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Second, the plan must prioritise. NHS plans tend to suggest everything will get better, everywhere, all at once. But if everything is a priority then nothing is. And there’s not enough money to do it all anyway. Health spending is increasing at around the long term average to 2026, but growing pressures—for instance, from pay increases—will eat up a chunk of extra spending.13 The broader outlook for public finances is gloomy.14 Improving primary care should be high on the list. General practice is the foundation of the NHS, yet people are struggling to get appointments, and continuity of care is declining.15 Priorities include recruiting and retaining more general practitioners, better integrating GPs and other primary care staff, and fixing pervasive operational failures.16 This will take investment. Like many before it, this government has pledged to shift resources from hospitals to the community. Yet the flow of NHS resources since 2000 has gone in the other direction.17 Hospitals risk remaining the over-riding priority. The prime minister’s six pledges for change by the end of the parliament include one NHS target: 92% of patients waiting no longer than 18 weeks for routine hospital treatment.18 This has been missed since 2016, and making it happen will require substantial resources.

Improving primary care should be high on the list. General practice is the foundation of the NHS, yet people are struggling to get appointments, and continuity of care is declining.15 Priorities include recruiting and retaining more general practitioners, better integrating GPs and other primary care staff, and fixing pervasive operational failures.16 This will take investment. Like many before it, this government has pledged to shift resources from hospitals to the community. Yet the flow of NHS resources since 2000 has gone in the other direction.17 Hospitals risk remaining the over-riding priority. The prime minister’s six pledges for change by the end of the parliament include one NHS target: 92% of patients waiting no longer than 18 weeks for routine hospital treatment.18 This has been missed since 2016, and making it happen will require substantial resources. Third, policy makers should focus on how change will happen. Recent NHS plans have been weak on how care will improve.19 And government’s guiding ideas on the NHS are muddy. The health secretary’s focus on league tables20 and rewarding higher performing trusts21 sits oddly with the new NHS structure based on organisational collaboration.22

should focus on how change will happen. Recent NHS plans have been weak on how care will improve.19 And government’s guiding ideas on the NHS are muddy. The health secretary’s focus on league tables20 and rewarding higher performing trusts21 sits oddly with the new NHS structure based on organisational collaboration.22 A mix of policy levers can be pulled to guide the system in a new direction. For example, NHS targets shape what gets done but are skewed towards hospitals. The NHS payment system is a complex mess of conflicting incentives and is ripe for reform. But none of this will make much difference unless policy makers strengthen the NHS’s capacity to innovate and improve in response—for instance, by developing the capabilities to identify, implement, test, and spread promising service changes.23 This includes time and resources, skilled managers, and data analytics. A stronger national approach is also needed to shape the development of new technology to benefit the NHS—rather than just shift towards adopting it. For example, artificial intelligence could help diagnose disease but risks exacerbating inequalities.24 As a national system with a single payer structure, the NHS should fund and evaluate totemic innovations in a coordinated way. One priority should be technology that could free up clinicians’ time—for instance, by automating administrative tasks.25

ence could help diagnose disease but risks exacerbating inequalities.24 As a national system with a single payer structure, the NHS should fund and evaluate totemic innovations in a coordinated way. One priority should be technology that could free up clinicians’ time—for instance, by automating administrative tasks.25 Fourth, the plan needs cash. Labour has emphasised policy change—“reform”—over investment.26 But increased spending is often a major driver of NHS improvement. Labour’s NHS reforms in the 2000s were backed by real terms funding growth of almost 7% a year.27 Policy change—like targets and performance management—helped make use of extra spending.28 But the story makes little sense without the investment.29 Capital investment—in buildings, equipment, and IT—will be essential this time around. Improving care and productivity is hard in crumbling buildings and with outdated equipment.30 31 Yet the NHS’s maintenance backlog—including urgent repairs to avoid serious injury—stands at £13.8bn.32

sense without the investment.29 Capital investment—in buildings, equipment, and IT—will be essential this time around. Improving care and productivity is hard in crumbling buildings and with outdated equipment.30 31 Yet the NHS’s maintenance backlog—including urgent repairs to avoid serious injury—stands at £13.8bn.32 Finally, the plan needs to go with broader policy change to improve health. The social care system in England is a threadbare safety net failing too many people and adding pressure on hospitals.29 33 Government has promised a plan reform after an independent review,34 but this may mean reform is ducked or delayed (again).35 A cross-government strategy for reducing England’s vast health inequalities is also needed. Labour’s last version in the 2000s—involving investment in public services and new social programmes, like SureStart—contributed to reductions in inequalities over time.36 37A plan for the NHS will not be enough on its own.