A new document on the state of play in England’s NHS is sounding the alarm on Labour’s vague “10 Year Plan,” which was eventually published in July, a year after they had taken office, and to less than fulsome applause.
The 80-page “Impact Statement; the 10 Year Health Plan for England” was published last month by the DHSC. If anything, it is even more vague and evasive than the Plan it is critiquing. It begins by emphasising how sketchy the Plan is, lacking any clear costings or discussion of funding:
“The plan sets the overall strategic direction for the whole NHS, and individual proposals are at different stages of development and specificity – many of them to be designed and implemented locally. Therefore, at this stage, a full costings and benefits assessment is not feasible…”
It goes on to add in even more uncertainty and complexity:
“The pace of delivering the commitments over the full 10 years of the plan will be subject to future decisions such as future government spending reviews or wider changes in economic and fiscal circumstances. For many longer-term proposals, it is not possible to robustly quantify future costs given that choices over implementation will affect costs and benefits.”
The Impact Statement does attempt an “overview of costs and benefits” of increasing resources for community health, primary care and social care. It therefore cannot avoid pointing out that the evidence on the cost-effectiveness of this shift of focus is at best mixed:
- “a review of the academic literature by the Nuffield Trust (2017) suggests that many of the initiatives identified could improve patient outcomes and experience but only some were associated with cost savings while others were cost neutral or increased costs.
- studies, such as an NHS Confederation report, found that systems that invested more in community care saw on average 15% lower non-elective admission rates and 10% lower ambulance conveyance rates, together with lower average activity for elective admissions and A&E attendances
- an evaluation of initiatives to integrate primary, community, social and acute services in Mid-Nottinghamshire by the Health Foundation also found reductions in emergency care use (4.3% fewer A&E visits and 6.7% fewer emergency admissions per 10,000 people per month). Notably, it took between 2 and 6 years for lower rates of hospital utilisation to emerge.
- a [2015] literature review by Monitor also found that moving services from hospital settings into the community has the potential to reduce hospital admissions though findings were mixed and the strength of evidence is not consistently strong.
- a recent evaluation of England’s Vanguards integration programme in 2024, found the most notable early reductions in emergency admissions occurred in care home focused sites. However, these reductions diminished quickly once funding was stopped.…”
What is especially striking is that the Statement makes no estimate of what level of investment might be necessary to deliver positive results, even if the new focus of care works as intended. Nor does it examine the extent to which, given the absence of any promise of further significant increases in funding until 2029, the necessary level of investment can be diverted from elsewhere in the existing NHS budget without doing serious damage to acute services or other vital work.
There are also doubts on whether the new model of neighbourhood health centres (NHCs) can deliver actual cash savings, as these researchers pointed out back in 2007:
“While some studies have identified cost savings from moving services into the community, there are cases where these have been offset by increases in service volume and loss of economies of scale.”
There is similar evasion on the long-standing chestnut of Personal Health Budgets (PHBs). Rolling these out was notoriously promised by the newly-appointed Simon Stevens as he took the helm at NHS England in 2014. Stevens told the Guardian of his vision, in which: “North of five million patients could each have a personal combined health and social care budget by 2018.” However nothing like this has been delivered
The 10-Year Plan, 11 years later, was much less optimistic. It promised numbers of personal health budgets would “double” by 2028, without committing to any actual numbers, or giving any idea of how much money would be on offer as PHBs for patients to somehow negotiate their own way through the warren of non-profit and for-profit providers. The promise is now for just ONE million to be receiving PHBs by 2030 – after the next election, and 16 years after Stevens’ boast.
The Impact Statement carefully avoids any detailed discussion to weigh the pros and cons of PHBs, and hedges its bets on the issue, suggesting PHBs can do the magic trick of both saving money and improving care: “The increased use of PHBs could benefit the health system, both in terms of reduced spending and improved patient outcomes and efficiency.”
However, this ignores the many warnings raised about the rollout of significant numbers of PHBs. Back in 2013, a study published by the Nuffield Trust drew attention to the increased costs involved of setting the new system up, and the danger that the viability of existing services could be jeopardised by the choices of budget holders:
“Clinical commissioning groups will […] need to be ready to decommission services not chosen by budget holders; but at a pace that allows providers the chance to adapt and minimises the risk of market shrinkage (leaving individuals with fewer choices than before). Likewise, efforts aimed at diversifying the market of providers need to be carried out with care to avoid destabilising existing providers.
“For the system to work, new infrastructure around budget setting, care planning and system monitoring is required; funding for which would need to be found in existing budgets.”
The Impact Statement itself goes on to warn of the unknown unknowns of a large-scale shift of services from hospitals into the community. Despite this policy having been the common coin of ministerial speeches and plans for 35 years and more, “Reform of this type, and on this scale, has not been delivered previously.”
The Statement spells out the extent of uncertainty:
“The evidence base is therefore only partial, and the scale of impacts is very difficult to assess. As services develop, ongoing work will be required to assess the funding and value for money implications of the neighbourhood health service, as well as legislative changes required.”
It cites a 2007 [!] study on shifting care from hospitals to the community, which concluded in a much less than a categoric thumbs up:
“Our findings suggest that the policy may be effective in improving access to specialist care for patients and reducing demand on acute hospitals. There is a risk, however, that the quality of care may decline and costs may increase.”
The Statement continues to raise concerns, citing another, much more recent statement of policy by the NHS Confederation, which represents trusts and commissioners:
“Previous efforts to move care closer to home were considered to have been hampered by insufficient scale of change in moving resources between settings. For example:
“• a 2024 survey by the NHS Confederation found that 9 in 10 integrated care system leaders were concerned that plans to shift more care out of hospital were constrained by a lack of long-term investment.”
The Confed is clearly seeking an overall increase in investment, with a greater share going to community and primary care. But the 10 Year Plan is hooked on the idea that directing more patients towards NHCs will automatically reduce the need for avoidable hospital care. It may eventually do so: but this will not immediately reduce the running costs of the hospitals by anything like the amount that needs to be invested in neighbourhood centres.
There will inevitably be a period of double-running as the old pattern of care evolves into the new – while there is still a need for hospitals to provide timely treatment for unavoidable care – including emergencies, surgery and more complex medical treatment. And they will still require scanning, imaging and diagnostic services on site.
Whether it makes any real sense or value for money to replicate these in a series of scattered neighbourhood centres – which will require substantial investment, and staffing – is open to doubt.
However the 10 Year Plan has already plumped for the shift away from hospitals, without any more assessment.
The Impact Statement goes on to raise more concerns on the financial front:
“The size and scope of the neighbourhood health centres will be determined by local systems, and they will be expected to assess and maximise the value of capital expenditure. Where they are based in existing buildings, there will be costs associated with repurposing, upgrading or refurbishing to meet appropriate standards and suit their new use. … Where new buildings are required, these could be met through a range of delivery options including re-purposing existing buildings, adding capacity through private finance or rental routes, or constructing new buildings. … For all facilities, there will be ongoing maintenance costs.” (p7-8)
Here too the prospect of these changes delivering efficiency savings is preceded by a very big “if”:
“The shift to community would likely represent an efficiency saving in capital terms if NHCs deliver activity that would have taken place in secondary care settings. […] (p8)
And in any case the Statement warns that efficiency gains will not be delivered immediately, or even soon after the new NHCs are opened:
“These efficiency gains may only be realised in the long run, given increased short-term expenditure to establish the NHCs.”
Gearing up the new NHCs to deliver care on the scale proposed will also need a substantial increase in staffing, and to set the new system up properly requires a major step change in the systematic care of people with long term conditions, few of whom are receiving systematic care at present. This means increased caseload for the NHS, on a considerable scale. The Statement notes:
“Recent data shows that around 20% of people with long-term conditions have a care plan, with an aim to reach 95% of people with complex needs by 2027.” (p9-10)
The achievability of this ambitious target within the next 12 months must be questionable – but the Impact Statement does not question it, nor does it raise the need for (and cost of) concerted action right across the country if it is to be achieved. It merely notes it as an unresolved issue.
The Statement does, however, flag up the need for additional investment in GPs and in primary care to make the shift and increase in care a reality, noting that to train each GP costs as much as £504,000. In reality, successive governments have frozen or reduced funding of primary care. In its first 18 month,s the Labour government has fallen short of restoring previous levels of funding. The Doctors Association now argues that an additional £40 per patient per year is now needed to restore the real terms value of the GP contract to 2015 levels.
Perhaps more shocking is the Statement’s later bland admission of the level of inequality that is already rife in NHS cash allocations, with GP practices serving England’s most deprived quintile receiving on average £14 less in NHS payments per weighted patient in 2022 than their counterparts serving patients in the least deprived quintile. (p58) Nor does it suggest any change to this situation, despite the fact that:
“The Royal College of General Practitioners and the Nuffield Trust have previously recommended this formula be reformed to take socioeconomic deprivation into account.”
Even if the system could be set up with the right level of investment the Impact Statement appears far from convinced that it will work as intended:
“Where equivalent capacity is then available in downstream services, patients may be able to access subsequent treatment more quickly, leading to expected improvements in health outcomes as conditions are prevented, treated earlier or managed better. This could enable patients to have their health concerns addressed by professionals more quickly, improving people’s wellbeing. These improvements have the potential to disproportionately benefit disadvantaged groups who experience poorer health outcomes.” (p11)
The Statement is also wary of the claims for the cost benefit of establishing neighbourhood Multi Disciplinary Teams (MDTs):
“This improvement in joint work and reduced hand-offs between services can result in the patient experiencing much more joined-up and holistic service.
[…]“however, a Health Foundation briefing28F reviewing MDTs for adults with complex health and care needs in 2015 or 2016, found that MDTs did not reduce emergency hospital use and may even lead to short-term increases. Longer-term evaluations of the broader programmes in which these teams were implemented found some evidence of reductions in emergency hospital use, but this took between 3 and 6 years.” (p12)
The statement goes on to warn of the costs of another pet theme of Wes Streeting and the 10 Year Plan, the turn to technology and “digital health innovations,” almost all of which involve much greater involvement of private providers as well as increased costs (including the cost of people living longer!):
“Technology can put upward pressure on health system costs, both by increasing the scope of diagnostics and treatments available for use and by driving increases in life expectancy. Technology also carries delivery risks and risks of obsolescence, so careful strategy and programme management is important to achieve value.” (p13)
Its discussion of the issues raised by establishing the Single Patient Record as the way to integrate the information on each patient from a varied range of providers also highlights the various substantial costs involved. (p15)
The Statement also notes the considerable scepticism among doctors, who are far from convinced the new technology will be properly resourced or rolled out, with 76% regarding the “interoperability of systems” as a likely barrier, 68% “not very confident” or “not at all confident” that seamless and instant data will be available across the NHS in the next 10 years, and only 5% confident it would be. (p20-21)
It goes on to highlight the growing inadequacy of resources to deal with the rising tide of mental health problems among children and young people, where services up to now have been anything but proactive:
“There are long waiting lists for services, with nearly 360,000 children and young people referrals still waiting for contact with NHS mental health service at the end of April 2025, of which 10% have been waiting over 861 days.” (p30)
Moving on to the proposed changes to the operating model of the NHS, the Impact Statement notes without comment that the 10 Year Plan includes reducing the number of ICBs from 42 “to create clearer lines of accountability…” (p34)
It does not raise the problem of ICB mergers creating even larger organisations and reducing accountability to local communities even further. Nor does it question the realism of the hope that ICBs can reduce health inequalities. (p34)
The Statement goes on to accept without question the rehash of New Labour’s argument from the 2000s that patient ‘choice,’ and more aggressive commissioning by ICBs, coupled with a competitive market of “diverse” NHS and (presumably) private sector providers, is the way to improve the quality of services. (p36-37)
However, on page 41, there is some discussion of the added costs and complexity of a market in health care (with Cheshire and Merseyside ICB having 4,722 separate contracts). It does note that
“Decommissioning services and replacing providers will take time within ICBs and regions and could create short-term service disruption while new suppliers are found and bed-in.”
The Statement accepts without question the need for market competition and the disruption it can cause, arguing:
“The credibility of threats to decommission services or terminate contracts where services are not meeting the required standards will be dependent on the availability of alternative providers to replace the incumbent provider to continue service delivery.” (p41)
However, it does not explore the risks of increased transaction costs and bureaucracy, or the danger that a competitive market could undermine the viability of some NHS providers, threatening access to services in whole areas. It appears to discount the fact that the first choice of most patients is not to have to choose between providers, but to have safe, efficient NHS services accessible from their local NHS provider.
Not until page 61 does the Impact Statement get to grips with the underlying problem that trying to increase the share of spending on community health and primary care, and set aside funds from existing budgets for service transformation, while keeping the changes “cost neutral” brings a real danger:
“These are intended to be cost neutral proposals, that set priorities for the system and, if implemented, will benefit those areas that funding is redirected to. In doing so, the areas funding is being displaced from could be adversely impacted. There is also the risk that the requirements to meet these targets reduce local flexibilities and discretion over planning and budget setting.” (p61)
Towards the end of the Statement it belatedly recognises the contradiction between giving greater freedoms to the new “reinvented NHS foundation trust (FT) model” (p33) proposed in the 10 Year Plan on the one hand, and on the other trying also to steer more resources away from hospitals and the acute sector:
“As the provider landscape becomes a more mixed economy of new FTs and those still progressing towards FT status, there will be a need to ensure capital investments by FTs do not crowd-out the spending requirements by other providers. Historically, FTs have principally been providers of acute activity and we cannot be certain that unconstrained capital spending will not result in greater investment only into secondary care, risking neighbourhood health ambitions.” (p65)
And later still comes the belated recognition that cranking up NHS productivity (a preoccupation of ministers and the National Audit Office) is held back by the dilapidation of too many buildings and too much NHS equipment, and the lack of modern tools to speed diagnostics and treatment:
“The NHS currently faces challenges relating to both the quality and quantity of capital assets. For example, the poor quality of the NHS estate has been identified as a contributing factor to care being disrupted at 13 hospitals a day. Furthermore, the UK has just 10 CT scanners and 8.6 MRI scanners per 1 million people, compared to the average number in OECD EU nations of 20.5 and 12.4 respectively.”.”
Earlier the Statement (published in January) cited an outdated, lower figure for what is now a £16 billion backlog of NHS maintenance that should have been done to keep hospitals and clinics safe.
It underlines the fact that the Impact Statement says enough to raise serious concerns that the costs of implementing the 10 Year Plan have not been properly taken into account, or covered by planned funding, and to question the practicality of some of the key proposals, even though it fails seriously to question other important aspects of the Plan.
As it stands, the Plan is more pipedream than practical, a timid attempt to return to the competitive market that was created from 2004, and entrenched by the Cameron coalition “reforms” in 2012. Even the Tories belatedly recognised the costs and bureaucracy of that system, and moved from competition to collaboration in the Health and Care Act 2022.
Now it seems Labour’s 10-year plan would drag us back 20 years – but without the bold commitment to a decade of increased funding that meant the NHS could grow and improve services despite the costly and wasteful market system.
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