Performance Tracker 2025: NHS

Arguably, the Labour government has tied its hope of re-election to the fate of the NHS more than any other service. This is understandable. The NHS is consistently ranked the most important public service, voted above education, crime, or the welfare system almost every month since 2011.^{*, 107} YouGov, ‘The most important issues facing the country’, YouGov, 2025, https://yougov.co.uk/topics/society/trackers/the-most-important-issues-facing-the-country  Labour understands this and Keir Starmer appointed one of his most trusted allies – Wes Streeting – as secretary of state for health and social care in the hope that he would be able to deliver the massive improvements needed.

Streeting has not shied away from headline-grabbing promises. The highest profile of these is the promise to improve elective waiting times to levels the NHS has not achieved in over a decade. Before the general election, Streeting also promised to hit national targets for A&E waiting times, ambulance response times, and cancer waiting times, among others, by the end of this parliament. ¹⁰⁸ Illman J, ‘Streeting commits to hit four-hour target in first term’, HSJ, 19 June 2024, retrieved 28 October 2025, www.hsj.co.uk/policy-and-regulation/streeting-commits-to-hit-four-hour-target-in-first-term/7037339.article  That was always extremely ambitious, and Streeting has since admitted that it would be impossible for the NHS to achieve all those targets. ¹⁰⁹ Ibid.

Simultaneously, Streeting has embarked on a far-reaching reform programme which, if realised, would represent a significant shift in the way that the English NHS operates. In July 2025, the government published the NHS 10 Year Health Plan for England (referred to as the 10YHP from now on), which outlines its goals to shift care out of hospitals, to make health care more preventative, and to increase the use of technology, among other things.

These are admirable aims. But they are also reforms that previous governments have attempted and largely failed to deliver. Streeting will need to overcome substantial institutional, financial, and political barriers to deliver his promises.

The government’s record on the English NHS since the 2024 general election has been mixed. There have been minor performance improvements in hospitals, a fall in hospital staff turnover, and a substantial uptick in the number of salaried GPs. At the same time, there is evidence of increasing financial pressure in hospital trusts, industrial action by resident doctors is once again dampening activity, and the government has forced the service to focus time and money on abolishing NHS England (NHSE), reorganising integrated care boards and making redundancies, at the expense of a focus on improving performance.

Time before the next election is running out and there is still a long way to go before voters notice a marked improvement in the health service.

_{* This report looks exclusively at the NHS in England.}

Streeting deserves credit for resolving last year’s resident doctors’ strikes

When Labour won the election, resident doctors^* were the remaining staff group that had not reached an agreement with the government. Their strikes over 2023 and 2024 had been extremely disruptive. Hospitals were forced to cancel or reschedule more than 1.2 million elective appointments on the days they walked out. That lost activity had severely hampered the service’s ability to reduce waiting times.

Streeting acted quickly, meeting the resident doctors’ committee less than a week after the election. ¹¹⁰ Roberts M, ‘Streeting begins talks to halt junior doctor strike’, BBC News, 9 July 2024, retrieved 28 October 2025, www.bbc.co.uk/news/articles/ckvgql945y5o  They subsequently agreed a pay deal in early August, which the British Medical Association’s (BMA) members voted to accept in mid-September. ¹¹¹ British Medical Association, ‘Junior doctors in England vote to accept pay offer’, press release, BMA, 16 September 2024, www.bma.org.uk/bma-media-centre/junior-doctors-in-england-vote-to-accept-pay-offer  Streeting also accepted the 2024/25 recommendations of the NHS pay review body – which covers nurses, paramedics and other staff – within a month of the election.

Getting resident doctors off picket lines and back into wards was one of the most pressing and impactful things that Wes Streeting could have done after entering the Department of Health and Social Care (DHSC). He deserves credit for doing what Conservative predecessors failed to do.

_{* Then known as junior doctors.}

New industrial action may be a harder test

That success was short-lived, however, as resident doctors renewed their industrial action in July 2025. Though only a year apart, the context of 2025 is very different to 2024. The fiscal situation is arguably more constrained now than it was, meaning it is harder for Streeting to use pay as a negotiating lever.

The context differs for doctors as well. Support for these strikes is much lower in 2025 than in 2023 and 2024 ¹¹² Smith M, ‘Public support for strikes slips as 2024 begins’, YouGov, 8 January 2024, retrieved 28 October 2025, https://yougov.co.uk/politics/articles/48279-public-support-for-strikes-slips-as-2024-begins : a majority of the public now oppose strikes. ¹¹³ YouGov, ‘Would you support or oppose resident doctors (formerly junior doctors) going on strike over pay and job insecurity?’, YouGov, 7 October 2025, https://yougov.co.uk/topics/health/survey-results/daily/2025/10/07/ece33/1  Resident doctors’ consultant colleagues are also reportedly far less supportive than they were the first time around. ¹¹⁴ Otte J, ‘Resident doctors on strikes: ‘For those of us who are working class, the stakes are different’’, The Guardian, 22 July 2025, retrieved 3 November 2025, www.theguardian.com/society/2025/jul/22/nhs-resident-doctors-on-strikes-callout-responses  Continuation of strike action is in the hands of the BMA’s resident doctor members, but the BMA may be more inclined to push for a resolution to the dispute if they feel pressure from colleagues and the public.

The NHS claims that fewer resident doctors walked out in this round of strikes than in the last, ¹¹⁵ NHS England, ‘NHS protected thousands more appointments during doctors strike’, NHS England, 3 August 2025, www.england.nhs.uk/2025/08/nhs-protected-thousands-more-appointments-during-doctors-strike/  though the BMA disputes this, arguing that strikes are not directly comparable. ¹¹⁶ Courea E, ‘BMA rejects NHS claim that less than third of resident doctors went on strike’, The Guardian, 3 August 2025, retrieved 28 October 2025, www.theguardian.com/society/2025/aug/03/bma-rejects-nhs-claim-that-less-than-third-of-resident-doctors-went-on-strike  The NHS also claims that it managed to maintain 93% of planned elective activity. It is difficult to know how this compared to previous rounds of strikes. But it is true that the NHS seemed to become more effective at responding to each successive round of strike action in 2023 and 2024. As the figure below shows, the NHS cancelled or rescheduled 2.0 elective procedures for each resident doctor on strike the first time they walked out. This had fallen to 0.7 in the most recent round of strikes in July 2025.

Trouble could be brewing among other staff groups. Hospital nurses have also expressed dissatisfaction with their pay deal in 2025/26, which included a lower uplift than for either consultants or resident doctors, albeit in line with the recommendations of the National Health Service Pay Review Body (NHSPRB). They have threatened strike action, though their demands focus less on achieving an across-the-board pay rise and more on reforming Agenda for Change (AfC) – the pay scale for all non-doctor NHS staff – including better progression through pay bands. ¹⁵¹ Triggle N, ‘Boost our pay or risk strike action, warn nurse leaders’, BBC News, 31 July 2025, retrieved 28 October 2025, www.bbc.co.uk/news/articles/c36je08d111o

Ending the resident doctors’ industrial action and avoiding further strikes should now be one of Streeting’s most urgent tasks.

The NHS mission has so far failed to change the government’s priorities

Labour has identified five ’missions’ – policy priorities which generally require cross-departmental collaboration – that will guide decisions over the course of this parliament. It chose building “an NHS fit for the future” as one of those five missions, ¹⁵² The Labour Party, ‘Plan for Change’, The Labour Party, 2025, https://labour.org.uk/missions/  with improved elective waiting times the key ‘milestone’ used to judge success. ¹⁵³ HM Government, Plan for Change, CP 1210, The Stationery Office, 2024, p. 27  As a metric for that success, the government wants the NHS to hit the long-standing target that 92% of patients are treated within 18 weeks of a referral for elective care by the end of this parliament. In July 2024, when Labour came to office, that number stood at 58.8%.

Choosing that metric makes some political sense. Improving elective care is one of the public’s top three priorities for the NHS ¹⁵⁴ Taylor B, Lobont C, Dayan M and others, Public satisfaction with the NHS and social care in 2024 (BSA), The King’s Fund, 2 April 2025, www.kingsfund.org.uk/insight-and-analysis/reports/public-satisfaction-nhs-social-care-in-2024-bsa  and, given that there are approximately 6.2 million people waiting for care, most of the population will either be waiting for care themselves or know someone who is. It is also easy to track, with consistent data having been collected since the 2000s.

However, there are also reasons to think it is not a well-chosen metric. As previously discussed, Streeting identified “three shifts” that he wanted to achieve in the NHS: from hospitals to the community, from sickness to prevention, and from analogue to digital. Those are all reasonable aims. But focusing on elective performance could conflict with the shift to the community and making care more preventative.

It will be very difficult to substantially improve elective performance without an uptick in productivity and effective working in acute hospital trusts. The acute hospital sector is already disproportionately powerful in the NHS, sucking up attention and funding. Choosing the elective waiting time target risks further entrenching power in acute trusts and delaying the work of shifting care to the community and towards more preventative actions.

There is potentially a set of policies which could be conducive to both outcomes: a heavy focus on treating people in the community and preventing them from needing elective care. It is possible this is what the government intends (the decision to increase GPs’ use of a tool designed to divert unnecessary referrals supports this).

However, achieving that within one parliament seems unlikely. And, as time passes, there is a risk that slow progress on elective waiting times will result in the government directing more attention towards hospitals, further delaying more substantive reforms and coming into direct conflict with the 10YHP commitment to shifting the balance of funding away from hospitals.

More widely, missions are intended to drive cross-departmental collaboration towards improving thorny problems. It would have made more sense, therefore, for the government to have made this a ‘health’ rather than an ‘NHS’ mission. Raising performance in the NHS should not be an end by itself. Instead, the government should be aiming to improve the nation’s health, with the NHS one tool among many to achieve that. A well-designed mission and milestone would reorient the Department of Health and Social Care (DHSC) away from its current, disproportionate focus on hospital performance towards other services, such as adult social care and public health, and the major drivers of ill-health such as poor housing, stable employment, and poverty. ¹⁵⁵ Marmot M, Fair Society, Healthy Lives: The Marmot review: Strategic review of health inequalities in England post-2010, The Marmot Review, 2010, www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf  That could have driven genuine change in the way government approaches health policy, while also supporting Streeting’s ambition to make the NHS more preventative and to shift care into the community. As it stands, focusing purely on elective care risks deepening long-standing flaws in DHSC’s policy making.

The decision to abolish NHS England was rushed and chaotic

Throughout the NHS’s history, governments have repeatedly swung back and forth between placing operational management of the service within or outside ministerial control. The creation of NHS England (NHSE) in 2013 by the coalition government was the most extreme and cumbersome version of placing operational control of the service outside the department that has been tried so far.

The result was duplication of functions such as policy and strategy in both the Department of Health and Social Care (DHSC) and NHSE, as well as frequently confusing lines of accountability for those working on the frontline. It is difficult to argue that anyone looking to reform the service (other than Andrew Lansley, then secretary of state for health) would choose the institutional arrangements that have existed since 2013. A pragmatic government might legitimately continue with the current institutional configuration, knowing that any reorganisation would be unlikely to deliver rapid improvements in performance.

At an Institute for Government event at the 2024 Labour Conference, Streeting said that abolishing NHSE was “the last thing he wanted to do”. Despite that, less than six months later, ¹⁵⁶ Mason C, ‘Thousands to lose jobs as Starmer scraps NHS England to cut ‘bureaucracy’’, BBC News, 13 March 2025, retrieved 29 October 2025, www.bbc.co.uk/news/live/cx29lrl826rt  the Labour government announced the abolition of the organisation. It is unclear what changed in that time.

Regardless of why Streeting changed his mind, the government’s handling of the announcement was chaotic and ill-judged. Streeting announced “thousands” of job cuts in NHSE on Tuesday 25 February, the same day that Amanda Pritchard, then CEO of NHSE, resigned. ¹⁵⁷ Campbell D, ‘Wes Streeting to axe thousands of jobs at NHS England after ousting of chief executive’, The Guardian, 25 February 2025, retrieved 29 October 2025, www.theguardian.com/society/2025/feb/25/wes-streeting-to-axe-thousands-of-jobs-at-nhs-england-after-ousting-of-chief-executive  He followed that with an announcement that he would cut half of NHSE jobs on Monday 10 March. ¹⁵⁸ Campbell D, ‘NHS England to cut workforce by half as Streeting restructures’, The Guardian, 10 March 2025, retrieved 29 October 2025, www.theguardian.com/society/2025/mar/10/nhs-england-cut-workforce-half-streeting-restructures

Then – only three days later, on Thursday 13 March – Starmer announced NHSE’s abolition in a speech ¹⁵⁹ Morton B, ‘NHS England to be axed as role returns to government control’, BBC News, 13 March 2025, retrieved 29 October 2025, www.bbc.co.uk/news/articles/c70w17dj258o  that was originally briefed as being about investment in technology and reduction in business regulation. ¹⁶⁰ Department for Science, Innovation and Technology, ‘Prime Minister: I will reshape the state to deliver security for working people’, press release, 12 March 2025, www.gov.uk/government/news/prime-minister-i-will-reshape-the-state-to-deliver-security-for-working-people  If the government knew that it intended to abolish NHSE, it is exceedingly odd to repeatedly brief about headcount reductions in the days leading up to the announcement. ¹⁶¹ Campbell D, ‘Wes Streeting to axe thousands of jobs at NHS England after ousting of chief executive’, The Guardian, 25 February 2025, retrieved 29 October 2025, www.theguardian.com/society/2025/feb/25/wes-streeting-to-axe-thousands-of-jobs-at-nhs-england-after-ousting-of-chief-executive  There are a host of issues with this approach.

The structure of the NHS is foundational to how the service operates. It is strange to spend months conducting policy work for the 10YHP before then deciding to abolish NHSE. Given that the problems with NHSE were perfectly clear from opposition, it would have made more sense to announce it much sooner after the election, with other reforms following.

It was also a terrible way of handling an announcement that will result in thousands of public servants losing their jobs. It is extremely damaging for the morale of staff in DHSC, NHSE and the wider NHS for the government to subject them to so much uncertainty and weeks of ambiguous briefing in the press. The abolition of NHSE has so far been a case study in how not to make complex policy decisions and announcements.

Putting aside the process, there is also a good chance that abolishing NHSE will not result in the types of performance improvements that Streeting hopes, particularly between now and the next election.

Reorganising the NHS’s superstructure is a time consuming and distracting endeavour. It will monopolise attention and resources in the centre of government and NHS systems for at least the next two years. By the time the new NHS structure is settled, the next election will be fast approaching, leaving little time for the new system to deliver performance improvements.

While the status quo is odd, there is also no perfect institutional structure for the NHS. Whatever emerges from this reorganisation will also be imperfect, albeit in different ways.

The government launched a reorganisation of integrated care boards without funding to realise its plans

The day before the government announced its intention to abolish NHSE, it also announced that it is to cut Integrated Care Boards’ (ICB) staffing budgets in half by December 2025. ¹⁶² Williamson S and Tether V, ICB clusters and mergers: what you need to know, NHS Confederation, 6 October 2025, www.nhsconfed.org/publications/icb-clusters-and-mergers  In total, this equates to 12,500 staff losing their jobs across systems. ¹⁶³ Gault B, ‘ICBs asked to reduce workforce by over 12,000’, Healthcare Leader, 13 March 2025, retrieved 31 October 2025, https://healthcareleadernews.com/news/icbs-asked-to-reduce-workforce-by-over-12000/  ICBs are also merging, with the plan to reduce the number from the current 42 to 26. ¹⁶⁴ Gault B, ‘Six new ICBs confirmed by NHS England’, Healthcare Leader, 11 September 2025, retrieved 31 October 2025, https://healthcareleadernews.com/news/six-new-icbs-confirmed-by-nhs-england/  There are already plans in place for 12 ICBs to merge into six, starting from April 2026. ¹⁶⁵ Ibid.

ICBs were placed on a statutory footing and rolled out nationwide in July 2022. Their existence since then has been fraught. Less than a year later, in March 2023, the Conservative government announced that it would cut ICBs’ staff budgets by 30%. ¹⁶⁶ Anderson H, ‘30pc cut to ICB staffing budgets’, Health Services Journal, 2 March 2023, retrieved 31 October 2025, www.hsj.co.uk/workforce/30pc-cut-to-icb-staffing-budgets/7034349.article  Two years after that, the Labour government announced the cuts described above.

In short, ICBs have been in a near-constant state of reorganisation, rationalisation, and turmoil in the three years since they were established. It is therefore unsurprising that they have not made as much progress as expected on improving health outcomes.

One welcome development from these announcements is the explicit intention to align the boundaries of ICBs with mayoral strategic authorities (MSAs). ¹⁶⁷ Williamson S and Tether V, ICB clusters and mergers: what you need to know, NHS Confederation, 6 October 2025, www.nhsconfed.org/publications/icb-clusters-and-mergers  This makes sense. Matching boundaries of different public organisations supports more effective working and co-ordination between services. There are, however, differing timeframes for 100% coverage of strategic authorities and ICB reorganisation.

All ICBs are expected to have completed their mergers by April 2027, while full coverage of strategic authorities across England is not expected until the end of this parliament, ¹⁶⁸ Ibid.  with plans yet to be finalised for the footprint of those MSAs. As a result, it is possible that the NHS will constitute new ICBs on footprints that do not subsequently become MSAs. In that case, the government says that those ICBs will undergo another round of reorganisation. ¹⁶⁹ Department of Health and Social Care, Integrated Care Boards: Reorganisation; written parliamentary question UIN 73486, 29 August 2025, retrieved 31 October 2025, https://questions-statements.parliament.uk/written-questions/detail/2025-08-29/73486/

As a further indication of how poorly planned this NHS reorganisation has been, a row has broken out between NHSE and the government over the money required to pay ICB staff’s redundancy packages. Rachel Reeves reportedly refused Wes Streeting’s request to provide the NHS with £1.3 billion (bn) of additional funding to cover that cost. ¹⁷⁰ Campbell D, ‘NHS leaders warn of longer waiting times if demand for extra £3bn not met’, The Guardian, 27 October 2025, retrieved 31 October 2025, www.theguardian.com/society/2025/oct/27/nhs-leaders-demand-extra-funding-waiting-times

As a result, ICBs are reporting that they will not be able to lay off staff in this financial year, given existing allocations. ¹⁷¹ Discombe M, ‘Workforce Ex-NHSE director slams ‘appalling’ treatment of ICB staff’, Health Services Journal, 31 October 2025, retrieved 31 October 2025, www.hsj.co.uk/workforce/ex-nhse-director-slams-appalling-treatment-of-icb-staff/7040286.article  That has left systems in suspended animation, unable to go ahead with reforms and with staff having little motivation or incentive to deliver the government’s agenda while there is so much uncertainty over their own roles.

The government’s approach to management and administrative staff is damaging

Every year, millions of people benefit from the hundreds of millions of appointments, operations, follow-ups, tests, and more provided by the NHS. Those appointments are delivered by clinical staff but would not happen without management and administrative staff orchestrating the system. The NHS is a large and intensely complex organisation that spends close to £200bn annually. Inefficiencies in spending processes result in wasted taxpayer money and poor outcomes.

It is vital, therefore, that the NHS effectively recruits, trains, and retains sufficient management, analytical and administrative staff who are responsible for allocating resources and supporting clinicians. However, the NHS is currently undermanaged. It has fewer managers per clinical staff member than it did in 2010 and fewer than in the private sector and other health systems. Despite this, Streeting has asked ICBs to cut staffing spending by 50%, ¹⁷² West D, Anderson H and Kituno N, ‘ICBs ordered to cut costs by 50%’, HSJ, 12 March 2025, retrieved 29 October 2025, www.hsj.co.uk/policy-and-regulation/icbs-ordered-to-cut-costs-by-50/7038846.article  the second time a government has cut ICBs’ budgets substantially in the three years since they were established, as previously discussed.

Streeting has also adopted much of the damaging rhetoric of previous governments. The abolition of NHS England was framed in terms of “freeing up” resources for the “frontline”. ¹⁷³ Mason R and Campbell D, ‘Wes Streeting’s ‘high-stakes’ abolition of NHS England will cut 10,000 jobs’, The Guardian, 13 March 2025, retrieved 29 October 2025, www.theguardian.com/society/2025/mar/13/wes-streetings-high-stakes-abolition-of-nhs-england-will-cut-10000-jobs  And cutting management staff has not been confined to NHSE and ICBs, with a DHSC spokesperson saying: “We have underlined the need for trusts to cut bureaucracy to invest even further in the frontline.” ¹⁷⁴ Campbell D, ‘Hospitals in England reducing staff and services as part of NHS ‘financial reset’’, The Guardian, 9 May 2025, retrieved 29 October 2025, www.theguardian.com/society/2025/may/09/nhs-hospitals-england-cuts-financial-reset

The suggestion that cutting back-office functions to invest in more frontline staff is an inherent good is misleading. If it were true that having more “frontline staff” automatically improved performance, then performance in NHS hospitals would be much better in 2025 than in 2019. Instead, it is much worse.

As discussed in more depth in the hospitals chapter, it appears there is already evidence of some of these cutbacks happening. There has been close to no growth in non-clinical staff since the beginning of 2024 as trusts battle financial pressures. Cutting management, analytical and administrative staff is a false economy. In their absence, administrative work often falls to clinical staff. And without effective analytical capacity, trusts are left flying blind on how to best improve performance.

Bashing managers may generate approving headlines in sections of the press, but it negatively affects morale. One interviewee said that high performing management staff are questioning why they would stay in service when they face such hostility from the centre. That’s an understandable view. There must be few high performing people within the lower and middle ranks of NHS management who can bear to spend their entire career in a role that is frequently derided by political leaders and in which their jobs are thrown into the lottery of NHS structural reorganisation every couple of years.

The 10-year plan’s ambitions are laudable, but the government doesn’t have a coherent delivery plan

The government’s major policy for reforming the NHS was the long-trailed 10 Year Health Plan for England, which it published in July 2025. ¹⁷⁵ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025  A year in the making, this was supposed to be the document which laid out exactly how Streeting intended to achieve his three shifts and meet the NHS mission milestone.

There are certainly a huge number of ideas in the document. It includes proposals such as new types of GP contracts, mental health A&E departments, neighbourhood health centres, a revamped and improved NHS app, increased use of wearable technology to monitor patients after operations, and, more prosaic though no less important, a commitment to multi-year budgeting.

It is hard to argue against any of the broad ambitions in the plan. It is welcome to see a strong focus on prevention, and it is wise to use tools like regulation and taxation (which are relatively low cost or even revenue-raising) to address some of these issues.

Likewise, it makes sense to leverage financial flows – for example, paying GPs to increase the use of specialist advice (please see the general practice chapter for more details) or merging health budgets under ‘integrated health organisations’ – to achieve the government’s goals. If done well, this could meaningfully shift activity to the most appropriate parts of the NHS.

The plan is also right to note that the NHS must make better use of technology. However, some of the key proposals seem to overclaim, or are contradicted by established evidence. On the former, the NHS says that ambient capture transcription technology, digital triage and the implementation of a single patient record will result in “over 2,000 full time equivalent worth of GP capacity” ¹⁷⁶ Ibid, p. 29.  (equivalent to a 7.3% increase in the number of fully qualified GPs).

There are some positive evaluations of ambient capture technology, finding that they save clinicians’ time. ¹⁷⁷ Great Ormond Street Hospital, ‘Use of ambient voice technology with generative artificial intelligence in multiple clinical settings across the NHS’, GOSH.NHS.UK, 9 July 2025, https://media.gosh.nhs.uk/documents/AAI_Phase_4_NHSE_Final_Report_1.2.pdf  But GPs are already reporting high workloads, and many work overtime, often completing admin tasks. Even if voice capture tools reduce admin burdens, that could just result in GPs working closer to their contracted hours, rather than in a large expansion of time available for clinical work.

Another of the plan’s “big bets” is that virtual wards “become the norm for managing many conditions at home”. ¹⁷⁸ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 120.  But this approach is not supported by the current evidence, as discussed in more detail in the hospitals chapter.

It is especially risky for the government to rely on still-emerging technology for productivity improvements. If those technologies do not deliver on their promises, it may mean that government directs substantial funding to areas that do little to improve hospital productivity.

Critically, this plan seems to pull the NHS in many different directions. Prioritisation is crucial given how tight the public finances are, but the plan does not properly address the trade-offs facing the system. It wants to shift more care into the community. But it also proposes ‘integrated health organisations’ (IHOs), under which high performing foundation trusts will take responsibility for the “whole health budget for a local population”, ¹⁷⁹ Ibid, p. 81.  a potential recipe for a greater focus on hospitals in those places.

As others have argued, ¹⁸⁰ Dunn P, Mays N and Alderwick H, ‘Dazed and confused? Policy ideas behind the 10-Year Health Plan’, The Health Foundation, 28 July 2025, retrieved 29 October 2025, www.health.org.uk/reports-and-analysis/analysis/dazed-and-confused-policy-ideas-behind-the-10-year-health-plan  the plan also (rhetorically) commits to devolving power to high performing areas and encourages the tailoring of neighbourhood health services to local needs by organisations in a place. ¹⁸¹ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 120.  But the government is reconstituting the NHS to bring more power into the department.

The plan is also largely a continuation, restatement or revivification of previous policies. Foundation trusts are back. The government wants to move care into the community – a goal of all governments since at least the 1970s. ¹⁸² Baird B, Fenney D, Jefferies D and Brooks A, Making care closer to home a reality, The King’s Fund, February 2024, p. 6, https://assets.kingsfund.org.uk/f/256914/x/ab65341d7a/making_care_closer_home_reality_report_2024.pdf  It says there should be a greater focus on prevention, an ambition that was first stated on page 1 of the National Health Service Act 1946. ¹⁸³ 1946 National Health Service Act, c.81, Available at: www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/coll-9-health1/health-01/ (Accessed: 29 October 2025)  That is not necessarily a problem. All of these are worthy goals. But the plan does not explore why previous policies have failed and what this government will do differently.

Most importantly, the plan provides very little detail on how it will be delivered. Notably absent from the document is any implementation plan, which was reportedly removed the week before publication. ¹⁸⁴ McLellan A, ‘Exclusive: 10-Year Plan published without delivery chapter’, HSJ, 3 July 2025, retrieved 29 October 2025, www.hsj.co.uk/policy-and-regulation/exclusive-10-year-plan-published-without-delivery-chapter/7039607.article  Given how important the NHS is to people’s lives and Labour’s re-election hopes, it is surprising that the government does not have a more practical plan for the NHS after more than a year in power. 

Higher capital spending will help with NHS productivity

Previous Institute for Government work identified cuts to capital investment in the NHS in the 2010s as one of the core reasons for the decline in hospital productivity since the pandemic. It means that staff are forced to work in decrepit buildings, with insufficient diagnostic equipment, on out-of-date IT systems.

There is a record maintenance backlog in hospitals. The cost to eradicate that backlog rose from £6.8bn in 2015/16 (in 2025/26 prices) to £16.3bn in 2024/25, a 139.0% increase in real terms. The backlog is substantially larger than the entire DHSC capital budget, which is £13.6bn in 2025/26. In general practice, roughly a quarter of the estate pre-dates the creation of the NHS and is woefully inadequate for the recent expansion of direct patient care staff, both in terms of the amount and type of space available. It may also, therefore, harm the government’s plan to further expand the GP workforce. If there is nowhere for them to work, then they will be far less effective than they could be.

Both the Johnson and the Sunak governments increased capital spending in the NHS compared to the 2010s. And this Labour government has increased it further from 2025/26. That means that DHSC capital spending is budgeted to be £124.3bn in the 2020s, compared to £71.4bn in the 2010s, a 74.1% increase in real terms (all amounts in 2025/26 prices and the 2020s excludes Covid-related spending).

Increasing capital budgets is the first, necessary, step to redressing historic underinvestment. But the NHS then needs to spend the money it has been allocated. All departments underspend their capital budget, but the DHSC was one of the worst offenders in the 2010s. The department also transferred £6.9bn (in 2025/26 prices) of its capital budget to day-to-day Resource Departmental Expenditure Limits (RDEL) budgets in the 2010s, approximately 8% of its budget across that decade.

This practice did not end in the 2020s. The department shifted a further £2.3bn (in 2025/26 prices) in the three years between 2022/23 and 2024/25, or 6.4% of its budget in those years. Given the impact historic underinvestment in capital has had on NHS productivity, it is imperative that the NHS does not continue the trend of underspending its budget or shifting capital budgets into RDEL.

Previous Institute for Government work has described some of the problems with how the government spends capital budgets. These include lack of long-term capital allocations, departments not being allowed to shift funding between years, and an over-centralised approach to allocating funding.

Some of the measures outlined in the NHS’s 10YHP – which include a commitment to multi-year capital budgets for systems, streamlining the approvals process, and devolving more control to local areas ¹⁸⁹ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 138  – will begin to address some of these issues. This will improve planning and certainty for systems (though ICB reorganisation may negate this benefit).

How the government chooses to allocate budgets is also important. On this front, some of the government’s decisions so far have been questionable. “AI” tools^* may improve performance in a wide range of use cases. But it is odd for the government to invest limited capital resources in some of these more speculative technologies when there are plenty of areas – which are less flashy and headline grabbing than AI – where higher capital spending is more likely to improve performance.

Most glaring of these needs is the general practice and wider primary care estate. But investment in hospitals’ maintenance and better IT hardware would also deliver good returns: provide staff with computers that turn on quickly before worrying about “AI” tools with questionable returns.

_{* Which we will use for shorthand but which, in reality, encompasses a wide range of tools including ambient voice capture, transcription, clinical decision support systems, chatbots, and others.}

There has been no progress on adult social care and mixed progress on general practice

The government has made a reasonable start on addressing some of the issues in hospitals. It published the Reforming elective care for patients plan in January 2025 ¹⁹⁰ Department of Health and Social Care, Reforming elective care for patients, NHS England, January 2025, www.england.nhs.uk/wp-content/uploads/2023/04/reforming-elective-care-for-patients.pdf  and followed that up with the 10 Year Health Plan for England in July. Both documents were very heavily focused on improving hospital performance.

On general practice, the government has allowed more flexibility on funding which has led to the recruitment of substantially more salaried GPs – an outcome in contrast to the last government’s largely failed attempts to increase that staff group. But the government has made little to no progress on other pressing issues.

Most importantly, there haven’t been any steps taken to address the decline in the number of GP partners, the single greatest existential threat to the current model of general practice. This would be forgivable if the government had a fully articulated, workable alternative to the partnership model that had support from the service.

Instead, some of its potential alternative models that it proposed in the 10YHP (integrated health organisations and neighbourhood health providers) are still incredibly vague and will not come to fruition for years – if at all – while the partnership crisis is happening now.

In the absence of any proper plan, the government is allowing the drawn-out demise of the partnership model to continue. There has also been relatively little progress on the heavily trailed multi-year GP contract, with the BMA now saying that it expects implementation to come in April 2028 “at the latest”, ¹⁹¹ Colivicchi A, ‘NHS 10-year plan must commit to a new GP contract, BMA demands’, PULSE, 3 December 2024, retrieved 29 October 2025, www.pulsetoday.co.uk/news/contract/nhs-10-year-plan-must-commit-to-a-new-gp-contract-bma-demands/  the last year of this parliament.

On adult social care, the government has effectively shrugged off responsibility for reforming the system in this parliament by launching the Casey commission, which is not due to publish its final report until 2028. The government also risks exacerbating staffing problems in the sector by abolishing the health and care visa – which has facilitated much of the recent growth of the workforce. The government’s proposed solution to reducing reliance on international staff is the introduction of a Fair Pay Agreement (FPA), which is intended to raise the wage paid to British staff in the sector (please see the adult social care chapter for more). This is welcome. But the government only launched the consultation for this in September 2025 – two months after closing the health and care visa. That means that details are still unclear, and implementation is not due until April 2028. ¹⁹² Department of Health and Social Care, ‘Fair pay agreement process in adult social care - consultation document’, GOV.UK, 30 September 2025, www.gov.uk/government/consultations/fair-pay-agreement-process-in-adult-social-care/fair-pay-agreement-process-in-adult-social-care-consultation-docu…  Until then the sector is left in a certain amount of limbo.

Failure to grapple with these difficult problems in general practice and adult social care will make it much harder for the government to achieve its wider objectives for the NHS. More importantly, these two systems are not just adjuncts to acute hospitals but are instead key to a health and care system that supports people to live healthy, fulfilled lives. Failing to fix both would leave a serious blot on this government’s record.