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20 August 2025 | Policy Analysis
Ten Year Plan for the English NHS
2.4. Planning
England, Scotland, Northern Ireland and Wales have their own planning mechanism with different roles for their own government and the NHS at both national and local levels (Table2.3).
Table2.3
On 3 July 2025, the UK Government published “Fit for the Future: 10 Year Health Plan for England” [1]. This strategic document sets out a long-term vision for changing and improving care delivery and financial resilience in England’s public sector healthcare system. It will be followed by a specific delivery plan, and an updated workforce strategy.
This plan’s creation was announced by the incoming Labour government in July 2024, in the context of a change of ruling party and of historically high dissatisfaction with the English NHS [2]. Its remit and definition of problems were informed by the Darzi Review into the performance of the service [3]. During late 2024, a national engagement effort to inform the plan – “Change NHS” – gathered more than 250 000 contributions from staff, patients and the public. Its drafting emphasizes an urgent need to change, faith that great improvement is possible through efficiency and innovation and the goal of choice and improved experience for patients.
“Shifts” envisaged in the plan
The plan emphasizes “three fundamental shifts” in the English health service, with an extensive collection of commitments and over 200 specific initiatives.
- A shift from “Hospital to community”. This includes a commitment that the share of expenditure on hospital care will fall within three to four years. “Neighbourhood health services” will be created that connect primary and community care services through different contract models. Shared locations for this will be created as 250–300 “neighbourhood health centres” that provide integrated local services that will be staffed by multidisciplinary teams. The plan argues that this shift in resources and structure will enable savings in hospital services. There is a pledge to reform the dental contract, widely seen as unfit for purpose.
- A shift from “analogue to digital”. This would enhance the existing English NHS App, widely downloaded during the COVID-19 pandemic but limited in usage and functionality into a central interface for patient self-referral, appointment booking to neighbourhood health services, repeat prescription management, and collecting patient feedback shared with care providers. There is also to be a mandated single patient record by 2028. The plan envisages a rapidly growing role for both patient-facing and clinician support AI, with a national scheme to procure “Ambient AI” scribing interactions for care records.
- A shift from “sickness to prevention”. New public health measures include easier access to weight loss medications, restrictions on junk food advertising and restrictions on high caffeine energy drink sales to minors. The plan commits to “genomics population health service” with universal screening for newborns.
Other measures
The plan also contains several other significant policy commitments, on quality, workforce, technology and innovation, structure, and financing.
- Self-referral enabled for services such as mental health, audiology, podiatry and musculoskeletal care via the NHS App.
- An aspiration for high-performing provider bodies in the NHS to earn greater autonomy and to be rewarded with financial incentives, with 50% fewer officials employed in the central bodies of the health service.
- An emphasis on “strategic commissioning” (purchasing) as the core role of Integrated Care Boards, which are the regional fund-holding bodies of the English NHS covering populations typically around 2 million.
- Health technology appraisals conducted by NICE for compulsory adoption will be expanded to medical devices and digital products. The body will also review previously approved pharmaceutical products to eliminate those that are no longer cost effective.
- There will be a trial of “Patient power payments”, a concept where patients are contacted after care and decide whether to deduct an amount from the provider’s payment based on satisfaction with their care.
- The plan continues the long-standing interest of the English NHS in expanding the roles of different professions to take on tasks traditionally reserved for those with certain medical and nursing qualifications. It aims to expand the paradigm of training healthcare workers to individual tasks rather than wider roles, and states that there are “significant opportunities to move beyond traditional professional boundaries in a safe and productive way.”
- Measures to enhance personalized care, including the introduction of personal health budgets for up to one million people by 2030, with universal availability by 2035. A new standard that, by 2027, 95% of people with complex needs will have an agreed care plan.
- A maximum 10% reliance on overseas recruitment by 2035 – reliance on staff trained outside the UK is currently far higher, and above 50% for newly registering qualified doctors [4].
Reaction and analysis
Expert and representative bodies in the UK broadly welcomed the direction of the “three shifts” and accepted the problems the plan aims to address. Many expressed some scepticism around delivery. Common concerns were that such an expansive agenda would be difficult to deliver properly or sustainably given the relatively modest increases in the budget announced following the plan; that details of contracts and timescales were limited; and that social care and public health services in England remained unreformed and underfunded, creating a difficult context [5, 6]. The emphasis on adopting innovation has the potential to increase costs [7].
Several reactions noted that the plan brings back a higher reliance on financial incentives, competing providers and a divide between purchasers and providers [8]. This partially reverses previous moves towards greater collaboration to drive integrated care, though many of these initiatives are being retained or redeveloped as well.
References
[1] https://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future
[3] https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england
[4] Rolewicz L, Dayan M, Hemmings N, Palmer W (2025). Immigration crackdown threatens NHS workforce, data show. BMJ 2025; 390:r1554 doi: https://doi.org/10.1136/bmj.r1554 (Published 5 August 2025)
[6] https://nhsproviders.org/resources/on-the-day-briefing-spending-review-2025
2.4.1. NHS in England
Operational responsibility for the NHS in England has sat with NHS England since 2013. The United Kingdom Government sets legally binding objectives and budget for NHS England through an annual mandate, supported by detailed criteria and metrics. The mandate also sets out the capital and revenue resource limits for NHS England. As a mechanism for national level accountability, the NHS Outcomes Framework sets out national outcome goals that the Secretary of State for Health uses to monitor the progress of NHS England. Indicators are grouped in five domains: preventing people from dying prematurely; enhancing quality of life for people with long-term conditions; helping people to recover from episodes of ill health or following injury; ensuring that people have a positive experience of care; treating and caring for people in a safe environment; and protecting them from avoidable harm (NHS Digital, 2021a).
The NHS Long Term Plan, to which the mandate refers, was published in 2019 and sets out a plan for the NHS over a decade to 2029 (NHS England, 2019d). The Long-Term Plan is the first on a 10-year horizon, spanning beyond government terms and planning cycles. The Plan sets out priorities for improvements in care, including for infants and children, in relation to improving care, for the leading causes of morbidity and mortality and in supporting the population to age well.
At the local level, the 10-year plan provides the framework from which Sustainability and Transformation Partnerships and now ICSs develop and implement five-year plans locally. ICSs are intended to be operational by July 2022 and will replace CCG, which were previously responsible for commissioning and planning health care services for the local population (see section 6.2 Future developments). ICSs will be responsible for bringing together a wider set of system partners to promote partnership arrangements to address the broader health, public health and social care needs of the population (see section 6.1 Analysis of recent reforms). Membership will be determined locally, but as a minimum representatives will be required from local government, NHS trusts and primary care organizations, and it is likely that there will be further representatives of local voluntary and third-sector organizations, social care providers, housing providers and independent sector providers (Charles, 2021).
2.4.2. NHS in Scotland
The Scottish Government is responsible for setting the strategic direction for the NHS in Scotland as well as priorities for delivery. The Scottish Government National Performance Framework, first introduced in 2007, guides government policy generally, including for health. The aims of the framework are centred on creating a more successful country, providing opportunity to all, increasing the well-being of the population, creating sustainable and inclusive growth and reducing inequalities (Scottish Government, 2021c).
The Scottish Government devolves responsibility for delivery of health services to 14 local NHS boards, which are required to develop annual delivery plans that align with Scottish Government priorities and provide the delivery contract between the Scottish Government and NHS boards in Scotland (Scottish Government, 2016b). This process is under review as we emerge from the pandemic. For the last 18 months, NHS boards have produced and worked to implement Remobilisation Plans, but as these expire, NHS boards are moving towards the introduction of three-year operational plans. These plans support the delivery of the National Performance Framework and performance against objectives is measured using standards set by agreements between the Scottish Government and NHS boards. Standards include indicators around diagnosis, access, time to treatment and maternal, reproductive and child health (Scottish Government, 2019b). Since 2016, NHS boards have also been required to work with local authorities as part of the IJBs to plan and deliver integrated care services through the development of a strategic joint commissioning plan that is aligned with the achievement of nine national health and well-being outcomes published in 2015 (see section 2.5 Intersectorality).
Since 2018, NHS Scotland has convened an NHS Scotland National Planning Board (NHS Scotland, 2021b), which is intended to provide oversight, governance and decision-making in relation to national planning of NHS services, with a particular focus on financing, workforce, digital health and health care infrastructure. The national planning agenda is only intended to encompass services that need to be planned nationally, with criteria based on volume and workforce (specialists or scarce skills). Membership of the board includes Chief Executives of health boards, Executive Group Representatives (for example, Directors of Finance) and Scottish Government Directors/Deputy Directors.
2.4.3. NHS in Wales
In Wales, the Minister for Health and Social Services sets the overall policy context and direction for the NHS through national strategies and delivery plans. There is a 10-year strategy for health and social care in Wales, “A Healthier Wales: Health and Social Care Action Plan”, published in 2018, which outlines a long-term vision of a “whole system approach to health and social care”, which is focused on health and well-being, and preventing illness (Welsh Government, 2018a).
The implementation of national strategies is supported by the publication of three-year action plans by the LHBs, called Integrated Medium-Term Plans (IMTPs), which are reviewed annually by the Welsh Government, and, if IMTPs are approved as aligning with national priorities, LHBs are rewarded with three-year financial allocations and a measure of freedom in expenditure within the three-year period. Guidance is provided to LHBs through the NHS Wales Planning Framework (Welsh Government, 2019) and LHBs are expected to align their IMTPs within priorities outlined within the National IMTP, which is developed by the NHS Executive. There is also a statutory requirement that LHBs form formal partnerships with local authorities to coordinate provision of health and care services through Regional Partnership Boards, and to improve population health outcomes and well-being through Public Service Boards. Both Regional Partnership Boards and Public Service Boards involve joint membership from LHBs and local authorities, which produce integrated plans that align with priorities outlined within the 2014 Social Services and Well-being (Wales) Act and the 2015 Well-being of Future Generations (Wales) Act (see section 2.5 Intersectorality).
In tandem with these processes, the Welsh Government has developed a National Clinical Framework, which is a novel approach to governance and planning of high-quality services in Wales (Welsh Government, 2021a). The NHS Executive oversees the implementation of the National Clinical Framework and provides further support through its national programmes and networks. The National Clinical Framework is underpinned by the introduction of quality statements that set out in more detail the standards and outcomes expected from particular clinical services. All NHS organizations are expected to adopt quality management systems and provide annual reports on quality, in line with indicators outlined within each quality statement. In 2020, the Welsh Government also introduced legislation that outlines a duty of candour for NHS organizations to be open and honest regarding any failures to provide high-quality and safe services (Welsh Government, 2020).
2.4.4. Health and social care in Northern Ireland
In Northern Ireland, the Minister for Health is responsible for setting priorities for health and social care in annual “Commissioning Plan Directions, Indicators and the Programme for Government” (Department of Health Northern Ireland, 2018) and through national plans and strategies. National policy continues to be guided by the 10-year strategy published in 2016: “Health and Well-being 2026: Delivering Together” (Department of Health Northern Ireland, 2016), which was published in response to a review chaired by Professor Rafael Bengoa in 2016 (see section 6.1 Analysis of recent reforms). This review outlined some of the persistent structural, financial and demographic challenges faced by the Northern Ireland health system (Bengoa, 2016).
The Health and Social Care Board and Public Health Agency are required to respond to Commissioning Plan Directions by producing annual commissioning plans (HSCB Northern Ireland, 2019a). Performance against Commission Plan Directions is monitored using an agreed outcomes framework, the “Indicators of Performance Direction” (HSCB Northern Ireland, 2019b). The Health and Social Care Board commission health and social care, and reviews the performance of five health and social care trusts and the Northern Ireland Ambulance Service, in conjunction with five local commissioning groups, which are also responsible for commissioning social care services. While local commissioning groups can technically commission services from any appropriate provider, health and social care trusts are the main provider by default, and in reality, the relationship between local commissioning groups and health and social care trusts is linked to planning rather than commissioning.
Northern Ireland is currently developing a new planning model for health and social care services, which is due to be implemented in April 2022, centred around developing an ICS model (Department of Health Northern Ireland, 2021). A regional board will be established under the direction of the Department of Health in partnership with the Public Health Agency, which will oversee five separate Area Integrated Partnership Boards, one for each pre-existing health and social care trust (see section 6.2 Future developments).