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24 June 2025 | Country Update
Assisted dying likely to become law in England, Scotland and Wales -
08 October 2024 | Policy Analysis
Independent investigation of NHS performance and long-term plan in England
6.2. Future developments
All United Kingdom constituent countries experienced major health policy changes in 2020 as part of the COVID-19 response (see Box6.1) (Dunn et al., 2020). Questions about future health system reform are taking place in the context of broader policy debates about the shape of public services as the country recovers from the pandemic.
Box6.1
The Terminally Ill Adults (End of Life) Bill passed its third reading in the House of Commons on 20 June 2025 and is likely to pass into law for England and Wales during the next 12 months, after debate and amendment in the upper House of Lords [1]. An analogous law (the Assisted Dying for Terminally Ill Adults (Scotland) Bill) is also currently going through the Scottish Parliament [2]. The Bills would legalize physician-assisted suicide, limited to adults judged to be suffering from terminal illnesses.
Neither specifies in detail how assisted dying would be provided alongside or as part of state-provided healthcare services. They were proposed independently by parliamentarians, and governments in England and Scotland are neutral. Following their passage, governments would have latitude to decide when provisions come into effect and how to design services.
These changes will require extensive policy formulation as to what assisted dying services would be implemented, who would deliver them, and how they could work alongside end-of-life care services. It will take time to train staff and put clear processes in place for monitoring and compliance. The Secretary of State for Health has said there is no extra funding available for the launch of a new service at this time; an earlier impact assessment estimated savings from assisted dying, though with a wide margin of uncertainty [3].
Authors
References
[1] The Terminally Ill Adults (End of Life) Bill (June 2025): https://bills.parliament.uk/bills/3774
[2] The Assisted Dying for Terminally Ill Adults (Scotland) Bill: https://www.parliament.scot/bills-and-laws/bills/s6/assisted-dying-for-terminally-ill-adults-scotland-bill
[3] Impact Assessment: https://assets.publishing.service.gov.uk/media/68247bfdb9226dd8e81ab849/terminally-ill-adults-end-of-life-bill-impact-assessment-updated.pdf
On 25 September, the UK Department of Health published a review of National Health Service performance in England by the prominent surgeon Lord Ara Darzi [1]. This was commissioned by the Secretary of State for Health in July, following the electoral victory of the Labour party, presented as a stock-take of their inheritance from the previous Conservative party government [2].
The report warned that the English National Health Service (NHS) is “in serious trouble”, with a crisis marked by unprecedented public dissatisfaction, poor access to care, and declining health outcomes. It also made recommendations for a forthcoming 10-year plan for the service, expected in 2025 following a public engagement process.
Waiting times for GP appointments, community services, and mental health care have surged, with millions waiting for treatment, particularly among vulnerable populations like children. The NHS has not met key performance targets since 2015, leading to further erosion of public confidence. Cancer survival rates remain below those of comparable countries, and the rate of inclusion has slowed over the last 15 years. Despite recent increases in staffing, productivity appears lower than before the COVID-19 pandemic, which has left a difficult legacy of higher need, staff stress, and delayed treatment.
Lord Darzi noted that deteriorating population health, associated with worsening of the social determinants of health, such as housing and income, had exacerbated the situation. The report also pointed to diminished and limited managerial capacity, praising management generally for attempting to “keep the show on the road”, and to a lack of capital investment. It concluded that the move to “Integrated Care Boards” bringing together purchasers and providers “has the makings of a sensible management structure” and applauded the shift towards collaboration over competition. However, it noted that despite attempts to shift care from hospitals to community and primary care, spending and staffing had become even more concentrated in hospitals.
Specific policy recommendations were outside the report’s scope, but it provided a set of themes for a comprehensive 10-year health plan to address systemic issues and strengthen the NHS. These were:
- Re-engage staff and re-empower patients.
- Lock in the shift of care closer to home by hardwiring financial flows, reflecting a government commitment to expanding the share of the budget spent outside hospital.
- “Simplify and innovate care delivery for a neighbourhood NHS”, with multidisciplinary care across primary, community and mental health care.
- Drive productivity in hospitals through better management and capital investment.
- Improve the use of technology, particularly by expanding electronic records and digital data to services outside hospital, and by adopting AI.
- Contribute to the nation’s prosperity by reducing the number of people economically inactive due to health needs.
- Clarify roles and accountabilities, rebalance management capacity, and improve capital approvals so that the health service is better able to deliver on policies.
References
6.2.1. England
In July 2021, the United Kingdom Government published the Health and Care Bill 2021/2022 (UK Government, 2021b), which outlines major changes to NHS rules and structures in England. The Bill is the largest legislative overhaul of the NHS in a decade – and undoes many of the changes introduced by the 2012 Health and Social Care Act (see above).
The main measures in the Bill cover two areas. The first is a set of changes to promote collaboration within the health system, largely following the direction already set within the NHS Long-Term Plan (see above) (Anderson M et al., 2021c). Under these plans, England will be covered by 42 ICSs (which currently exist informally). Each system will be made up of two new bodies: integrated care boards – area-based NHS agencies, responsible for controlling most NHS resources to improve health and social care for their population – and integrated care partnerships – looser collaborations of NHS, local governments and other agencies, responsible for developing an integrated care plan to guide local decisions. Clinical commissioning groups will be abolished and their functions taken on by integrated care boards (see section 2.2 Organization). The role of competition will be reduced as Section 75 of the 2012 Health and Social Care Act, which required commissioners to competitively tender some clinical services, will be repealed.
The second area includes a set of changes to strengthen central political control over the day-to-day running of the health system in England – something that the 2012 Health and Social Care Act had sought to loosen. The bill gives the Secretary of State for Health and Social Care wide-ranging new powers. These include the power to direct NHS England over almost all its functions and intervene more freely in local service reconfigurations. These proposals have been controversial and are currently being debated in the United Kingdom Parliament (Alderwick, Gardner & Mays, 2021). The changes outlined in the Bill are due to be implemented from July 2022.
The public health system is also undergoing reform (Anderson M et al., 2021b). The United Kingdom Government disbanded Public Health England in 2021, dividing national public health responsibilities between several new agencies. The United Kingdom Health Security Agency has been established to focus on health protection and security, modelled on the Robert Koch Institute in Germany (Iacobucci, 2020c). A new Office for Health Improvement and Disparities has been created in the DHSC, taking on Public Health England’s responsibilities for health improvement and reducing inequalities at the national level. This dismantling and reorganization of Public Health England has been questioned as unnecessary and potentially disruptive at a time when the United Kingdom is still coordinating its response to the COVID-19 pandemic (Iacobucci, 2020c).
Reform has also been proposed to adult social care funding. In late 2021, the United Kingdom Government announced that it would introduce a cap on the maximum amount that individuals would have to pay for social care services over their lifetime – a decade after the policy was first proposed by the Dilnot Commission. The cap is planned to be introduced in 2023, initially set at £86 000 (€101 824). Once individuals hit the limit, the state will cover care costs. The proposed changes will help address the issue of catastrophic care costs for some people using care, but not wider issues related to access to care, quality, poor working conditions and other problems faced by the social care system. The cap on costs is also less generous than what was proposed in the 2014 Care Act (£72 000) and in practice provides little changes to catastrophic costs compared with current arrangements for those with low to moderate wealth up to around £100 000 (Tallack, 2021). A further white paper has been published by the United Kingdom Government on changes to the adult social care system, but the white paper did not propose any significant policy changes or major additional investment (Wise, 2021).
6.2.2. Scotland
The Scottish Government is considering major changes to its social care system. An independent review of adult social care in Scotland was published in 2021 (Feeley, 2021). It argued that a “national care service” should be created on an equal footing to the NHS, with accountability for social care moving from local governments to the Scottish Government. The Scottish Government accepted the recommendations and published a consultation on its more detailed proposals. Under the proposed National Care Service, standards for services and terms and conditions for care workers would be set nationally, new simplified outcome measures for health and social care would be established. Local IJBs would be replaced by directly funded bodies, with boards representing local care users, workers, unpaid carers and service providers, which would take responsibility for planning and commissioning of social care services. Legislation to establish the National Care Service is due to be brought forward in 2022, with the NCS established over the lifetime of the current Scottish Parliament. (Scottish Government, 2021b).
6.2.3. Wales
National health policies in Wales continue to focus on coordinating services to improve health and well-being. As mentioned above, parliamentary review in 2018 called for a clearer vision to guide health and social care services in Wales – focused on creating “one seamless system for Wales” – a greater focus on quality improvement, and testing and development of new care models (Welsh Government, 2018b). In response, the Welsh Government published a new plan for health and social care in 2018, A Healthier Wales: our Plan for Health and Social Care (Welsh Government, 2018a). The plan sets out how services would be supported to deliver the quadruple aim of improved population health and well-being, better quality services, higher value health and social care, and a motivated and sustainable workforce. The parliamentary review also recommended the implementation of “stronger” central governance of the NHS and there are now plans to introduce a central NHS Wales Executive to strengthen national leadership (see section 2.3 Decentralization and centralization). The Welsh Government has also passed legislation that supports the national strategy, specifically the 2020 Health and Social Care (Quality and Engagement) (Wales) Bill (see section 2.4 Planning).
The Welsh Government updated their vision to deliver effective, high quality and sustainable health care in their programme for 2021 to 2026 that includes several commitments including greater integration of community services, establishing a national social care framework, and investment in a new generation of integrated health and social care centres across Wales (Welsh Government, 2021e). Similar to Scotland, the Welsh Government also announced in 2021 that it would set up an expert group to support an ambition to create a “National Care Service”, free at the point of need (Welsh Government, 2021f). There are plans to agree an implementation plan by the end of 2023.
6.2.4. Northern Ireland
Northern Ireland has launched a consultation on the development of a new planning model for health and social care services in Northern Ireland (see section 2.4 Planning), which will be supported by proposed legislation, the Health and Social Care Bill (Department of Health Northern Ireland, 2021). A Regional Board will replace the pre-existing Health and Social Care Board from April 2022 and will oversee five separate Area Integrated Partnership Boards, one for each pre-existing health and social care trust. Area Integrated Partnership Boards will be expected to work with local councils, GP networks and voluntary organizations through collaboration and partnership in the design, delivery and management of health, social and community services. The Regional Board will produce an annual population health and well-being plan that aligns with the strategic direction set by the Minister and the Department of Health. Progress of Area Integrated Partnership Boards in achieving the objectives outlined in this plan will be monitored against agreed key performance indicators that reflect improving health and well-being and reducing health inequalities for their respective populations.