Re:Act 3 July, 2025

Re:Act: 10 Year Health Plan

Almost one year to the day since this Government was elected, we finally have the long awaited Fit for the Future: 10 Year Health Plan for England. Months of speculation and weeks of trailing, the full 168 pages leave few stones unturned across public health, primary care and secondary care.

Very few would dispute the goals of this plan. Neighbourhood Health Centres, healthier populations, more and better technology — these are all admirable intentions. But the truth is that successive governments have promised to deliver this vision and successive governments have failed.

Today we hoped to see more of the how rather than the what. Unfortunately, this is largely a plan without a plan. Indeed, I’m sure health leaders across the country felt slightly bemused to read NHS England chief executive Sir Jim Mackey say the document was designed to create “energy and enthusiasm” and not intended as detailed guidance.

Ultimately, what should have been the first step towards real reform could risk becoming a collection of good intentions rather than deliverable actions. This would be more aptly characterised as a 10 Year Vision rather than a plan.

It’s not without its merit: as we outline below, its ambition to change funding models, diversify the workforce, improve management and empower local authorities is aligned with Re:State’s ambitions. Delivering this could dramatically improve the NHS over the next decade.

But the implementation complexities in the NHS should not be underestimated — a highly fragmented system characterised by endless funding flows and leadership structures — and so failing to plan for the implementation could fatally undermine this Plan’s success.

Read on for Re:State’s analysis of what the Plan could be good for, bad for, what is missing in action and what the jury is still out on. Bear in mind the ‘good’ is based on the assumption that these things will be matched with detailed implementation.

👍 GOOD FOR

Pooling budgets

There are some promising signs of a shift towards consolidated budgeting through ‘year of care’ payments. These allocate a capitated budget for a patient’s care over a whole year, instead of reimbursing individual services (all with different incentives). Re:State has consistently endorsed this idea: integrating funding pools between primary care, acute care and local authorities is paramount. This kind of payment model has not been used at scale before in England, and experience from other countries suggests it could create system-level incentives for prevention, so that providers can share in the overall savings or suffer from cost overruns.

What’s more, local areas should have the flexibility to spend this money in ways best suited to boosting population health in their area. Given that control of numerous services which play a role in population health sit under local government — including housing, children’s services, leisure and cultural services — neighbourhoods may choose to prioritise non-healthcare spending to boost outcomes. The details in the Plan on what this could look like are scant, but if it really is pooling these budgets then this could be a game changing shift in how services are funded.

Financial incentives

Too often a lack of spending is seen as the root cause of the health system’s problems. This Plan rightly refutes that. Rather, it is how money is allocated in the health system that incentivises particular types of activity. This Plan takes on some of the misguided financial models in the NHS — ending block payments, for example, is something that will make many across the health system punch the air.

Block payments mean that those managing district nurses or A&E receive a fixed annual sum, regardless of volume of activity or particular quality metrics. Therefore, if an A&E ends up seeing more patients or undertaking more activity, they have to absorb the cost. This often means quality reduces in order to see a higher volume of patients. In its place, they wish to introduce a model that pays a bonus for high-quality care and withholds payment for poor quality care. This comes with some risk, but arguably less risk than a block contract.

Drawing on private finance

NHS buildings are expensive. They are also falling apart. Around 2,000 premises have been identified by GPs as not fit for purpose. But the convergence of a poor primary care estate with the urgent need to focus on population health presents an opportunity to fundamentally reset the approach. It has been fairly well established in recent years that pension funds and other private developers are increasingly expressing an interest in building new primary care premises, which can then be leased back to ICSs or GPs.

Using private finance, as laid out in this Plan, is a win win: there are a number of complexities to primary care estate financing (e.g. much of the estate is actually owned by GPs or they are locked into extremely long leases) that this model would circumnavigate, in a cost efficient way for the taxpayer. Provided it’s executed carefully, this is a logical step to be taking — and one we called for in our paper Prescription for prevention.

Improving management

Management is frequently, and unfairly, considered a dirty word in the NHS. Consistently disparaged by politicians and the media, managers are too often deprioritised in policy interventions. Re:State has long believed this to be wrong. Thankfully, the Plan makes a break from this pattern. The NHS does not have enough managers and they are not consistently trained.

It was therefore positive to see that a new Management and Leadership Framework will be published later this year setting clear standards and competencies for leaders of all levels, as well as establishing a new national and regional talent management system for leaders by April 2026, to identify and support those with greatest potential into future leadership roles. Supporting this talent development, the Graduate Management Trainee Scheme will be expanded by 50 per cent and an independent College of Executive and Clinical Leadership will be established.

Workforce diversification

As we explored in Prescription for prevention, crucial to the ‘leftward shift’ is diversifying the kind of people involved in the delivery of healthcare. This Plan proposes Community Health Workers — who are trained at a low technical level to support a group of households with a broad range of activities — as well as other necessary staff members from the local authority and voluntary sector, such as debt advice, employment support and smoking cessation, as part of the Neighbourhood Health Centres. Conversations about primary care are almost always about GPs, and currently these non-clinical roles only exist in pockets of innovation across the system. Ensuring they exist in all places, rather than just some, is crucial to the prevention agenda.

Empowering local government

This document sets out a notable commitment to alignment and more effective working with local government, with a promise to make “ICBs coterminous with strategic authorities by the end of the Plan wherever feasibly possible.” The “wherever feasibly possible” part of this commitment could end up being a significant pressure-point. Already, as Integrated Care Settlements “cluster” together in order to achieve savings, they are doing so in a way which does not align with the borders of existing Strategic Authorities.

Tantalisingly, though, the Plan also mentions work to improve the democratic oversight and accountability of how local health is delivered, with explicit mention of a possible future role for mayors. Coterminosity, direct strategic commissioning powers for ICBs, and an oversight role for mayors: ingredients for a system that would, if implemented, closely resemble the plans set out in Re:State’s Close enough to care.

Endorsing virtual by default

By 2028, patients will have access to their full medical history in one place — the Single Patient Record (SPR) — and the NHS App will be the “full front door to the entire NHS”. The NHS App will boast a plethora of transformative tools, from an AI-enabled ‘doctor’ to provide 24/7 guidance, to self-referrals for appropriate specialisms, to digital long-term condition, prescription and vaccination management.

And ‘virtual by default’ rings just as true for providers and staff, as for patients. From a “digital first HR strategy” supported by an HR app to the embedding of AI in practically every part of health services, the plans are extensive. Notably, a new technology platform will be procured specially tailored to the needs of the Neighbourhood Health Service. And ambient AI — which takes clinical notes automatically for clinicians — will be available to all GPs and trusts, following a national procurement process in 2026-27.

Patient empowerment

Patient empowerment is at the heart of much of the Plan. Patient agency, activation and education are crucial to improving prevention so this is a welcome step. Through the SPR and NHS App, individuals would be the holders of their full medical history, from long-term condition care plans, to vaccination records, to wearable device data. Individuals will, for the first time, be able to self-refer to secondary care for appropriate specialisms and remotely send questions to specialist consultants to answer.

The Plan details that patients will, via the My Choices tool in the NHS App, be able to compare providers across the country based on wait times, health outcomes and patient satisfaction scores, then choose where to receive secondary care based on this information.

Patient agency is also prioritised for patients who are often excluded. My Companion, another tool of the NHS App, will support translation, enabling everyone to engage with healthcare in their first language.

Precision prevention

Population health management has emerged in recent years as a particularly compelling way to make public health more precise. Genomics — the study of genes and their functions — combined with population health data augments this even further. Therefore, substantially expanding the NHS Genomics Medicine Service, in order to boost secondary prevention and manage population health, is a welcome initiative.

From new-borns to older cancer patients, the wide-ranging use of genomics will be used to screen for future disease, identify and mitigate risks, and equalise access to knowledge so that individuals are empowered and informed about their own health. The plan to develop the genomics population health service also has a unique level of implementation detail — with a clear direction for realistic delivery, along with a thorough consideration of medical and ethical risk.

👎 BAD FOR

Technology realism

At Re:State, we love an ambitious, radical idea (see the abolition of NHS England). But if there was one way to characterise this plan, it was its ruthless commitment to using technology for almost every problem. In a world where technology dominates our lives, this should not be a surprise, and they are right to aspire for technological transformation in every crevice of the NHS. However there was no recognition that technology adoption in such a fragmented system is fundamentally difficult. Electronic Patient Records (EPRs) started being rolled out in 2002 and some hospitals are, inexplicably, still paper-based.

Almost every technology recommendation has a target date of 2028 — when you look at the 23-year turnaround for EPRs, you can see how a modicum of delivery strategy is essential. Change management in the NHS is also famously suboptimal. Introducing new technologies requires rethinking clinical workflows and processes, and usually relies on uniquely motivated clinicians to push through the change. And these don’t always exist. All evidence suggests that just throwing technology at the NHS doesn’t always achieve its aims: failure to develop an implementation plan in this area could ultimately compromise the entire effort.

Operational burdens on providers

The Single Patient Record (SPR) will aggregate all of a patient’s medical data, from all health and care providers, into one record. This is a welcome goal, crucial for improving NHS efficiency, delivering more joined-up care and patient empowerment. To this end, the Plan requires providers to make recorded patient information available to the patient, in turn requiring uniformity in how clinical information is recorded and coded across every provider. Currently, each provider's patient record system codes information uniquely, as well as wide variation in how information is recorded by each provider.

Despite garnering only a single sentence in the 10YP’s 168 pages, shifting from this current reality to uniformity by 2028 will be a vast burden on providers. A necessary shift certainly, but there is little acknowledgement of how this (rightly) ambitious target will be achieved or supported.

Urgent and emergency care

This Plan falls victim to one of the most dangerous assumptions in the NHS: that if prevention improves, everything else — especially A&E — will organically improve. It is certainly true that reducing demand at the source will help to reduce some pressure on hospitals. But A&E doesn’t work because hospitals don’t work, and hospitals don’t work because there is too little focus on congestion in hospitals, and high demand is not the only thing driving this, as we explored in 2023. Indeed, inefficiency drives congestion as much as demand does.

There was a huge opportunity here — as we outlined in Hospital as a service, not a building — to radically reform how A&E works. For example, virtual accident and emergency services have compelling evidence to support their rollout — they are quick to deliver, and once scaled, they are notably efficient. Moorfields Eye Hospital, for example, estimated that it was able to avoid more than 540 face-to-face appointments within the first two weeks of launching its service. A new AI tool that helps to navigate the health service does not create anything close to this.

Assuming co-location and integration are the same thing

When we published Designing a neighbourhood health service in March this year, we were keen to highlight the transformative powers that hyper-local, co-located health services can have. However, we went to lengths to stress that simply having medical staff and patients under the same roof does not necessarily mean that services are integrated effectively. What’s the point in having both a physio and nurse in the same building, if the only way a patient can see both is through duplicative and convoluted referral processes?

Yet, it seems that the Plan fails to effectively take into account that co-locating services and placing them in the community does not magically transform them into integrated health services.

Changing financial flows, culture, and technology are essential for this. And given the emphasis on neighbourhood care, it is striking that integration is so absent.

🧐 MISSING IN ACTION

Discharge

Discharge is famously one of the most wicked issues in the NHS. It is consistently highlighted as one of the major barriers to effective and efficient hospital care, and yet is barely mentioned in the Plan. It is, of course, a focus of other plans, such as the Urgent and Emergency Care Plan, but given that a significant proportion of delayed discharges are due to hospitals having to engage with local authorities on social care, on homelessness or patients with uninhabitable accommodation, this is a massive oversight. Improving discharge is essential to unlocking capacity in secondary care.

Referral management

The Government has repeatedly told the electorate to judge them by their actions, not their words; and in particular, the Health Secretary has put elective care at the forefront of how he should be judged. Yet the Plan says nothing at all about innovative approaches to waiting lists and referral management. Given that the volume of referrals being rejected by secondary care are greater than pre-pandemic, despite similar levels of referring, this seems to be an obvious oversight.

If you want some ideas Wes, we have some here: Hospital as a service, not a building.

⚖️ JURY'S OUT

Capital reform

It’s impossible to have a conversation with any senior leader in the health service without the lamentable capital regime emerging as the blocker to most innovation and improvement. Capital funds long-term investment, so it is impossible to meaningfully change how things are done without a sensible capital regime. It often requires trusts to obtain approval from DHSC in order to spend their capital allocation, particularly if it is a larger sum. DHSC also often holds back allocations to avoid overspend, meaning that trusts might receive some of their capital allocation half way through the year, and rush to spend it to avoid losing it.

The proposal to reform the capital regime however is still fairly convoluted. Introducing multi-year capital budgets, on a 5-year rolling basis, is welcome and overdue. As is radically streamlining the capital approvals process, but it’s not clear what this actually means in practice. And the changes to capital allocation and expenditure for new foundation trusts is ambiguous.