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The Labour government published its 10 year health plan on 3 July1—a year after it entered office. Life expectancy in the UK has stalled,2 and public satisfaction with the NHS is the worst on record.3 The government’s prescription is for “radical change” to “reimagine how the NHS does care.”
The plan fleshes out the government’s proposed “shifts” for NHS services: “hospital to community,” “analogue to digital,” and “sickness to prevention.” New “neighbourhood health services” will see general practitioners working together at greater scale alongside nurses, physiotherapists, care workers, and social support such as debt advisers. Neighbourhood health centres will become “one stop shops” for care in every community—including some outpatient services that are currently delivered in hospitals. The NHS will focus on helping people manage their health and keeping them out of hospital.
Better data and new technology will—we are told—do almost everything: help identify and manage people’s health risks, provide advice and support, help people access services, and more. Much of this will be provided through the NHS app—the “front door” for the new NHS. A mix of policy changes are proposed to make it all happen, including new contracts for local services, changes in how the NHS is organised, and an updated workforce plan.
The broad ambitions in the plan are right. Boosting primary care, strengthening prevention, and coordinating care around people’s needs are all good priorities. But these ambitions have appeared in a long line of NHS plans over decades.4 So what will be different this time around?
Plans for neighbourhood health look a lot like previous initiatives to integrate health and care services.5 Evidence suggests these may improve access and patient satisfaction, but politicians hoping for cost savings or reductions in hospital use will be disappointed.67 New care models take time and investment to deliver—and bringing services under one roof doesn’t automatically make them better.
Behind the rhetoric, it’s hard to believe the power of hospitals will be dented. High performing NHS trusts will be given more freedoms—for instance, to retain and reinvest surpluses. The plan’s commitment to increase the share of investment in primary and community services is vague. And detail is lacking on how policy—like the NHS payment system—will change to make it happen.
The plan also proposes that the best NHS trusts become “integrated health organisations,” responsible for managing all health services in their area. Forms of “vertical integration” have been tested in the UK and elsewhere, with mixed impacts.8910 The idea seems to draw inspiration from accountable care organisations (ACOs) in the US. But evidence suggests Medicare’s physician-led ACOs and those with a larger proportion of primary care providers tend to do better than hospital-led models.1112
Meantime, the prime minister’s big NHS pledge is to meet the waiting time target for routine hospital care.13 This has been missed since 2016 and is a long way off.14 Making it happen will be tough,1516 and—whatever the plan says—waiting times will be the over-riding focus of top-down political management of the NHS.
More hope than substance
New technology offers hope—for instance, in reducing administration for clinicians17—and government is right to try to harness it. But the plan borders on techno-optimism. For example, giving patients more information and choice through the NHS app is expected to reduce inequalities in care.18 But more information will not tackle the structural issues that shape inequalities—for instance, some patients being unable to afford to travel further for treatment or facing discrimination in their care.19 New technologies can also widen inequalities if richer groups make better use of them.20
Standing back, the guiding ideas behind the plan are muddy. A mix of measures rely on competition and choice to stimulate improvements—for instance, by encouraging a “plurality” of providers and asking patients to shop around between them. Yet large integrated providers will become the “norm.” And some measures look destined for perverse effects. For example, a scheme where patients will be asked to rate their care and decide whether the provider gets reimbursed in full is likely to result in already struggling NHS hospitals being penalised for issues beyond their control, such as crumbling buildings.
What is clear is that the plan means more NHS restructuring. Government had already announced plans to abolish NHS England and cut spending in NHS integrated care systems.21 But now these systems will be reorganised too—merged across larger areas, with changes in their role and governance. This is not radical: it is part of the constant cycle of “redisorganisation”22 that characterises NHS policy making. Evidence suggests it won’t help.23 Taken together, these changes signal a shift back to a sharper purchaser-provider split in the NHS, away from the more collaborative approach envisaged for integrated care systems just a few years ago.
The rhetoric in the plan will soon meet the reality of the resources on offer to deliver it. Health spending will grow by 2.8% a year in real terms between 2025-26 and 2028-29—lower than the historic average (3.7%) and much lower than during Labour’s last period in government in the 2000s (6.8%).24 Capital investment—in new buildings, equipment, and technology—will grow by just 1% a year.
A bigger problem is that the “health plan” is really an NHS plan. The document rightly talks about social and economic conditions shaping health, and includes some tougher measures on obesity. But most of the document’s 150 pages cover the NHS. Stronger action on other major health risks, such as alcohol, is lacking. And social care is left for Louise Casey’s review.25 Improving the NHS may be Labour’s best route to re-election, but it will not be enough to improve the nation’s health.
