Unpacking the NHS 10 Year Plan
The NHS 10 year plan was published earlier this month. I caught up with Dr Sandra Danso-Bamfo, fellow GP and blogger to discuss. Here are the highlights from our chat!
SDB: Hi Lara. I’m glad we found the time to chat about this. 3rd July was a Big Day for the NHS! Now that we’re two weeks in, first question, have you read the plan in full or just the executive summary?
LS: I have not read the 170 pages in full! I like reading the executive summary then reading more via a deep dive on sections that are salient to what’s on my mind.
SDB: Let’s dive straight in then. The ‘Sickness to Prevention Section’ of the document mentions ‘joined up support across work, health and skills systems’. This is something we're both passionate about. What are your initial thoughts?
LS: I welcome the focus on the social determinants of health, and it’s great to see some tangible case studies of what employers are doing well. I don’t think there is anything new from a work and health perspective, the plan mostly refers back to what is going on in welfare policy.
I believe there needs to be clearer communication on what public service stakeholders can expect to see unless we solve for what we are currently seeing at the work health interface. With many people economically inactive due to ill health drawing on health and welfare services and not contributing to tax revenues, the government will have less money to spend across public services, unless borrowing or taxes are increased. This is relevant to everyone.
Finally, it’s interesting to see the NHS highlighted as the UK’s biggest employer. To me, the NHS should be a trailblazer organisation that sets standards and demonstrates good practices. The NHS staff survey is a great start as there is a decent amount of data collected- anyone can take a look at it here. You’ll notice that respondents report working conditions that are pretty far off the mark. This is also alluded to in the 10 year plan…’Staff have faced harassment, have gone without access to basics like food and hydration and have experienced high rates of short-term and long-term sickness as a result’.
SDB: That’s a very important point. I’m not sure if it’s ironic or intuitive that a healthcare employer has unhealthy staff. Do financial companies- auditors, banks etc have employees who are worse at managing their finances than average? I don’t think so. There’s definitely an issue with the NHS and given that it’s more representative of the UK as a whole than any other employer, it’s the biggest canary in the coal mine anyone could ask for.
Moving on to another big chapter for you here: An NHS workforce, fit for the future. What do you think?
LS: I think tech augmentation of human professional capability is the main leverage the NHS has to meet demand. This was baked in throughout the plan. However, without an implementation strategy it is difficult to make sense of this. Supporting a professionally diverse workforce to work alongside more technology is a huge challenge which has its own risks to service provision and care. Technical leadership will be required at all levels and NHS staff should be supported in upskilling to meet this demand. The details on this are missing from the report.
SDB: Speaking about the healthcare workforce, let’s focus on doctors. I'm not sure which came first, the BMA JDA's recent push for local graduate priority access to training spots or the government's aim to significantly reduce reliance on international recruitment, but as a locally trained doctor, what are your thoughts on how this has played out over the past 12 months to now being mentioned in the 10 year plan?
LS: This is an extremely interesting topic and one I would like to explore further. It is part of a much bigger debate around working conditions and skills migration. UK medical graduates have been trained within and for the NHS. Retaining talent is important in reaping the benefits of this investment but has been difficult for the NHS to achieve, so much so that the UK has incentivized international recruits by open routes into training on equal terms with UK graduates.
To attract and retain more UK trained talent, working conditions - including but not limited to pay in the NHS will have to improve.
SDB: As a follow on, what do you think of the plans for the NHS/ Health and Social Care workforce overall?
LS: There was not much focus on the social care workforce and I would argue that the NHS and social care have to be seen as more of a continuum to achieve progress. The social care workforce is fragmented. Many social care professionals are in insecure agency employment. Many social care roles are parallel in role and responsibility to what would be expected of an NHS HCA. Their working conditions are relevant to the NHS because social care capacity is a direct limiting factor to NHS care.
On the subject of workforce planning, data from previous government pledges shows us that recruiting and training more GPs does not necessarily lead to more FTE GPs. Why is this and what needs to change?
SDB: The document states 1,700 newly qualified GPs have been recruited since 2024 however, one of the biggest recent developments is GP unemployment in the face of GP appointment scarcity. The plan only mentioned the creation of 1000 new speciality training posts with a focus on need and an expansion of medical school places. It still sounds like policies are implemented in silos. Increasing the number of GP training posts is a long standing national aim. The numbers have increased from 2,671 in 2014 to 4000 in 2021 so while this came to fruition, the requisite funding and structures needed to employ these GPs 3 years down the line wasn’t matched. Furthermore, a parallel initiative to increase non GP primary care clinical staff contributed to a perverse incentive to hire them over GPs. Without placing a value judgement on this particular policy, it is clearly cost inefficient to spend resources on training without a plan for deployment. Flexible working should lead to increased productivity so while it’s important to know how many FTEs these 4000 training places are yielding, I’m not as focussed on the fact that most GP trainees do not take full time GP work as I am on why. Various RCGP, BMA and NHS surveys show that there is significant burn out in General Practice and over the years, this has trickled down to affect new entrants and not just practitioners with decades of experience. What needs to change? In short. Almost everything. The overall experience and prospects of working as a GP in the UK has become unattractive and this needs to change. Some potential solutions are scattered throughout the plan but a lack of coordination will be our undoing. Unfortunately, the world of work has changed and in many cases, the people who design large systems and plan for the workforce are from a different generation and lack insight into their prospective employees goals and lives in general.
LS: This is a plan to create a new model of care, fit for the future. It will be central to how we deliver on our health mission. We will take the NHS’s founding principles - universal care, free at the point of delivery, based on need and funded through general taxation - and from those foundations, entirely reimagine how the NHS does care so patients have real choice and control over their health and care. Is this something real that all stakeholders can all agree on?
SDB: I'm a bit of a universal healthcare and NHS traditionalist. I spent a good part of last Autumn digging through archived content in the British Library for a hobby (if I can still call it that) and while the NHS's founding principles have been accurately captured, I think the 'why' has been lost over the decades. Nigh on its 80th anniversary I think the current proposed reform doesn't go far enough. The underlying practical purpose of the NHS was to build a healthy and fit nation but even this ambitious 10 year plan seems to be stuck on reactive rather than proactive mode.
LS: Organisational memory is very short. Some of the plans detailed are explicitly highlighted as things we have seen before, such as the Foundation Trust delivery model. What do these cycles of change mean for the workforce and service users on the ground?
SDB: Centralisation is a big issue in the UK, however the NHS is already devolved and the efficacy of the NHS’s of the devolved nations needs to be studied. There is a role for central control-almost all the funding for healthcare comes from central sources and I think the goal of the DHSC should be national. The objectives and the 'how' to achieve these goals should be local. This delineation of what is regional vs national vs neighbourhood should be informed by a thorough understanding of the issues and their drivers. The NHS is a huge part of the DHSC but the differences need to be clarified in the policies, budgets and the national psyche. I’ve heard a potential move towards creating IHOs instead of ICBs. Rather than making every NHS provider a Foundation Trust, I suggest giving ICBs (or their equivalent) more power and resources to manage all services in their area-primary, secondary and social care. They should be the Foundation Trusts with the ability to set locally relevant targets, commission services and lead on the local agenda for health and social care. Change is a constant but there is an efficient way to go about it. The issues are 2-fold. In addition to the natural learning curve and resistance to change, the ever-present spectre of ‘big changes’ every 3, 5, 10 years, especially among staff who’ve been around long enough to ‘witness’ these big reforms leads to a kind of passive resistance and despondency that is extremely difficult to overcome. We don't need more teams or better branding, we need better motivation and coordination of the players we already have. Is Jose Mourinho available for a locum?
LS: The executive summary makes it clear we're on a burning platform. 'Demographic change and population ageing are set to heap yet more demand on an already stretched health service. Without change, this will threaten yet worse access and outcomes - and even more will opt out and go private if they can afford to. They will increasingly wonder why they pay so much tax for a service they do not use, eroding the principle of solidarity that has sustained the NHS. We will be condemned to a poor service for poor people'. What do you think about this statement?
SDB: I think the writing has been on the wall for decades, one need not read the tea leaves. Demographic change and its impact on future resources has been the classical example used in undergraduate public health teaching for generations. I think the statement puts the cart before the horse in that lowered sense of community and solidarity is what drives an erosion of public services. This is where prescience comes in. The demographic changes to focus on aren't just an ageing population but one that is more culturally diverse and maybe more individualistic too. The success of mutual insurance funds hinges on pooled resources and pooled risk. All for one and one for all. As the nation moves further away from a group identity and ethos, trust reduces and risk increases, such a system is bound to struggle. Insurance as a vehicle for expense coverage is always at risk of moral hazard but the mind set of the participants needs to shift. If you take out as much as you put in, that's pay-as-you-go. People the world over grumble about taxation but dissatisfaction with the overall tax funded services in the UK cannot be overlooked.
LS: What impact do you think the plan will have on health inequalities?
SDB: Unfortunately the publication reads more like a manifesto than a plan. Universal Health Care is a significant corrector of health inequalities but it doesn't fix social inequalities. All the risks mentioned (...people in working class jobs, who are from ethnic minority backgrounds, who live in rural or coastal areas or deindustrialised inner cities, who have experienced domestic violence or who are homeless are more likely to experience worse NHS access, worse outcomes and to die younger..) are well known social determinants of health and it is neither effective nor efficient for a health service to take on the radical social reform that is required to bring about significant change. Can I also say that the term 'working class' was buried post WWII and its continued use in modern parlance is intentionally obfuscatory. Significant and rapid demographic and socio-economic change occurred in the decades following WW II-mass migration, women in the workforce, globalisation and while the NHS was built on and has flexed through all these changes, the time has come to thoroughly interrogate every aspect of the system.
Deep in the section on 'Quality Care' we learn that a national independent investigation into maternity and neonatal services will be set up. This is great, but once again reactive and not what embedded quality is about. For a nation that is grappling with an ageing population, it's incredible that we also have poor maternal and neonatal services. Our priorities clearly aren't right but we're also not addressing the obvious social, economic and racial drivers of this metric. I don't say this lightly- this is a health urgency. Currently the CQC does well at finding issues but the feedback loop to DHSC needs to be buttressed.
LS: How do you think technology will change healthcare in the next decade? Is it really a panacea that can replace ⅔ of outpatient appointments, to name just one goal highlighted in the plan?
SDB: Since NHS Digital became a thing and even after its demise, I get the sense that there’s a significant section of power-brokers who truly believe ‘technology’ will save the NHS. It won’t. The NHS is behind the curve and is so deeply inextricable from our flawed morbidity and mortality as humans that I think we’re missing the whole point. I think technology has already made healthcare more available and accessible but just like the internet which initially made information more readily available, a failure to adequately control it meant all kinds of ‘information’ was now also accessible and has brought us to the point where we can’t agree on what ‘truth’ is. Will technology change healthcare? Yes. Will we become healthier? Only some of us. On average? No. I think it’s ironic that we’re talking about a seismic shift in healthcare delivery but still using potentially obsolete metrics like ‘outpatient appointment’. This is what I mean by missing the point. Paradigm shifts are truly uncomfortable. I think our concepts of doctor vs patient; sickness vs health are going to change. We’re seeing it with DNA mapping, bio-hacking, self monitoring but bringing it back to my earlier point about health equity, while technology has enabled some of us to live in the Sci-Fi world of the Jetsons, others are dying from measles and living next door to Jane Eyre.
LS: Neighbourhood teams are a hot topic. How do you see the GP’s role evolving in neighbourhood health model delivery? Clinically and non clinically?
SDB: I don't think GPs working over large geographic areas is a good idea and I don't see how this benefits the community. I'm a GP but I'm also a person registered with a GP who also happens to have ongoing secondary care needs. I can see how economies of scale can be leveraged but I thought the whole point of Neighbourhood Teams was to realign the community's health and social resources for the benefit of the community. Two years ago GP’s were pitched as the conductors of the community health orchestra but reading the 10 year plan has left me more uncertain of our role.
LS: As another one of your areas of expertise is healthcare management, what do you think the plan got right and/or wrong?
SDB: I think workforce planning was hinted at and several targets were mentioned but it wasn't given the priority it should have had. Many of the goals in the ' An NHS workforce, fit for the future' section are valid. One of the 'promises' is to “introduce new arrangements for senior managers’ pay to reward high performance and to withhold pay increases from executive leadership teams who do not meet public, taxpayer and patient expectations on timeliness of care or effective financial management”. This is best practice and if we're not doing this already across the board, there needs to be an overhaul of people management across the DHSC and the public sector as whole. While an over reliance on international recruitment is risky for a few reasons, it is a fact baked into the NHS- the sheer numbers speak to an international and ethnic status quo by design and default. A reduction from X% to10% in 10 years is not just bold, it's potentially counterproductive. The NHS productivity crisis and poor financial discipline are public sector/national problems. Some things require personalised solutions, some require honesty about their wide-sweeping nature. I think they meant equitable distribution of funding. Equal funding locally can't be aligned with health need. If it's a typo- great, if it's not...well it needs to be corrected. The responsibility for a deliverable needs to come along with the resources and the power to deliver, so yes, providers should be rewarded and 'punished' for want of a better term, but incentives only work when the person or organisation being incentivised has the ability to act differently. I want recipients of NHS services to have more agency and a recognition of the role they play in their own health outcomes to be factored into the entire set up and delivery of health services. Including the reward system.
LS: To that point, there are so many interesting new concepts in the plan. To highlight one, what do you think about ‘patient power payments?’
SDB: Loved it! My small group during my last VTS away day pitched something along these lines and I’d be very grateful if we could get the credit we deserve. It’s critical that all stakeholders are involved in improving national health. Ever since the disease trend shifted to chronic/non communicable, the importance of what happens outside of the hospital and outside of the patient-provider interaction has been well known. I think it’s a very good idea. I would even take it further to say that an Uber-like rating system needs to be created. If patients are being encouraged to rate their providers then perhaps providers should also be able to rate their patients. I can see some people not being onboard with something like this but it’s just formalised accountability. We’ve already accepted the premise of financial incentives for performance.
LS: Did you like anything else about the plan?!
SDB: Yes, a lot of it made perfect sense. The NHS is the best placed system in the world to harness advances in AI and genomics. The 3 shifts aren't radical: hospital to community; analogue to digital; sickness to prevention. All very obvious and in my opinion inevitable. We may incorrectly continue to place a premium on hospital care but we can't argue against the diminishing returns. The world shifted to digital a decade ago and I've previously written about primary care and public health on one side against secondary and tertiary care on the other. This isn't even a developed or first world problem. It's global. I was very pleased to see a commitment to change the pattern of health spending. I think this is the beginning, middle and end of the required healthcare reform. A single patient record is the stuff of Health System geeks' dreams. Can I ask for a single app (that actually works) to access the whole system while we're at it? I think we're missing the fact that there's an MVP already in wide scale use that has significant issues with syncing across the system and again, the plan seems to sell a utopic vision that we've already bought into without honestly confronting the issues that are causing poor performance. Loved the Tobacco and Vapes Bill. Low hanging fruit in the grand scheme of things. Everything in the 'Sickness to Prevention' section was spot on.
LS: The lack of implementation strategy is top of mind for me. As someone working on the front line, at the front door, what do you think needs to be in place for these plans to become a reality? What do you think will drive success?
SDB: The speed and diligence with which funding patterns change is key. People follow money. I know I said the plan read like a manifesto but at some points it got too into the weeds mentioning very specific details like care plans for 95% of the population. This is a process/outcome measure at best. I love SMART goals but one can't set targets before a clear aim. Secondly, we need to commit to the consequences of no/low adoption. Just like vaccination uptake we know that 100% is ideal but understand say 85% will provide herd immunity and thus structure resources to achieve this and avoid spending resources on the remaining 15% with insignificant returns. It's not a question of should we move to digital but why there are still paper based providers and processes in operation in 2025. Knowing that about 20% of us will be slow/no adopters but the system can't function at a level above 5% means a firm plan to manage that 15% is needed. Carrots, sticks and potentially exclusion.
LS: That’s a harsh line to take in context of how challenging we both it can be to even do the basics in a healthcare system where demand outweighs resource!
SDB: Yes...quite. Probably why it hasn't been done in 70 years but that's the name of the game. Set an honest aim, outline objectives and the means to achieve them will write themselves. We might feel the end doesn't justify the means but again, this is something we need to be honest about
Moving on…What do you think was left out of the 10 year plan? What would you have liked to see?
LS: My two main gaps are
1- Implementation! The plans are so ambitious… how are we going to get there? I have no idea and this seems a pretty critical chapter to omit.
2- Some acknowledgment of the dynamism we expect to see in the next decade. From tech to changing demographics to global instability… I am skeptical that a 10 year plan has a place anymore. For one thing, many of the changes outlined won’t even begin until the next parliament. Policy needs to be dynamic and planning for and communicating this may be more realistic.
SDB: I totally agree. Having just become a certified PMP, I’ve been immersed in non- traditional project planning methodologies and yes, a 10 year ‘plan’ doesn’t have the same relevance in the modern world so sadly this well thought out document isn’t really Fit for the Future. There are some changes that will take years to come to fruition so a 10 year timeline or roadmap is still necessary however there’s far too many assumptions and details for things 5-10 years down the line and not enough about changes to come in the next 6-12 months. Part of the issues raised with stagnation and outdated processes is because change doesn’t happen until a big bold national vision is laid out (often years after the need for change has become obvious) and the only solution to this is for the system to become nimble and responsive. That’s a change in mindset and culture and I don’t see this being addressed at all. I also agree the plan is light on implementation. It’s quite a bulky document and some things such as the NHS app were presented with significant UX details but others like the 2 new contracts for GPs…were just that.
LS: What about you, what did you think was left out of the plan?
SDB: Dental care was mentioned but the proposed changes didn't go far enough. Not even close. We need more dentists in general and specifically in the NHS and while I'm not impressed by statements in other parts of the plan to 'train more X staff', the need to train more dentists being absent from the whole 10y plan is a huge omission.
LS: Any parting words?
SDB: I have a hot take
LS: Go on…
SDB: The NHS should have less money
LS: Explain!
SDB: The policy paper states that the NHS accounts for 38% and a predicted 40% of day-to-day government spending. This is just the NHS, not the DHSC. I'm just saying this isn't how I would balance my books. The US is a classical example of more health spending not leading to better health outcomes but given how the US healthcare system is set up, the disparity makes sense. Not so much for the UK. 38% is a lot. We've known for a long time that improving social determinants is the key. Not just for developing countries but those who appear to be riding the wave of diminishing returns. While this plan is for the NHS specifically, much of the desired outcomes are dependent on factors outside of the DHSC and for the country that birthed Sir Michael Marmot, we’re STILL not fully addressing this. I’d rather see more funding go towards Education-not just of children but adults which feeds into employment and improved abilities across the board; Infrastructure-physical and virtual which leads to increased efficiency and effectiveness, improved physical activity, access to green space; and Sustainability which encompasses air & water quality, minimising environmental degradation and social stability.
LS: Big thanks to you Sandra for reaching out to discuss the recently published NHS 10 year plan. What an interesting chat that was!
I am always up for connecting on work, health and everything in between. Get in touch if you’d like to chat!
