does not mean they are bad ideas. But it is vital that the government learns from the past and engages with the reasons these have previously failed: the true test of this plan would therefore be actually implementing it, doing so well, and making change stick.

In the rest of this analysis, we set out some of the key proposals in more detail and consider what needs to happen for the ambition to turn into action.

What does the plan mean for patients?

If patients are to be active partners in their care and in control of their data, they must be involved at every stage

Public satisfaction with the NHS is at its lowest-ever level. So, it is welcome that so much of the plan focuses on how our daily experience of using the NHS might improve over the next 10 years. The ambition to move patients from ‘passive recipients of care’ to ‘active partners’ is also a clear thread running throughout the plan, from the introduction of a ‘doctor in your pocket’ to more personalised care plans and the expansion of personal health budgets. We have seen much of this thinking in previous plans but never before has a boost to patient power felt so hard wired throughout everything being proposed.

The plan reaffirms some of Nye Bevan’s commitment to put a megaphone to the mouth of every patient, with a welcome refocus on patient experience and quality of care – and very clearly reignites the Quality Framework used by the 2008 Darzi Review. For too long patient experience has dropped down the list of priorities for the NHS, despite a depressingly long list of scandals and inquiries concluding that patient voice is too often ignored. This plan clearly seeks to redress some of that recent historical imbalance.

The commitment to ‘reform the complaints process and improve response times to patient safety incidents’ is long overdue and much needed. There is a focus on patient feedback and a commitment to collect patient-reported experience measures (PREMs) in a more systematic and comparable way. This is positive and recognises that how the NHS collects feedback from patients has grown over time and no longer feels coherent.

But the challenge has often not been how to collect feedback but how to use it to drive change in organisations that too often have poor cultures and react in defensive ways to negative feedback from patients. The events leading up to the adoption of Martha’s rule demonstrate the reality that too many people have experienced when trying to hold NHS organisations to account – having to really fight to make their voices heard. Collecting more feedback or changing how feedback is collected does not lead to change in and of itself. It will take focus and a shift in culture at both national and local levels of the NHS to ensure patient experience is at the heart of everything organisations do. 

The plan describes patient feedback, experience and outcomes as among the most important measures that will be used to assess providers and commissioners. Yet as the plan itself acknowledges, many of the issues with patient care are due to poor co-ordination between providers – not just poor care delivered by a single clinical team or organisation. So more thought, particularly for the new wave of integrated health organisations (IHOs), should be given to how measures of care co-ordination can play a role in assessing whether the NHS is really delivering what patients and the public need.

The plan includes a range of proposals to better hear the individual voice of patients to drive improvements in services. But more thought should also be given to how the NHS can benefit from hearing the collective patient voice. The decision to abolish Healthwatch will come with consequences that need to be carefully thought through. Healthwatch was able to bring power to people’s individual voices by bringing them together and showing the scale and impact of what was happening – such as the huge impact poor admin processes can have on people’s care and wellbeing. The government will therefore need to address concerns about how the collective patient voice will be heard and acted upon when some of these functions are moved from a body at arm’s length from the government into the Department of Health and Social Care.

Another mechanism for change adopted by the plan is to give people a choice of provider. As this is taken forward, it will be important to remember that not all people are able to exercise choice in the same way; access to information and digital tools varies across populations. Some areas will have fewer providers or limited transport options, and some people don’t have the resources to make choice a reality. The government will need to demonstrate how it will ensure that extending the choice agenda doesn’t inadvertently exacerbate pre-existing health inequalities.

There are also proposals that would see patient experience data directly influencing payments to providers. This is a welcome recognition that patient experience has to be a key metric upon which providers are both judged and rewarded. Using large-scale surveys and robust collections to determine this is sensible and the overall approach should mean patient experience is prioritised.

The plan also states that trials will be run where individual patients will be contacted to ask them whether the full payment for the costs should be given to the provider or whether a proportion should go instead to a regional improvement fund. This will need to be approached very carefully with a keen eye on potential unintended consequences. We know people are already worried about giving feedback to the NHS for fear of repercussions – will it make patients worry that withholding payment will negatively affect their future care? Could it adversely affect the relationship between those who provide care and those who receive it? Again, the government will need to be transparent about what issues the trials of these new payment schemes unearth.

The plan states that neighbourhood services will be designed in a way that reflects the specific needs of local populations. The most radical and hopeful change that The King’s Fund is seeing in the health and care system right now is where there is true partnership between services and the people and communities they serve. However, the plan seems to suggest that the system will still decide on and design what services are needed, and patients will feedback on whether it works or not. This is still doing to rather than doing with – it misses the opportunity for working with people and communities to design and deliver those services in the first place, to work with local people to ensure that neighbourhood health services meet their needs, and even more than this recognise the assets that the community itself brings.

What does the plan mean for staff and leaders?

Collaborative, relational leadership will be vital to bring about change

The 10 Year Plan for Health has an honest focus on the issues to be addressed for workforce transformation. It acknowledges the immense pressures facing staff and leaders and outlines a range of reforms aimed at improving culture, capability and care delivery. Although the plan contains many welcome commitments, its success will depend on how these are implemented – and whether they resonate with those delivering care on the ground.

The plan’s recognition of the need to improve staff wellbeing is a positive step. Its emphasis on compassionate leadership and flexible working signals a welcome move away from traditional, hierarchical ways of working. The focus on digital tools – such as AI scribes and virtual assistants –to reduce administrative burden and free up clinicians time to deliver is also welcome.

Despite its strengths, the plan leans too heavily on technocratic solutions. There is insufficient attention to the relational aspects of leadership and the trust-building needed to restore morale. The assumption that digital transformation alone can ease workload pressures is unrealistic without parallel investment in digital literacy, improving infrastructure and designing solutions with staff.

The plan also underplays the impact of change fatigue. Years of top–down reform, post-Covid trauma and structural churn have left many staff sceptical. Rebuilding trust will require visible, consistent leadership and meaningful staff engagement, not just new policies.

Open and transparent communication with staff at all levels will be critical so they can engage in the change process rather than learning about changes from the media. Creating an environment where staff feel safe to speak up will also be essential; evidence shows clearly this will both improve productivity and support the change process.

This new plan is strikingly critical of the 2023 Long Term Workforce Plan, stating that it simply extrapolated past trends into the future. It proposes a new 10 Year Workforce Plan to be published later in the year, which will mean fewer additional staff than projected in the 2023 plan – instead focusing on how staff can work with digital tools to maximise productivity and focusing more on staff skill mix and capabilities over expansion of the workforce.

As discussed above, we question how far the use of digital tools can meaningfully reduce workloads in the short term. The risks around this ambition should be carefully and transparently monitored when the refreshed workforce plan is published.

Ultimately, people – not plans – deliver care. To realise the plan’s ambitions, we must balance aspiration with realism and ensure that staff feel valued and empowered to lead change and work with patients and communities in different ways. This will require new skills, better care co-ordination, and a deeper understanding of what makes integrated care work.

Several shifts are needed to realise the ambitions of this plan, including a greater focus on shared local leadership to support organisations to work together more, greater empowerment and flexibility for staff from different organisations to work together, and a different relationship (working in partnership) between staff and the local communities they serve.

What does the plan mean for shifting care from hospital to community?

Neighbourhood health is the right direction, but general practice and community services must be the cornerstone

The plan’s vision for neighbourhood health, supported by a shift in the overall proportion of expenditure, while welcome, is not new. The radical change would be delivering the vision in the right way.

True neighbourhood care is not just about the location of services but improving the population’s health. Effective neighbourhood services are hyper-local, co-designed with communities, and supported by trusted relationships that extend far beyond clinical care. This includes recognising the voluntary, community and social enterprise (VCSE) sector not just as service providers (as is presented in this plan) but as a strategic partner, advocate and bridge to communities. All too often, the model described reads as an offer to individuals – focused on delivering services to patients rather than building services with and for communities. The plan also prioritises convenience and speed over continuity and relationship-based care for patients with less complex needs, even though it has clear benefits for all people – not just those with the most complex needs.

General practice and community services need to be the cornerstones of neighbourhood health but are under immense strain and lack the capacity to lead this shift without significant support. The plan does not address how already overstretched primary care or community services staff will be resourced or empowered to take on expanded leadership roles in neighbourhood care and develop the skills they will need to co-create services alongside communities.

Where NHS trusts assume responsibility for neighbourhood health services, this will need to be done in partnership with local organisations and with a focus on communities and improving the health of their local population, rather than reducing the pressures on existing services. There is a risk of simply relocating hospital-based, biomedical models of care into community settings, or that those best suited to lead these services in the long term may not currently have the capacity to take on these contracts. The neighbourhood health service must be fundamentally different and more than a local, smaller outpost of an NHS hospital.

The development of high-functioning multidisciplinary teams does not just happen through co-location or record sharing but requires time and skills to build relationships, understand each other’s roles, and develop trust. The leadership and support to do this work will need to be a key part of the implementation plan. Our research has also found that if this shift is to be realised, the best managers and clinicians should want and be trained to work in primary and community care settings. While the commitment to expose nursing students to neighbourhood settings is welcome, there is no equivalent requirement for doctors, managers or allied health professionals. This could limit the pipeline of future leaders who are trained and motivated to work in community-based care.

Shifting care to the community can improve the value taxpayers receive from their health service, but this shift will not yield significant financial savings in the short term. Hospitals operate with high fixed costs and interdependent services, making it difficult to realise immediate financial benefits from reduced demand. Instead, the impact of investment in neighbourhood health should be measured in long-term improvements in health outcomes. This requires the development of robust metrics for measuring outcomes beyond cost-efficiency or impact on hospital admissions.

What does the plan mean for shifting care from analogue to digital and pursuing innovation?

Technology is at the heart of how people will access and interact with services and productivity improvements

The plan majors on the shift from analogue to digital, revisiting many past ideas, dusting them off for the modern age and adding in references to cutting-edge technology.

The vision for this shift over the long term seems largely achievable, but it doesn’t represent enough learning from past struggles to benefit from technology. The key foundations for good implementation of technology, such as infrastructure, shifting behaviours, and changing workflows and processes, remain largely ignored. This makes the aspirations around more cutting-edge technology feel less believable in the short term, as many in the NHS would say the focus should be on getting the foundations right, building capabilities and reducing variation across different parts of the system.

The majority of the technology shift focuses on patient-facing care. It is in areas like this that we can see the potential for most significant changes to how we interact with health care services in the future. New capabilities mean the NHS App will provide personalised and tailored information in the patient’s preferred language and help with signposting to self-care support or triage for follow-up services. Patients will be able to self-refer, manage their care plan and add their own health data.

In short, patients are being given a huge amount of control and capability. The greater focus on technology may improve care for patients and make it easier for people to access services in the first place – for example, being able to have more interactions with services in a preferred language or letters automatically read aloud for people with visual impairments. But we must be careful that everyone can benefit from these changes – good care shouldn’t entirely rely on the quality of smartphone you can afford. The plan states inclusion will be designed into the NHS App by default, but more detail is needed on how this will happen – and minimising digital exclusion needs to be the standard for all digital interactions.

The HealthStore is another good idea returning that will enable patients to have access to health apps that are paid for centrally. It’s a significant shift in how people access and receive care and will need wraparound support for the patient provided at multiple points to build skills, familiarity and confidence to use these new tools.

The single patient record is intended to bring a patient’s medical records into one place, improving patient experience by not having to repeat their clinical history or story. This will require new legislation so that health care providers are required to share information to the record and patients have the right to access it, and the data can be used for service improvement and research. And the government will need to learn from past attempts to join up patient records that have failed, where insufficient thought was given to data-sharing challenges and a lack of data standards.

For staff and the system, AI scribes will form a key part of the future of care provision. This is positive, as AI scribes could significantly improve workload for staff and experience for patients. There are other areas in which staff experience is a clear focus, including introducing single sign-on for NHS software. To meet the full ambitions of the plan, these tools should not just be focused on productivity improvements but also on helping reduce pressures on over-stretched staff.

To support the neighbourhood health service, there will be a new platform for all NHS providers to ensure community-based services have the digital tools and capabilities they need. Our own research has highlighted the problems that health services run into when IT systems designed for hospitals are extended to other settings. So this new platform needs to be designed and procured with real thought about what digital support a community-based service needs.

 Five ‘big bets’ set to accelerate health care reform through innovation but require collaboration and leadership

Following on from the prioritisation of technology, the section on innovation in the plan also places five big bets on ‘the most direct and impactful technological levers for transforming NHS care delivery’. These are data quality and interoperability for research and innovation AI tools, genomics and predictive analytics, wearables, and robotics.

There are exciting possibilities here that could bring real benefits to people, particularly the signalling of a shift in how genomics is used, from something at the very specialist end of treating cancers and rare diseases to ambitions for it to be used ‘in routine preventive care’ and to ‘mainstream genomics population health’. This is a hugely ambitious step from the space that genomics is currently occupying, but the starting point for this will be a large-scale study, so there is space for concerns to be worked through. There is definite ambition to take a preventive lens not just through genomics but also around the other technologies such as wearables and sensors.

The big bets could revolutionise care, but on the more cautious side, some raise moral, ethical and practical questions, for example the consequences for people of detecting untreatable disease through genomic testing. For these big bets to succeed, working with people and communities to build confidence and trust, and supporting them to prepare for a different system is crucial to the NHS truly being able to benefit from them. 

It is welcome that the plan does recognise where there have been barriers to innovation and adoption and looks to tackle these. It describes new regional health innovation zones, which will look to create partnerships across a locality to drive innovation, make changes to operating models to give more freedom to foundation trusts to innovate, and introduce innovation passports as a new proposed route to addressing issues with scaling innovation from the ‘best to the rest’.

However, as in other areas of the plan, it feels like a good chunk of the ‘how’ of doing this is missing, from how to foster public and clinician trust and confidence in these technologies, to how culture and leadership will be supported to embrace innovation, but also critically the infrastructure needed for the NHS to embrace these changes.

Technologies such as genomics, AI and robotics will also present competing demands to the NHS’s infrastructure, so it’s important that alongside implementing AI infrastructure, sufficient thought is given to other technologies. Innovations such as genomics will require new supply chains, clinical pathways and ways of working, which aren’t as heavily featured in the plan. Similarly, data sharing has been an intractable challenge for 20 years and the plan could have said more about how to overcome this knotty issue.

Crucially, transformation, innovation and partnership working in the NHS require good leadership. Implementing these changes will need leadership from the centre that focuses on a ‘how to’ approach complemented by increased peer support that enables knowledge sharing and supports reduced variation. It will also require a workforce empowered and upskilled to make the most of these big bets and the changes to clinical pathways that they can drive.

What does the plan mean for shifting from sickness to prevention?

Focus on prevention is welcome, but there is still further to go on ambitions for a healthier nation and primary prevention

There is lots to welcome in the plan, including: the renewed focus on secondary prevention (the roll out of lung cancer screening and the testing of ‘prevention accelerators’ to tackle variation in the uptake of CVD and diabetes interventions); the new idea of setting mandatory targets for major retailers and others to improve the healthiness of our food; and the emphasis on helping people with health problems stay in work, piloting work advisers in the neighbourhood health service. We must also not forget the work of this and the previous government on the Tobacco and Vapes Bill to help create the first smoke-free generation.

Measures aimed at creating the healthiest generation of children are welcome, including better access to dental care and obesity and mental health support, as well as children and young people being an early focus of the neighbourhood health service, particularly the commitment to expand the Start for Life programme, which brings together children’s services, NHS and public health.

And there are signals that changes to incentives, accountability and commissioning for population health could make preventive activity much easier to do. For example, aligning the geography of the NHS to that of strategic authorities could help hard-wire action on the wider determinants of health, and rewiring of NHS finances and payment systems could also incentivise more prevention.

But what do we do in the meantime? Best estimates are that we currently spend around £1 on prevention for every £20 on treatment and we also know much of this is good value for money for patients and taxpayers in preventing and improving heath: local government public health services are 3–4 times as effective as the NHS in producing health gain.

This plan has nothing to say about this balance of spending, nor a wider commitment to a significant increase in preventive spending in the short-term. Suggestions for ring-fenced funding on prevention now or a significant uplift in local government public spending (which has fallen 25% in real-terms over 10 years) have not been taken up in the plan, nor is there anything specific on the public health workforce.

It is truly disappointing that the government has ducked out of anything that will shift and target harmful alcohol consumption such as minimum unit pricing, as recommended by Public Health England in 2016. There is also less on air pollution than many were expecting, and fewer overall signs of the role of other government departments than there needed to be, where we know much of the policy that drives our health sits.

This brings us to the government’s ‘overall ambition’, reiterated in the plan, of halving the healthy life expectancy gap between the richest and poorest regions. This would be a truly bold shift, especially as our health has slipped so far down international rankings, healthy life expectancy continues to fall and inequalities in life expectancy and healthy life expectancy widen. The UK’s life expectancy was the lowest amongst comparable countries in 2023.

There is too little said on health inequalities and exactly how this plan will deliver the government’s ambition to halve the healthy life expectancy gap between England’s richest and poorest regions – in fact the last paragraph of the prevention chapter says that by the end of 10 years this plan will only have begun narrowing health inequalities and restarted progress on longevity. That is an unacceptably low ambition.

We therefore hope that there is much more coming to show how this specific plan docks into a bigger strategic cross-government strategy for population health and health inequalities, drawing the preventive contribution of the NHS together with action on child poverty, growth, housing and the other drivers of our health.

We know there are plenty of potential vehicles for change coming, including a Department for Digital, Culture, Media and Sport plan on physical activity, a Department for the Environment, Food and Rural Affairs plan on air pollution, and a schools White Paper that will prioritise early intervention and schools and health providers working together. The government must be braver and bolder over time, as the public wants it to be on regulating and taxing, where it will make a significant difference to its health. The health mission was meant to be an opportunity to align all of government in the same direction, transforming our population’s health. There remains an opportunity to do so – but this plan is only a piece of that puzzle.

What does the plan mean for systems and finance?

A slimmed-down centre and increased autonomy for providers, but they will need to continue working with local partners

The plan signals a clear change of tack in how the health and care system will be structured and governed. The aim is to simplify the current arrangements, clarify responsibilities and give providers increased autonomy from national control.

Over the past decade, health care leaders have been asked to look beyond their own organisational boundaries and to work in partnership with others in the NHS, local government and elsewhere to overcome the kinds of problems – such as long waits or deepening health inequalities – that cannot be solved by organisations acting alone.

Some of the measures in the plan could be interpreted as signalling that this era of ‘system working’ is now over. The abolition of ICPs removes one of the key mechanisms for collective planning across the NHS and local government (although local councils will still be involved in developing local neighbourhood health plans, led by health and wellbeing boards). Changes to ICBs – including the removal of providers from ICB boards and the greater emphasis on the use of market mechanisms – reinforce the separation of roles between commissioning and provision.

However, other elements of the plan indicate that the shift from organisational silos to a focus on systems will continue in some form. For example, the plan states that the new generation of foundation trusts will be different from earlier waves in that they will have a stronger focus on partnership working and population health. This is a welcome principle but needs to be put into practice effectively – the ‘earned autonomy’ for providers introduced by the plan needs to be autonomy from national bodies, not from their local partners. Government will also need to resist the temptation to undermine foundation trusts’ freedoms in response to challenges, as seen in the past.

The plan also proposes that some providers go further, becoming integrated health organisations (IHOs) responsible for managing the whole health budget for a local population. This could create stronger incentives to invest in prevention and community-based care but needs to be informed by previous attempts to use novel organisational forms and contractual levers to drive integration, many of which ran into complex practical challenges and were abandoned.

Taken together, these changes add up to significant structural reform over the next two years. To get this right, the key will be to remove some of the complexity and ambiguity that has slowed down decision-making in the recent past without reducing the ability for ICBs, providers, local government and others to work together on the challenges facing patients and populations. The government should make sure that the commitment to increased collaboration across organisational boundaries remains strong, and that the new approach builds on successful examples of integration and partnership working developed in recent years.

Finance arrangements aim to hardwire in the shifts and incentivise activity differently

The King’s Fund has long called for the financial wiring of the NHS to reflect the stated priorities and for the implementation of longer-term three- to five-year planning and funding cycles so that systems can more cohesively plan their priorities over a longer time period, so to see this reflected in the plan is really welcome. As is the commitment to make a ‘decisive’ shift in the pattern of health spending, reducing the share spent on hospital care in order to grow investment in primary and community services within the next 3–4 years.

But far more detail is needed on just how much the ‘hospital share’ of NHS funding should fall by or how quickly, to demonstrate the government is committed to investing in a new community-focused NHS and aware of the inevitable trade-offs to hospital care that will be needed.

Alongside this headline commitment, the plan also reveals a clear intention to hardwire in the shifts through a deliberate re-examination of the financial foundations of the NHS. For example, seeking to implement changes that elevate patient voice in financial flows or address longstanding issues around fairness of allocations. It is also good to see a commitment to longer-term capital spend planning.

On capital, the promise of investment and a new public–private partnership framework is encouraging, but past failures to deliver similar initiatives due to lack of revenue funding and regulatory barriers remain unresolved. Without reform to planning rules and sustainable funding for ongoing operations, new neighbourhood health centres risk becoming underused or unsustainable.

As noted in the plan, the current combination of activity payments for hospitals and capitation or block contracts for primary and community care is very complex and often incentivises the wrong things in the wrong places. Moving from block contracts, which often cannot flex to recognise changes or unexpected pressures such increased patient demand, seems sensible for some providers and services, such as urgent and emergency care. However, it is not clear if this means an increase in activity-based payments instead, which is unlikely to work for all – for example, there has been difficulty in moving from block contracts in mental health. Any wider use of activity-based payment could also run counter to the ambition to focus financial flows on patient experience and outcomes rather than episodic instances of care.

The plan signals a clear uptick in the use of financial incentives to reward or penalise organisations based on the quality of the care they provide or on the experience of individual patients. But history suggests the need for caution in this as it has proved difficult to design effective incentive schemes, and there is a danger that the extent to which either rewarding or punishing NHS organisations can lead to the quality of care becoming fundamentally inequitable.

In the current financially pressurised environment, it is right that the NHS is asked to return to financial discipline, improve productivity and reduce waste. Yet we know that in some cases compromises are already having to be made, with a knock-on impact for patients on the range or quality of services the NHS offers them. In this context, the widespread financial distress in the NHS jars with the ambitions in the plan for deficit support to become a thing of the past, while expectations of organisations being in surplus by 2030 seem hard to square with the now. While the big bet on technology seems to be the path to financial sustainability in the mind of the government, there will inevitably need to be realism, and tough decisions made, about what cannot be prioritised in this financial envelope.

Conclusion

If the government delivers on the promises in this plan, the health service in England would clearly improve. And in reading this plan, you can see the vision of a more digitally enabled, community-centred and prevention-focused health service that could be in place by 2035, and that would be welcomed by the public, patients and staff alike.

But will that vision become a reality? From what we can see in the plan itself, that is difficult to say.

Where there are concrete actions, such as shifting the balance of funding away from hospitals, there is a lack of detail over how quickly this shift will happen or how substantial it will be. Without a delivery plan (or even delivery chapter), many parts of the health service will be reading the plan and agreeing with the vision while wondering what their next practical step should be.

In practical terms then, alongside the plethora of reviews that the plan commissions, eyes will turn towards NHS planning and implementation guidance that will have to set out far more clearly what the expectations are for the health service over the first three years of this 10-year plan.

In several places, the plan is arguably too implicit on the trade-offs the government has promised to be open about. The plan includes a long list of what the public might get under the right conditions. Yet this is a hugely ambitious set of tasks that will have to be delivered with below-average funding growth and fewer staff than projected under the current long-term workforce plan.

The public and staff in the health service are aware that there will always be constraints and trade-offs in any service. And the nation’s health cannot improve if the NHS continues to take an ever-growing share of funding at the expense of wider services that maintain and improve our health. Yet until the government is clearer about what will not be delivered or prioritised over the next ten years, the national conversation the government wants to have with the public will not be as honest as it could be.

The government has spent its first year in office developing this plan. It’s got to get on with delivery and what matters now is how the next steps turn a vision into reality. And if the plan can be realised in full, the NHS – and the nation’s health – will be on a much better footing.