Just this week, Health Secretary Wes Streeting and Prime Minister Sir Kier Starmer launched the ‘biggest ever national conversation about the NHS’, calling on everyone – from members of the public and people working in health and care to organisations working with the NHS – to have their say.

The national surveys will inform the government’s 10 Year Health Plan, which aims to reform healthcare in England over the next decade.  

This comes off the back of the widely talked about Lord Darzi review, where the independent peer and former health minister carried out a thorough investigation into the current state of the NHS, and ahead of next week’s hotly anticipated Budget – where it’s expected that the NHS won’t receive a significant enough boost in funding.

With all this in mind, what are the government’s plans for healthcare and what specific issues and problems could their change agenda come up against?    

Improvement and reform over more funding  

In its short time in charge, the NHS has featured heavily in the new government’s outlook. It took early action on ending industrial action, while the Chancellor, Rachel Reeves,  announced a pause on the previous administration’s controversial 40 new hospitals programme while it undergoes a review.

And now it has opened a national conversation on the future of healthcare. That’s even before we come to the Budget, where the NHS is expected to feature heavily in Reeves’ inaugural address.  

We know that the government is committed to the improvement principles of shortening waiting times, improving quality and enhancing the experience of patients.

So far, so unsurprising. But we also know, from plenty of talk pre- and post-election, that this government places a high emphasis on NHS reform. And, more significantly, that there will be ‘no new money without reform’.

In fact, we know that the Secretary of State plans to reject any proposals that suggest sticking with the status quo, or bids for more money without reform.  

We also know that the government will be placing a lot of value in Lord Darzi’s comprehensive report into the state of the NHS, released to much coverage in September. The review, commissioned by the government as soon as they came to power, aimed to provide – according to the Prime Minister - a ‘raw and honest assessment of where we are’. It delivered on this task and found that the NHS was in critical condition, but also showing clear signs of life.

Streeting has been clear to both the Department of Health and Social Care and NHS England staff that he wants the content of the report treated ‘as gospel’.  

Finally, we know the government’s response to the healthcare challenges will be via the 10-year plan mentioned above, which will focus on three key priorities:

• Establishing a digital and technology-enabled NHS

• Shifting care away from hospitals and towards communities

• Transitioning from treating sickness to preventing sickness.  

What might be left out?

There is a danger, in setting out a bold, radical, reformist agenda, that you don’t focus on things which don’t fit these conditions. Are there, for example, areas that need funding but can’t feasibly make a case for being suitably reformed?

Similarly, are there things that are highlighted clearly by  Darzi as drivers of difficulties that don’t neatly fit into the three priorities outlined above?  

We must also ask whether there are elements of the proposed 10-year plan that will be awarded funding but struggle – at least in the short to medium-term – to deliver on the key improvement principles?  

The answer to all these questions, perhaps inevitably, is yes, and therefore begs the question of whether the government risks being hamstrung over what it can pursue.  

Here are three examples of areas that are likely to cause the government headaches.

Problem 1 - capital investment arrears

Large elements of the 10-year plan will need to be funded through new capital investments. The Prime Minister has envisioned a technologically thriving NHS delivering knifeless surgery, widespread smart biometrics for chronic condition monitoring and seamless, centrally held digital medical records. All of which will come at a huge cost.  

At the same time, there is a case for the getting the basics right. The Darzi report highlights that the NHS has been “…starved of capital”. He describes the NHS as having too few modern imaging scanners, outdated lab technology and buildings which are falling apart.  

So, perhaps, some elements fundamental to the success of the NHS don’t really need reform or innovation, they just need to function. But to do this, there is a need for additional funding. And this should be treated as a case in point for a wide range of issues across the NHS where wheels do not need reinventing, the solution is perhaps simply time, effort and the restoration of funding.

Things that might not fit comfortably with the mantra of ‘no new funding without reform’.  

Problem 2 - management and leadership reform

The Darzi review, and the influential review in 2022 by General Sir Gordon Messenger, both highlighted the need for an increase in high-quality management.  

Darzi also very effectively summarised the decade-long disruption to the NHS’s systemwide management and oversight arrangements, and explicitly highlighted the opportunity cost to the NHS as result of these imposed changes.  

If indeed the report is to be treated as gospel, then the Health Secretary in particular will need to privately, if not publicly, think again on the opinions of those that lead him to criticise the ‘dead weight of management bureaucracy’ in the NHS.  

There will need to be a rapid and almost complete volte- face on the perception of management of the NHS, which has crept in to the political and public consciousness. It will also need to be a fundamental consideration at every step of the 10-year plan and cannot afford to be an afterthought.  

Problem 3 - prevention

In recent years, the NHS has evolved away from any real preventative role in the health of citizens. The NHS currently has its hands very full treating those who are already ill (and those who are unfortunately already on a path to  getting ill).  

Successful public health interventions will, in time, have the effect of reducing demand for NHS services, but public health is rarely the territory of quick wins. As such, it will take time for any interventions to have traction in an already heavily over-burdened system.

Ironically, given the fact it is probably the most important aspect of the nascent NHS 10-year plan, it is also the part that will have the least impact on any of the indicators of success over the course of those 10 years. One area it will hold its own in, of course, is cost.  

In short, then, it is an essential programme of work, but it may need to be seen as an enabler to the NHS thriving in the long-term rather than a key contributor to its recovery. It will also need to attract its own funding.  

None of the above is to say that the 10-year plan or the desire to reform the NHS is the wrong approach, but rather that the government risks boxing itself in too much if it becomes obsessed only with reform.

As outlined above, there are crucial things that don’t need reinventing or reforming, they just need more funding. And we ignore these at our peril.

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