INTERNATIONAL PERSPECTIVES
Beyond Ambition: Global Lessons for an Integrated NHS
Views on realising the ambition for integrated care in Fit for the Future: 10 Year Health Plan for England
24 October 2025
The contributors
Editor: Niamh Lennox-Chhugani
Authors:
Áine Carroll
Amarjit Maxwell
Anne Hendry
Carmen Huckel Schneider
Carolyn Gullery
Kerry Kuluski
Ng Yeuk Fan
Niamh Daly Day
Pamela Barkhouse
Rachel Harris
Shreya Chhugani
Foreword
The International Foundation for Integrated Care (IFIC) held its 5th International Conference on Integrated Care (ICIC05) in Birmingham back in 2005. It was the International Network for Integrated Care back then, but the goal was the same as it is today and will be when we return to Birmingham for ICIC26 in April 2026, to promote integrated care so that everyone experiences joined-up care at all points in their life.
As we prepare for ICIC26 in Birmingham, we invited contributions from different perspectives on the Government of the United Kingdom Department of Health and Social Care’s policy paper; 10 Year Health Plan for England: Fit for the Future.
We invited people from across our international network to reflect on the Plan as published in July 2025. Our contributors come from seven different countries and a variety of perspectives, from system leaders to family caregivers, to newly graduated health and care professionals. The perspectives they have shared offer a different view from the many informed and informative commentaries we have seen from different bodies in England.
We asked our contributors to focus on how the new 10 Year Health Plan for England is likely to fulfil the ambition of “a single, co-ordinated, patient-orientated service” and whether they can see any learning that can be shared across their own health and care system and the NHS in England.
Reading across the contributions, some common themes emerge.
The most common word used to describe the Plan is “ambitious”. The ambition that people refer to is in the scope, intent, vision, and the proposed three shifts in the Plan. Equally, the contributors acknowledge the necessity of this ambition, not only for the NHS in England, but in all health and care systems.
The contributors admire much in the Plan. The case for change is clear and resonates strongly with other systems around the world. The shifts from hospital to community, analogue to digital, and sickness to prevention, are welcome and essential if we are to see a meaningful shift to people- and community-centred integrated care for population health. The focus on creating the conditions for these shifts is particularly welcome.
However, most contributors caveat this admiration, many based on lessons already learnt elsewhere. They share these lessons in the contributions and invite their colleagues in the NHS in England to learn from them rather than repeat them.
One caveat has been well rehearsed in other commentaries, the 10 Year Health Plan for England is not actually a plan, it is very difficult to know what steps are being taken to execute the vision set out in the document. Our contributors encourage the NHS to prioritise what needs to happen sequentially, creating the conditions for the three shifts.
The Plan is limited to healthcare, and effectively ignores the wider determinants of health, public health, and social care. There can be no real Fitness for the Future if the plan does not capture these at a minimum as critical dependencies.
Most importantly in many ways, the plan misses what matters to people and communities. The voice of people and communities is practically silent in this document. This cannot be the way forward in an environment of growing distrust of public services when population health has never been more important.
Lessons learnt in other countries that can and should be applied in the execution of this plan include:
- Leverage technology as an enabler of high-quality care that is coordinated and person-centred making sure to avoid further fragmentation and a task-focus that tries to “drive efficiency” but ends up doing the opposite.
- Ensure that a greater emphasis on digital tools does not exacerbate inequalities for groups that are already being excluded from health and care.
- A broader focus on prevention is necessary, specifically a focus that acknowledges wider determinants of health have proven more effective for population health than individual choices. The plan as it stands puts too much responsibility on individual behaviour change, genomic innovation and AI technology, where the latter are untested and potentially wishful thinking.
- Avoid adding further complexity to an already complex system of funding that exacerbates fragmentation. Learn the lessons that other systems such as the Canterbury System in Aotearoa, New Zealand has embedded over that last two decades. In Canterbury, transparent resource allocation, simplified funding models, alliance-based accountability and investment in basic digital infrastructure, shared analytics and new care models all continue to drive improvement.
- Shift the focus from performance management to building a learning system. The proposal to introduce patient feedback-driven payments is fraught with perverse incentives and the evidence-base for it is thin.
- Linked to the shift from performance management to learning system, is the leadership shift from command and control to devolved power and trust in collaboration.
Enjoy these contributions. There is so much that other health systems around the world take from the NHS in England, which is rightly held up as an exemplar of the universal coverage health system. Where policy makers in England go, many around the world look to follow.
Increasingly though, we are seeing other health systems leapfrog in their ambition to make integrated care for population health a reality by learning from the English experience over the last decade since the NHS Five Year Forward View. There is an opportunity in this paper and at ICIC26 in Birmingham next April for that learning to be shared in both directions.
I would like to thank our contributors for their consideration and time in sharing their thoughts with us. I also acknowledge the contributions of our reviewers.
Dr Niamh Lennox-Chhugani
International Foundation for Integrated Care (IFIC)
An Irish perspective: lessons and cautions
Author: Áine Carroll, Professor of Integrated Care and Improvement Science, University College Dublin (UCD); Consultant in Rehabilitation Medicine, National Rehabilitation Hospital; Co-Director IFIC Ireland and Chair, International Foundation for Integrated Care.
From this side of the Irish Sea, the newly launched NHS 10 Year Health Plan (Fit for the Future) has a familiar ring. The vision of a digitally enabled, community-centred, and prevention-focused health service is admirable, but it also evokes a sense of déjà vu. In both Ireland and England, we’ve seen successive governments sweep in with bold reform agendas, only to overlook a critical foundational step: evaluating what has already been tried, learned, and often, abandoned.
Ireland’s own experience with Sláintecare [1] mirrors many of the NHS plan’s aspirations. Like the NHS, we aim to shift care from hospitals into communities, integrate services around the needs of people rather than institutions, and harness digital tools to empower both citizens and professionals. But the path to these goals has been obstructed by fragmented governance, weak implementation structures, and the perennial intrusion of short-term political priorities. The NHS plan, for all its ambition, may fall prey to the same forces.
To be fair, the plan’s diagnosis is largely correct, waiting times are untenable, outcomes are stagnating, and the current model is unsustainable. Its ambitions to strengthen prevention, decentralise care delivery, and embed digital tools are directionally sound. Yet these “radical” shifts; neighbourhood health services, digital-first access, and a new focus on prevention, have appeared in one form or another in the Five Year Forward View (2014) [2], the Long-Term Plan (2019) [3], and earlier reform cycles. Without a transparent evaluation of why previous iterations fell short, there is a real risk of what Partha Kar in the BMJ has aptly called “old wine in new bottles” [4].
Ireland can particularly relate to the tendency toward what Hugh Alderwick in the BMJ describes as “redisorganisation” [5]. The NHS plan’s proposal to abolish NHS England, restructure integrated care systems, and reinvent provider roles echoes the ongoing flux of organisational reform in Irish health policy. We too have repeatedly seen new structures established before prior ones were embedded or evaluated. Change fatigue is real, for staff, citizens, and leaders alike.
Notably absent in both jurisdictions is a commitment to building robust learning health systems, frameworks that prioritise feedback, reflection, and iterative change over one-off transformation plans. We are still trapped in a cycle of implementation without evaluation and reform without reflection. The NHS plan claims to have consulted widely, but even this engagement seems to have fallen short of genuine partnership. Patients may be asked to rate their care or choose their provider through an app, but rarely are they involved in shaping system reform at its source. Ireland, despite a rhetorical commitment to co-design and partnership in Sláintecare, faces similar deficits in embedding citizen voice into governance and decision-making.
Another shared vulnerability is the growing allure of financialised care and market-driven mechanisms. England’s proposal to link payment to patient ratings, use “patient power payments,” and expand private sector delivery may create incentives that distort care priorities and exacerbate inequities. In Ireland, while the system remains predominantly public, similar pressures exist around contracting and outsourcing. Equity cannot be an afterthought in system design.
The workforce dimension also warrants closer scrutiny. The NHS plan suggests that a leaner, digitally supported workforce will suffice in future, a premise at odds with reality. In both countries, healthcare professionals are burned out, under-resourced, and navigating increasing complexity. Technology should be seen as an enabler, not a replacement for the relational, context-sensitive work of health and social care. Without sustained investment in staff wellbeing, training, and team-based models of care, no plan will succeed, however visionary.
The plan’s techno-optimism also risks overselling the transformative potential of data, AI, and genomics. While digital transformation is essential, trust, literacy, and access remain serious challenges, especially for marginalised groups. Simply offering patients more information or app-based control does not address the structural determinants of inequality. As Alderwick notes, the NHS may be designed as a universal service, but the risk is that it becomes a poor service for poor people, a fate Ireland must also guard against.
And finally, the NHS plan, for all its breadth, remains an NHS plan, not a comprehensive health and wellbeing plan. The document acknowledges the role of social determinants but defers action on social care and offers limited proposals for intersectoral collaboration. Ireland too struggles to align its health reform agenda with wider action on housing, education, and income. Health systems alone cannot create health.
In summary, Ireland can both learn from and caution the NHS as it embarks on this new chapter. We share similar ambitions and face parallel challenges. The temptation to restructure without reflection, to digitise without equity, and to reform without partnership must be resisted. A better future for our health systems lies not in reinventing the wheel every electoral cycle, but in building the structures for learning, listening, and long-term collaboration.
Rather than repeating mistakes in parallel, perhaps our two systems can now look across borders, share lessons honestly, and place a shared commitment to equity, trust, and continuous learning at the heart of health system renewal.
References
- Committee HotO. Sláintecare Report. Houses of the Oireachtas Committee; 2017.
- NHS England. Five year forward view. 2014.
- Alderwick H, Dixon J. The NHS long term plan. British Medical Journal Publishing Group; 2019.
- Kar P. Partha Kar: The NHS 10 Year plan is torn between genuine change and political expediency. British Medical Journal Publishing Group; 2025.
- Alderwick H. Government’s 10 Year plan for the NHS in England. British Medical Journal Publishing Group; 2025.
Prof Áine Carroll
International Foundation for Integrated Care (IFIC)
Professor of Healthcare Integration and Improvement, University College Dublin, National Rehabilitation Hospital
He tangata: an Aotearoa New Zealand perspective
Author: Amarjit Maxwell, Chief Executive Officer, THINK Hauora Primary Health Organisation, and PhD candidate at Victoria University, focusing on strengthening collective impact as an enabler for delivering Pae Ora Healthy Futures to address inequities in Aotearoa New Zealand.
He aha te mea nui o te Ao? He tangata, he tangata, he tangata. What is the most important thing in the world? It is people, it is people, it is people.
Māori proverb
With people-centred care as the foundation for quality and timely delivery of health and social services, this short reflection explores recent health legislation and strategic plans in England and Aotearoa New Zealand.
The National Health Service 10 Year Plan (the NHS Plan) offers a hopeful vision for achieving integrated health and social care. Based on my own experiences with the English health system, such an overhaul feels long overdue. The NHS Plan’s three radical shifts - from Hospital to Community, Analogue to Digital, and Sickness to Prevention - are ambitious but commendable. They signal a significant transformation in health and care delivery.
The NHS Plan provides a clear operating model that empowers local leadership through Integrated Care Boards (ICBs), and a reimagined workforce that includes new strategic roles. There is a strong emphasis on neighbourhood health services delivered through community hubs. While critics remain, this level of radical change is necessary to address the social determinants of health.
Knowledge and ideas continue to flow across borders, supported by organisations like the International Foundation for Integrated Care. The NHS Plan offers inspiring pathways that reflect the core principles of integrated care. Staying the course will be vital; it is still early days.
Aotearoa New Zealand has embarked on its own radical journey of transformation with the Pae Ora (Healthy Futures) Act, passed into law in July 2022. Te Tiriti o Waitangi, Aotearoa New Zealand’s founding document, is now embedded in health governance. This bold legislation was set to transform the health system with a strong focus on equity and locality-based care, where services are locally led and delivered, supported regionally, and enabled by national functions.
The updated New Zealand Health Plan 2025–2026 (Aotearoa, NZ Plan), issued in 2025, provides a one-year strategy. It incorporates a focus on need versus equity, financial sustainability, specific health targets, and a more devolved organisational model. There is renewed emphasis on infrastructure and openness to public-private partnerships.
Specific targets related to improving population health are providing clear priority areas to drive the change with the ability to measure success in terms of patient outcomes. This clarity is welcomed by health professionals.
More recently, in Aotearoa New Zealand the Healthy Futures (Pae Ora) Amendment Bill 2025 prioritises timely, quality care and a simplified delivery model. A primary care target to improve access is under development as there is an expectation to reduce wait times. Moreover, this is a contentious time as the Amendment Bill directly impacts equity for Māori, the Indigenous people of Aotearoa New Zealand through proposed changes to the powers held by Iwi Māori Partnership Boards.
Parallels between the NHS Plan and the A|NZ Plan
There are several parallels between the NHS Plan and that Aotearoa NZ Plan, particularly in their shared focus on improving access, enhancing operational efficiency, and transforming the delivery of care through local networks and technology. Both countries include a focus on preventative care as well as workforce development.
However, in Aotearoa New Zealand, the Pae Ora health reforms appear not to be reaping the benefits as hoped. A recent change in government has meant a shift away from the original intent of the reforms, and a lack of clarity in the arrangements for primary health care continues to cause uncertainty and disruption in the delivery of care. Clear and consistent policy settings are required to drive the intent of the health reforms.
As England and Aotearoa New Zealand are pursuing reforms to deliver timely access to quality healthcare, with greater emphasis on prevention and early intervention, these changes will require local engagement. Both plans highlight digital technologies, strengthening local care with financial sustainability and private investment as core pillars. However, while there are similarities, the contexts of each country are vastly different. Te Tiriti o Waitangi is unique to Aotearoa, New Zealand, and its principles -especially equity - continue to be upheld within primary and community organisations.
Considerations and learning: strategic focus and priority areas
Since Aotearoa New Zealand is further along in its journey of large-scale reforms to achieve improved health outcomes for all New Zealanders, there are some considerations or learnings that may be useful as the NHS Plan is implemented. Some of these are highlighted in the table below based on general reflections.
| Aotearoa New Zealand Focus Area | Consideration and learning |
|---|---|
| Achieving financial stability | Significant requirement for cost reduction comes with unintended consequences, such as loss of institutional knowledge and reduced productivity. |
| Urgent priority setting | Setting urgent priorities that focus on front line delivery at the cost of back-office support can compromise expected progress – maintaining realistic oversight is needed to avoid unintended consequences. |
| Locally led and delivered services | Involvement of communities requires ongoing communication, engagement, and careful planning. |
| Adopting a centralised structure to drive performance | This may be considered too ambitious and costly. The one organisation with devolved autonomy is difficult to implement, even with regional support. Loss of knowledge at the centre has a flow-on impact across the wider sector. |
| Clear health targets provide measurable outcomes | These should be embedded across the continuum of health systems to support the patient journey across primary and secondary care – supporting an integrated approach. |
| Enhanced clinical leadership | This has brought about improved quality, safety, and decision-making across the continuum of health, with stronger clinical governance. |
| New models of care that focus on prevention and digital technologies | These support the increasing demand due to a growing and aging population – ongoing innovation is essential to meet this need. |
| Building workforce capability and capacity | Dealing with workforce shortages and training is a global challenge that also requires a change in model of care towards team-based approaches to care. |
Conclusion
Across Aotearoa New Zealand health sector there is a need to focus on meaningful transformation – one that does not require dismantling equity structures, but instead calls for deep relationships, a shared sense of purpose, and sustained local leadership. Of course, financial sustainability, health targets and digital transformation should be woven into this vision of locally led care.
Many of the priorities within the Aotearoa New Zealand reforms align closely with the three core areas set out by the NHS Plan: shifting from Hospital to Community, Analogue to Digital, and Sickness to Prevention. Globally, health systems face shared challenges from rising demand, workforce shortages, and persistent inequities. Both the NHS Plan and Healthy Futures legislation represent significant efforts to address these challenges, though their success will be shaped by political climates, cultural contexts, and historical commitments.
Many of the priorities within the Aotearoa New Zealand reforms align closely with the three core areas set out by the NHS Plan: shifting from Hospital to Community, Analogue to Digital, and Sickness to Prevention. Globally, health systems face shared challenges from rising demand, workforce shortages, and persistent inequities. Both the NHS Plan and Healthy Futures legislation represent significant efforts to address these challenges, though their success will be shaped by political climates, cultural contexts, and historical commitments.
Amarjit Maxwell
THINK Hauora
Mind the implementation gap
Author: Anne Hendry, Director IFIC Scotland and Professor at the University of the West of Scotland. IFIC Scotland is a partnership between IFIC, the University of the West of Scotland and the Health and Social Care Alliance Scotland.
It is heartening to see shared ambitions in the recent flurry of health policy publications released by both the UK and Scottish governments. The three radical shifts in the 10 Year health plan for England [1] have long been pursued in Scotland yet remain elusive: a left shift from hospital to community, from sickness to prevention and from analogue to digital. Transformers know such shifts are challenging to achieve at scale. Ten years on from landmark legislation to integrate health and social care in Scotland, England can learn a lot from what has worked and what has not worked in Scotland [2]. The positive impact of integrated community services and new ways of working is acknowledged by many, but the promise of prevention remains largely stifled by financial and workforce pressures and by the incessant demand for acute care [3].
Implementation of the health plan for England in a similarly complex landscape will need ambitious investment in both healthcare and social care, and collaborative commissioning of third sector and community-led support in partnership with local government - sectors scarcely visible in the plan yet holding many of the levers that influence population health and wellbeing. System leaders invariably talk of partnership with other sectors, but experience tells us that power relationships are rarely equal. Experience from Scotland tells us that realising the shifts outlined in 10 Year plan for England will need brave leaders prepared to share power and to invest more equitably in the whole workforce, including in the voluntary sector and unpaid carers.
Transformation also needs practical, relational support and opportunities for teams to share knowledge and learn new ways of working together. Our recent report highlights eight enablers or navigators required for successful large-scale change [4]. It highlights the need to create headspace to nurture relationships, build trust and respect for different cultures, understand how to convene as equal partners and to promote adaptive mind-sets and behaviours that empower creativity and enable risk.
The 10 Year plan for England is not just light on detail around implementation. There is scant reference to workforce planning and development, perhaps except for a focus on advanced practice, enabling professionals to work at the top of their licence. Given the growing number of people living with frailty and multiple long-term conditions, any specialty or condition-specific approach must be complemented by building capacity and capability for expert generalists and more generic support. Service design for the emerging neighbourhood health services in England, as for Scotland’s integrated community services, should plan workforce around a clear understanding of place and local assets. Every community is different and urban, rural, remote and island communities have specific strengths and needs [5]. IFICs report on workforce education and training offers a timely challenge to bridge the gap between policy rhetoric and practice [6].
The plan heralds digital innovation as a key enabler for transformation. But, of course, the technology is only part of the solution. Adoption of digital solutions is enabled by workforce and social innovation and by optimising digital access and literacy. Failure to address these issues will result in digital becoming yet another systemic barrier for marginalised communities. The 10 Year plan rightly describes inequalities as intolerable injustice. This framing resonates with a rights-based approach championed by our IFIC Scotland partners, the ALLIANCE, in their work on the five ambitions for health and social care [7].
As a former talented student from a lower socioeconomic background, now proudly affiliated with a university leading the way in widening access, I applaud the 10 Year plan’s ambition to widen career opportunities for all. However, knowing the fragility of current funding for higher education in the UK reminds me of the many interdependencies of public policies. Implementation of policies to tackle health equity requires sustained funding that intentionally targets investment to place and population need. The proposed funding reform in England based on patient power, provider choice and reinvented foundation trusts seems at odds with a population health approach designed for care continuity, coordination and addressing the wider determinants of health. Scotland recently published its equivalent 10 Year plan [8], alongside a refreshed Public Sector Reform strategy [9] and a 10 Year Framework for Population Health that describes how national and local government will work with public sector partners, community organisations and business to tackle the root causes of ill health [10].
Despite critical gaps around workforce planning and funding for social care and third sector, I am cautiously hopeful for the future of the 10 year-health plans in both jurisdictions. The plans bring some much-needed coherence, but I know the real challenge lies in implementation. Now, more than ever, we need brave leadership, greater collaboration and wisely targeted investment to drive change. Transformation is messy. The journey towards change will be bumpy. But let’s stick with it and continue to share our transformation stories through future IFIC webinars and conferences.
References
- Department of Health and Social Care. Fit for the Future: 10 Year Health Plan for England. July 2025 - https://assets.publishing.service.gov.uk/media/68760ad755c4bd0544dcae33/fit-for-the-future-10 Year-health-plan-for-england.pdf (accessed Oct 7 2025)
- Hendry A, Thompson M, Knight P, McCallum E, Taylor A, Rainey H, Strong A. Health and Social Care Reform in Scotland - What Next? Int J Integr Care. 2021 Oct 29;21(4):7. doi: 10.5334/ijic.5633. PMID: 34754283; PMCID: PMC8555477.
- Hendry A, Gibb S. From strategic intent to procurement of adult social care and support in Scotland. Report 2. Analysis of current experience and ideas for improvement; CCPS September 2024. https://doi.org/10.5281/zenodo.14929466
- Gibb, S., Hendry, A., Rainey, H., Webb, A., Grant, S., Gamble, S., Mashkoor, A., Hendry, C., Craney, A., Carroll, R. (2025) Cultures and Leadership for Integration (CLI) In Health and Social Care: Navigating to Successful Change, CLI Convention Report. UWS Social Impact Leadership and Management Research Group, Report 2. https://doi.org/10.5281/zenodo.14918770
- Hendry, A., Kurpas, D., Munoz, S.-A. and Tucker, H. (2024), "Guest editorial: Integrated care in rural, remote or island communities", Journal of Integrated Care, Vol. 32 No. 1, pp. 1-5. https://doi.org/10.1108/JICA-02-2024-096
- International Foundation for Integrated Care. The State of Education and Training in Integrated Care Worldwide.
- The Health and Social Care Alliance Scotland. Five Ambitions for the Future of Health and Care. available at https://www.alliance-scotland.org.uk/health-and-social-care-integration/health-and-social-care-academy/five-ambitions-for-the-future-of-health-and-care/
- The Scottish Government June 2025. Health and Social Care Service Renewal Framework 2025-2035. available at https://www.gov.scot/publications/health-social-care-service-renewal-framework/
- The Scottish Government June 2025. Scotland's Public Service Reform Strategy: Delivering for Scotland. Available at https://www.gov.scot/publications/scotlands-public-service-reform-strategy-delivering-scotland/
- The Scottish Government June 2025 Scotland’s Population Health Framework 2025-2035 available at https://www.gov.scot/publications/scotlands-population-health-framework/
Different systems, shared challenges: Australia and the UK
Author: Carmen Hinkel-Schneider, Associate Professor of Health Policy, University of Sydney and Deputy Director, Leeder Centre for Health Policy, Economics and Data.
Australia and England share many of the same health system challenges, despite having quite different system structures. Difficulties accessing a GP [1], fragmented service delivery between hospitals and community care, and persistent inefficiencies are common themes in both the 10 Year Health Plan for England and Australia’s current reform agenda, including the 2022 Strengthening Medicare Taskforce report [2] and ongoing negotiations for the next addendum to Australia’s National Health Reform Agreement. This reflection focuses on four key themes that are particularly relevant to the Australian context: (1) moving care from hospitals into the community; (2) devolution and local planning autonomy; (3) data and technology; and (4) person-centredness.
Moving care into the community
The plan’s emphasis on neighbourhood health centres and expanded urgent care access reflects a clear intent to shift care out of hospitals and into community settings. This aligns with Australia’s own efforts to commission urgent care centres and multidisciplinary hubs under various integrated care initiatives. However, both systems face implementation barriers, particularly in enabling genuine collaborative care when patients require both hospital-based and community-based services. Determining which services should be hospital-based, community-delivered, or strategically commissioned to private providers remains a complex and ongoing policy challenge. Implementation will require careful negotiation of roles, responsibilities, and funding flows across sectors and within an increasingly diverse provider landscape.
Devolution and local planning
To address structural barriers to community care—including the mismatch between where costs are incurred and where savings are realised—the NHS plan proposes significant devolution of financial and commissioning authority to Integrated Care Boards, and trials of fully Integrated Health Organisations that would hold the entire health budget for a defined population. This is a major shift toward place-based accountability. Australia will be watching closely, as current reform debates increasingly favour population-based planning at local levels. The Australian Productivity Commission’s interim report Delivering Quality Care More Efficiently [3] recommends that the next National Health Reform Agreement addendum support governance and funding arrangements that enable collaboration between Local Hospital Networks (LHNs), Primary Health Networks (PHNs), and Aboriginal Community Controlled Health Organisations (ACCHOs). This includes the ability to collaboratively commission services, highlighting the need for meso-level governance reform and a rethinking of how funding decisions are made, how benefits and under what contractual arrangements services are delivered.
Data and technology
The NHS plan places a strong emphasis on advanced data and digital infrastructure, with the NHS App as a flagship initiative. While Australia has made progress in EMRs and telehealth platforms, its personally controlled electronic health record (My Health Record) has seen slow uptake and limited utility in streamlining care [4]. Significant effort has gone into ensuring data security and privacy as well as and clinician engagement. Meanwhile, a proliferation of private digital health tools reflects Australia’s mixed public-private system. The NHS app offers the opportunity to consolidate services into a single platform—encompassing My NHS GP, My Choices, My Medicines, My Care, My Health, and My Carer. Success will depend on technical capacity, interoperability, public trust, and the capability and motivation of providers to use the system as a clinical tool. More broadly, the plan’s reliance on quality data and technical infrastructure extends to performance monitoring, pricing reforms and the use of AI to increase the efficiency of clinical tasks. All require robust, clinically meaningful datasets and clinician buy-in. Implementation barriers include legacy systems, data silos, and the need for cultural change in how data is shared and used.
Person-centredness
The 10 Year Health Plan includes strong health promotion elements, with proposed vaping legislation mirroring several elements of Australia’s vaping and e-cigarette laws introduced in 2024. Both countries are investing considerable resources in establishing protocols and governance around genomics for predictive and precision medicine, with Australia establishing Genomics Australia and its first Australian Health Genomics Commissioner in July this year.
The proposed Patient Choice Charter aims to make the NHS more responsive to individual preferences. In Australia, patients nominally have a full choice of providers, though this is often constrained by cost, geography, availability, and limited access to information. Formalising choice mechanisms in the NHS may introduce demand-driven dynamics, and implementation will need to address health system literacy, equity concerns, and the risk of widening access gaps. Notably, the plan’s ambition to link person-centredness with funding mechanisms through performance incentives, penalties, and pricing reforms is perhaps its most significant proposed change. The emphasis on personal budgets has similarities with enrolled-direct packages of the Australian National Disability Insurance Scheme (NDIS). A major review the NDIS, released in July this year, demonstrates the complexities in balancing supply, demand and true patient autonomy and best care.
The NHS England 10 Year Plan is ambitious in scope and intent; there will be many trials and lessons for implementation that will be watched with interest to determine how to best tackle common problems across health systems.
References
- Australian Institute of Health and Welfare. (2025). General practice, allied health and other primary care services. Available at General practice, allied health and other primary care services - Australian Institute of Health and Welfare
- Australian Government. (2022). Strengthening Medicare Taskforce Report. Available at Strengthening Medicare Taskforce Report
- Australian Government Productivity Commission. (2025). Delivering quality care more efficiently – Interim report. Available at https://www.pc.gov.au/inquiries-and-research/quality-care/interim/
- Australian Government Department of Health and Aged Care. (2024). Health Legislation Amendment (Modernising My Health Record—Sharing by Default) Bill 2024 Impact Analysis. Available from https://oia.pmc.gov.au/sites/default/files/posts/2024/11/Impact%20Analysis_1.pdf
- Australian Government Department of Health, Disability and Ageing. (2025). Release of the final report of the Independent Review into the NDIS. Release of the final report of the Independent Review into the NDIS | Australian Government Department of Health, Disability and Ageing
Carmen Huckel-Schneider
University of Sydney and Deputy Director
Leeder Centre for Health Policy
Economics and Data
The vision is sound; the path requires reconsideration
Author: Carolyn Gullery, Executive leader in health system design, analytics and digital transformation based in New Zealand.
Vision meets reality
The Fit for the Future: 10 Year Health Plan for England presents an ambitious and necessary vision for transforming the NHS in "critical condition." The plan's strategic pillars—shifting from hospital to community, from analogue to digital, and from sickness to prevention—represent the right direction for modern healthcare. However, while the diagnosis is accurate, the proposed treatment contains fundamental contradictions that risk undermining its own transformative goals.
Drawing from decades of experience in successful health system transformations in New Zealand and elsewhere, this critique examines where the English plan aligns with proven principles of integration, and where it diverges into approaches that may inadvertently perpetuate the fragmentation it seeks to address.
The foundation: where vision and experience align
The plan's core ambitions deserve recognition. The shift towards neighbourhood health services, increased investment in community and primary care, and the dismantling of hospital-centric models reflect essential principles that have enabled successful transformation elsewhere. Similarly, the focus on digital enablement through the NHS App as a "doctor in your pocket" and the creation of single patient records mirrors the critical role that shared digital infrastructure plays in connecting fragmented systems.
These elements resonate strongly with the Canterbury transformation experience, where placing the person—not institutional structures—at the centre of the system enabled measurable improvements in outcomes while bending the cost curve. A genuinely integrated system cannot function without integrated data, and the plan's digital ambitions recognise this fundamental requirement.
The central contradiction: command and control vs. collaboration
However, beneath this promising vision lies a fundamental philosophical tension. The plan attempts to overlay 21st-century integrated care onto 20th-century governance structures with a strong thread of central control, market-style competition, and complex financial incentives. This approach misunderstands how sustainable transformation occurs in a complex, adaptive system.
The trust paradox
Real integration requires high trust and distributed leadership. Success comes from empowering clinicians and communities to co-design pathways and giving them permission to innovate within a framework of shared accountability. The Fit for the Future plan, conversely, maintains command-and-control thinking through proposals for "enhanced oversight, escalating to regulatory interventions" and systems where providers must "earn" the right to autonomy. The NHS in England already suffers from an obsession with single point accountability, which undermines the collaboration required for successful integration.
You cannot innovate your way out of a crisis while simultaneously tightening central control. The most effective transformation strategies are emergent, not prescribed—they arise from local leaders understanding their populations and co-designing solutions that work in their specific contexts.
One system, one budget vs. fragmented incentives
Canterbury achieved transformation through a simple yet powerful principle: "one system, one budget." This meant aligning incentives across the entire health system so that each dollar could only be spent once, and all providers shared accountability for population outcomes within a fixed financial pool.
This plan talks about integration while proposing mechanisms that maintain fundamental fragmentation. The move to "deconstruct block contracts" and implement "tariffs based on best clinical practice" misses a crucial insight: Canterbury succeeded precisely because we moved away from payment by activity. As we learned, fee-for-service models create a sense of entitlement over revenue and discourage providers from engaging in activities that improve efficiency or reduce demand.
Financial architecture: the heart of transformation
How a system is funded determines how it behaves. The plan's approach to "value-based care" through complex financial incentives risks creating the opposite of its intended effect.
The problem with performance payments
The plan's proposals to withhold payments for poor quality, tie leaders' pay to performance, introduce "patient power payments," and create provider league tables reflect a fundamental misunderstanding of what motivates healthcare professionals. People working in healthcare are intrinsically motivated to do their best for patients and populations they care for. Complex financial incentives often become perverse, fostering competition between silos and encouraging gaming of metrics rather than genuine improvement.
Instead of building trust, these mechanisms breed fear and uncertainty. Providers focus on avoiding financial penalties rather than innovating for people and communities. This approach has been tried repeatedly in healthcare systems worldwide, with limited success and often counterproductive results.
A more effective approach
Experience suggests that sustainable financial reform requires:
- Transparent resource allocation
Use good data to make problems visible to everyone, building shared understanding of challenges and collective ownership of solutions.
- Simplified funding models
Replace complex activity-based payments with allocative or population-based funding that rewards collaboration over competition.
- Alliance-based accountability
Create shared responsibility for population outcomes where "everyone wins or everyone loses," fostering genuine partnership rather than institutional self-interest.
- Investment in enablers
Focus funding on digital infrastructure, shared analytics platforms, and flexible community models that enable integrated care, rather than creating new competitive dynamics.
The culture question: competition vs. collaboration
The plan contains a fundamental contradiction in proposing to foster integration while simultaneously promoting competition as a quality driver. It seeks to "compete on quality and performance," use patient choice to make providers "raise their game," and leverage private sector competition.
This approach fails to recognise that you cannot build collaborative, whole-of-system culture while asking providers to compete with one another. Successful alliance contracting is built on the principle that collective success requires everyone to work together toward shared goals. When providers compete to be in the market, they inevitably prioritise institutional interests over system-wide outcomes.
Digital transformation: technology without cultural change
While the plan's digital ambitions are appropriate, they appear to suffer from a common technology implementation error: if digital tools will drive transformation rather than enable it.
The South Island’s (NZ) HealthOne electronic shared care record succeeded not because of its technical capabilities, but because we first established clinical relationships and pathways that made information sharing meaningful. This plan risks putting the cart before the horse—creating digital infrastructure without first establishing the collaborative relationships that make it valuable.
The human element
The plan's focus on AI scribes, digital-first care, and app-based services fundamentally misunderstands what patients want from healthcare. While efficiency matters, patients primarily seek relationships, trust, and continuity of care. Technology should enhance the capability and capacity of these human elements, not replace them.
More concerning is the emphasis on patient choice through digital league tables and provider ratings. This consumer model imported from retail misses the insight that better health outcomes come from stronger relationships with trusted providers, not from shopping around for healthcare.
Prevention: systems change, not individual responsibility
The plan correctly identifies prevention as crucial but approaches it primarily through individual behaviour change—health reward schemes, obesity "moonshots," and digital health coaching. This reflects the same individualistic thinking that contributed to current system failures.
Effective prevention requires system redesign that makes healthy choices the default option. Greater outcomes can be achieved through redesigning care delivery to keep people well in their communities through better discharge planning, community nursing, and integrated care for older adults.
Addressing the aging population
When viewed through the lens of the aging population the Fit for the Future plan represents a comprehensive transformation strategy that places older people at the centre of a new care model, addressing both immediate needs and long-term sustainability challenges through integrated, community-based, and technology-enhanced approaches to health and social care delivery. The risk is that it will be too slow and suffer from the centralised need for control that has hindered many of the NHS’s transformation efforts. Supporting older people to age well in their own homes and communities and stay out of hospitals is the most urgent transformation required because without a substantial change in direction to person-centred, primary and community-based care for this population the NHS will never become sustainable.
A path forward: reframing the approach
The Fit for the Future plan could achieve its ambitious goals through several critical reframes:
- From control to enablement
Rather than requiring providers to "earn" autonomy, empower local clinical leaders from the outset to co-design solutions appropriate to their populations. Success comes from unleashing local innovation within clear outcome frameworks, not from compliance with central directives.
- From competition to collaboration
Replace market-based mechanisms with alliance contracting approaches that create shared accountability for population health outcomes. When all providers share risk and reward within a fixed budget, they naturally collaborate rather than compete.
- From complexity to simplicity
Streamline funding mechanisms rather than adding new layers of financial incentives. Simple, transparent allocation based on population need creates the stability required for long-term planning and innovation.
- From measurement to learning
Transform transparency from a tool for ranking and shaming into a mechanism for shared learning and continuous improvement. Use data to build understanding and trust, not to create winners and losers.
Conclusion: right destination, better route
The Fit for the Future plan articulates a compelling vision for modern, integrated, preventative healthcare. Its diagnosis of NHS challenges is accurate, and its ambitions are appropriate for the scale of change required.
However, the plan's proposed methods—top-down directives, market-style competition, and complex financial incentives—risk destroying the very conditions needed for success: trust, collaboration, and local ownership. The irony is that these methods have been tried repeatedly in healthcare reform efforts worldwide, often with disappointing results.
Canterbury's transformation demonstrates that sustainable change is possible, but it requires different thinking about incentives, relationships, and the role of communities and clinical teams. Rather than centrally determined, effective transformation requires empowering local leaders, simplifying funding structures, and building trust through shared data and common purpose.
The choice facing the NHS is not between reform and transformation, but between approaches that have repeatedly failed and those that have demonstrably succeeded. England could learn from international experience and choose methods that align with rather than work against the collaborative culture required for integrated care.
The NHS deserves the kind of genuine system change that puts people and populations at the centre, empowers communities and clinical teams, deliberately drives equity and creates the conditions for sustained improvement. This is achievable, but only if the right lessons are learned and applied.
With appropriate modifications to address the funding and governance contradictions identified above, the Fit for the Future plan could indeed deliver the transformation the NHS so urgently needs. The vision is sound; the path requires reconsideration.
Carolyn Gullery
Executive leader in health system design, analytics and digital transformation based in New Zealand
Technical fixes for adaptive challenges?
Author: Kerry Kuluski, Dr. Mathias Gysler Research Chair in Patient and Family-Centered Care, Institute for Better Health, Trillium Health Partners and Professor, Affiliated Scientist, Institute of Health Policy, Management and Evaluation, University of Toronto
“From bricks to clicks,” “more choice and voice” and having a “doctor in your pocket”, at first read, the 10 Year plan is compelling. What is proposed is a de-institutionalized, digitized and AI-enabled, system offering faster access, democratization of data and funding (through apps and personal budgets), greater efficiency, and care closer to home with some attention to underserved populations. These proposed “fixes” are poised to address persistent health challenges. However, enabling this plan requires a context that supports news ways of thinking, working and behaving, across organisational boundaries and amongst a broad range of partners (including patients, carers, providers, managers and organisational leaders across the health and social ecosystem). The ideas in this plan have some potential to modernise a system that needs to be updated; however, it seems that the plan focuses more on the “what” and less on the “how.”
Moving from technical to adaptive solutions
Restructuring the NHS, like any health system, requires an adaptive approach, not a technical fix. Borrowing from the business literature and work of Heifetz, Grashow and Linsky [1] technical challenges can be solved using existing knowledge and tools and are more straightforward to implement. Adaptive challenges typically have no one “tried and true” solution and require input from various actors who need to think and work differently, learn together, pivot and embrace ambiguity to address the problem they are trying to solve. Tackling adaptive challenges requires engagement and co-design to leverage different forms of expertise to test and implement new models and pathways. Arguably, what is proposed in the 10 Year plan requires more adaptive than technical solutions. The neighbourhood model, an excellent idea to provide connected care closer to home, is an example of a new model of care that requires an adaptive approach in its design. Enacting this model entails the shifting of resources from hospital to community, providers working in teams, co-location of services and attention to the social determinants of health. What’s missing is the implementation plan, and perhaps that comes later. Despite the existence of neighbourhood-type models throughout the UK, this isn’t a “plug and play” solution but one that requires the leveraging of local assets, deep community engagement and co-design to implement a model that works for each specific locality.
Without some thoughtful consideration on how to tailor the reforms outlined in the 10 Year plan to account for individual and system complexity, it runs the risk of mostly benefiting relatively healthy, independent people who want more convenient access to health care via technology. To use a simple example- We can’t hand people an iPhone and expect them to self-manage their care and navigate the health system. While this technical “fix” will benefit many, others will fall further behind due to limited health literacy, medical complexity and engagement preferences that don’t involve technology. That said, the 10 Year plan requires attention to the behavioural shifts required to bring this plan into action and a realist approach to unearth, “what works for whom and in what conditions?”
We should focus on Partnership not Punishment
The 10 Year plan promises a highly accountable system with performance expectations placed on providers to be more person-centred, adhere to best practices and minimise waste. It goes so far as putting the power in patients’ hands to direct payments away from providers toward an innovation fund if patients deem the service from the provider to be subpar. While in some sense it raises accountability to deliver better care to patients, such “incentives” are divisive rather than collaborative. Instead of pitting providers and patients against each other, what if we create more capacity within health and social care practice for patients, families and care teams to work together, to learn about each other’s strengths and limitations, set goals of care and figure out a way forward, together? It’s through this type of co-production and teamwork that you build trust and operationalise a person-centred approach – honouring people’s unique needs, preferences and strengths.[2] Perhaps incentives should be around setting goals for care and engaging patients and families in continuous co-design, not meeting an arbitrary metric on a patient experience survey.
Moving toward community collaboration and social participation
As noted by Antoine Boivin et al [3]“lived experience and knowledge, especially that of people who struggle the most to access health, is pivotal in helping us design better and more inclusive health systems” [p.1]. Boivin’s reflection is written in response to the 77th World Health Assembly where member states made a commitment to enable and sustain ongoing and meaningful civic engagement in decision-making for health. [4] Such collaborative governance feels counter to the framing of the 10 Year plan, which gives off a top-down competitive vibe, rewarding providers and patients for behaving in particular ways and setting performance targets that don’t account for the complexities of humans and systems. Collaborative governance requires thoughtful leadership and allyship to mobilise local interests while setting and acting on the vision for the future. What the 10 Year plan needs is the chapter on adaptive leadership, “the practice of mobilising people to tackle tough challenges and thrive” [5, p.14].
References
- Heifetz R, Grashow A, Linsky M. The Practice of Adaptive Leadership: Tools and Tactics for Changing Your Organization and the World. Boston, Massachusetts: Harvard University Press; 2009.
- Lachman P, Batalden P, Vanhaecht K. A multidimensional quality model: an opportunity for patients, their kin, healthcare providers and professionals to coproduce health. F1000Res. 2020;9:1140.
- Boivin A, Mothci D, Dumez V, Shore F, Bok A. World leaders unite to embed social participation in health systems. BMJ. 2024;386:q1460.
- World Health Organization. Social participation for universal health coverage, health and well-being. Seventy-Seventh World Health Assembly 2024; Agenda item 11.1:https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_R2-en.pdf. Accessed June 22, 2025.
- Heifetz R, Grashow A, Linsky M. The Theory Behind the Practice. In: The Practice of Adaptive Leadership: Tools and Tactics for Changing Your Organization and the World. Boston, Massachusetts: Harvard Business Press; 2009:13-40.
Kerry Kuluski
Inaugural Dr. Mathias Gysler Research Chair in Patient & Family Experience and Scientist
IBH
Associate Professor
IHPME
What comes next? A systems transformation perspective
Author: Ng Yeuk Fan, Adjunct Associate Professor in the Saw Swee Hock School of Public Health, National University of Singapore, Director & Head of Corporate Development in Yishun Health, Singapore, and IFIC Board Member.
The Fit for the Future 10 Year Health Plan for England is an ambitious, well-articulated and timely call for change. At this level of publication - national strategy for a decade-long reform – it is expected that not every technical specification or operational detail can be laid out. Still, the Plan’s clarity of vision and structural framing is commendable. The three shifts outlined - from hospital to community, from analogue to digital, from sickness to prevention - resonate strongly with my own understanding of the trajectories of many health systems world-wide. In fact, it echoes Singapore’s own health system transformation agenda, such as the 3 beyonds: beyond hospital to community, beyond quality to value, beyond healthcare to health.
There is much to admire in the NHS Plan. The focus on neighbourhood-based integrated care, digitised access and AI-enabled personalised services is both progressive and necessary. The digital transformation track - if fully backed by robust data infrastructure, interoperability standards, and governance - can be a critical enabler for quantifying outcomes and value, shifting care upstream, and managing variation across regions. The prevention agenda, supported by genomics and precision public health tools, is future-facing and well-positioned.
However, what remains largely implicit - but critically important - is the challenge of how such large-scale systemic transformation will be achieved. Transforming a national health system is not merely a technical exercise in structure and resource allocation; it is fundamentally a socially complex change. As such, it demands a corresponding level of investment in process leadership, organisational development, and system-wide coordination.
The Plan rightly discusses a future-fit NHS workforce, particularly for the frontlines. But the deeper question to me is how will NHS teams will work differently together, and how will NHS leaders lead differently to bring about this transformation? Powering innovation is not only about technologies or even capital investments. It requires collective sensemaking, the alignment of diverse stakeholder narratives despite any power dynamics that may be present, and new behavioural norms across the organisation, such as how one might engage in brave, not just safe, conversations. These must be deliberately cultivated.
From my experience, systemic change of this nature requires not just policy and integrated care programme design, but new capacities in design and systems thinking, i.e. systemic design and innovation, as well as distributed leadership that is compatible with managing through local complexities but towards systemic goals, through time.
The Plan would benefit therefore from a clearer articulation of how the intended transformation will be governed. Leadership freedoms, while important, must be paired with a firm and organisationally agreed upon set of “rules of engagement” or constraints to enable systemic action in a complex, multi-actor change environment. For the NHS, this needs to be at the ecosystems level, and across the myriad of integrated care partners. This is exceedingly hard work! My sense, therefore, is that it will be useful to articulate also, the new leadership and managerial capabilities expected at different levels of the NHS and across the NHS’s different key partners and stakeholders.
My comments are not a critique of what is absent, but a reflection on what must inevitably come next. A plan of this ambition will require an equally thoughtful roadmap for enabling systemic change. That roadmap, I hope, is already in the making - and I believe many of us in the global health systems and integrated care community would be ready to support its next iteration.
Co-designing care: a young family caregiver perspective
Author: Niamh Daly Day, Young Family Care Giver and Digital Communications Officer, International Foundation for Integrated Care
The Fit for the Future plan presents an ambitious and integrated approach to tackling the ‘NHS problem’. As a young family carer based in Ireland, I find this both promising and necessary. The shift from hospitals to the community, from sickness to prevention, and towards greater digitalisation is a welcome approach. However, it is easy to be sceptical of how effectively it will be implemented. Too often, ambitious reforms overlook the voices of patients and carers – the people who live with the realities of a fragmented system every day. For this plan to succeed, it’s implementation must be co-designed with patients and carers at the centre as experts in the care experience.
Access to care
The plan outlines a stark reality: many patients struggle to access a GP or dental appointment, further straining emergency services. The proposal to make same-day appointments possible is ambitious but will this plan make that easier and more possible. The idea of having a ‘doctor in your pocket’ through the NHS App suggests progress but success depends on ensuring patients and carers can use these digital tools confidently. As a young carer comfortable with technology, managing my loved one’s care digitally would be helpful. Yet for many, especially older carers or those in rural areas, digital literacy and connectivity are barriers. Without proper training and support, these reforms will lead to further fragmentation for patients accessing services.
Continuity and coordination
Empowering patients to control their healthcare records through the NHS app is a positive step. The creation of a single patient record could reduce duplication and confusion across services, but the system must genuinely work between GPs, hospitals, pharmacies and social care services. Having to repeat the same story to different professionals is an exhausting experience and often leads to conflicting advice. It is also crucial that carers, with the patient’s consent, have appropriate access to records so they can coordinate care effectively. And if systems fail or information goes missing, accountability must be clear. While this move is a positive step towards a more person-centred service, support must be in place to prevent further fragmentation of care.
Support for carers
The My Carer function in the NHS App recognises the vital role of unpaid carers, but it must not unintentionally increase their workload or responsibility. As care shifts more into homes and communities, carers need practical support - training, respite or financial support – to sustain their role. This is especially important for carers balancing multiple responsibilities such as a full-time role alongside caring for their loved one.
Equity and inequalities
Moving care from hospital to community is a positive development, but it risks widening inequalities if not adapted locally. Different communities have distinct needs – migrant families may require translation support, while older populations may need more community nurses and home-help services. Recognising these differences means co-designing each locality with community representatives, patients and carers so the system reflects real experiences on the ground.
Technology and trust
Technology, science and artificial intelligence are necessary for the ‘modernisation’ of the NHS. However, tools should be simple and accessible so carers can confidently use them to support loved ones. Overreliance on digital systems as a ‘solution’ to the ‘NHS problem’ risks losing the empathy and connection at the heart of good care leading to further fragmentation. Training for patients, carers and staff must be co-designed and widely available to ensure technology supports, rather than complicates, care.
Prevention and long-term health
Shifting focus from sickness to prevention is a necessary change and empowers patients to take action to improve their well-being with the support of their carer and the multidisciplinary team supporting their care journey. Programmes addressing obesity, smoking and mental health are vital, but they must be realistic for families already under pressure. Patients and carers should be supported by multidisciplinary teams that address all aspects of well-being. Carers, too, need help to maintain their own physical and mental health, as caring for a loved one can take a heavy toll.
Transparency and choice
Patients and carers need meaningful opportunities to voice their concerns. While existing services such as Healthwatch provide avenues to challenge poor care, it remains unclear whether the new system will provide the same support in a faster, clearer, and less intimidating way. As a carer, I know how important it is to feel heard and supported. A service such as this makes one feel less alone and makes navigating your loved one’s care journey easier. The new Patient Choice Charter aims to empower carers, but it must not inadvertently leave them feeling more isolated or unsupported.
Workforce and culture
The NHS workforce is under severe strain. For reform to succeed, staff must feel valued and supported through proper training and resources. As care moves to the community, the pressure on community nurses and home-support workers will rise. My family is fortunate to receive daily home help in Ireland, but I know many do not. Without investment in the community workforce, the promise of integrated care cannot be realised in England.
Overall, the Fit for the Future plan is ambitious and hopeful. But its success depends on genuine co-design with those at its heart – patients, carers, and communities. The hope is that it truly becomes as patient-led as it claims. Without the inclusion of lived experience, even the most well-intentioned reforms risk creating further fragmentation instead of the compassionate, connected care system we all need.
From fragmentation to integration: including people with lived experience
Author: Pamela Barkhouse, Nova Scotia, Canada, an advocate for positive change in health and care and a Patient Family Advisor with NSHEALTH, Quality Care Team.
As a person who needs and uses the healthcare system both as a patient and as a long-term caregiver, I have come to realise our healthcare systems are primarily focused on tasks achieved in silos, which are often fragmented and detached from the person at the centre of care. I now understand why people say, “the healthcare system is broken”.
How do we fix the healthcare system? How do we create and sustain trust among a population where mistrust is embedded in a failed system? People have died during COVID. People are grieving, some people are angry. They key word is “people” in the systems. I suggest it takes time to heal and to rebuild trust. COVID shone the light on what was broken for a very long time in the healthcare system. We need to reflect and take time to learn from our mistakes. We need to grieve our losses, repair broken systems and rebuild trust with compassion and respect for the people at the centre of care.
I have read the National Healthcare Strategy for England from the viewpoint of a person with lived experience as a patient and a long-term caregiver. I was intrigued by the similarities between England’s and Nova Scotia’s challenges, and I offer the following commentary.
The National Healthcare Strategy for England seems to focus on fixing the healthcare system with innovation and technology rather than designing and building a healthcare plan based on what matters most to the person at the centre of care. It is primarily focused on adopting innovation and utilising technology to its fullest to solve their healthcare system problems. The use of AI, genomics, wearables and robotic surgeries are highlighted to solve administrative system burdens and to increase workplace efficiencies.
As most plans do, the ‘how’ the strategy will be implemented and evaluated over a 10 Year period appears to be lacking.
There are three themes in the NHS plan for England. These themes are not unlike the ones in Nova Scotia, Canada:
- Moving healthcare from hospital to the place of home/community.
- Adopting innovative technologies to assist the healthcare system to improve healthcare efficiencies; and
- Using technology to assist the patient/system to prevent illness.
Moving healthcare from hospital to the home/community will require a partnership and collaborative effort, one that must be focused on serving the patient/caregiver at the centre of care and responding to what matters most to them.
The use of AI technology and wearables as a “tool to assist” patients in health and care is a good approach if it is designed around what matters most to the person in their care relationships. The use of AI in the NHS plan, if not used with the person at the centre of care, could reinforce a task system for tracking data rather than freeing up the healthcare professionals to spend more quality time to care for their patients. The patient and the caregiver require human empathy, compassion and patience to fully attend to their needs in a holistic manner. If AI is used to assist with the recording of medical records, how are errors corrected? I wonder how AI will convince people who have cognitive or mental health disabilities to trust AI or a robot? I wonder if AI will be able to alleviate the fear or build trust with the patient/caregiver.
The NHS plan targets genomics to prevent illnesses in the future. How will the plan build trust among patients/caregivers to ensure their needs are protected and respected and how will it ensure an equitable and diverse society?
All strategies need to be SMART. Is this 10 Year Health Care Plan SMART?
- Specific – yes.
- Measurable – Remains to be seen. If the evaluation is incorporated throughout the timeline of the strategy with specific milestones and adjustments, then it will be measurable.
- Achievable – Remains to be seen. The plan could be achievable if there is a change in culture, moving away from the old way of doing things to trying something innovate and new. It will require building trust among the population, a population that is currently cynical due to the existing crisis in healthcare. To achieve success, the plan will require funding models that are collaborative with partners who believe in the same goals and vision. It will require a buy-in from all parties involved, including the patients/caregivers.
- Relative – Absolutely!
- Timely – Absolutely! The time to act on change in healthcare is now!
What, why, where, and when
The ‘what’ is covered in the problem statement. The ‘why’ is explained very clearly. The ‘where’ is the UK and the world. The ‘when’ is stated: a 10 Year Plan. It will be imperative for the plan to remain flexible and to adjust throughout the 10 Year period. The COVID experience has taught us that collaboration and flexibility toward a common goal is imperative for success.
The strategy makes several claims, to name a few, to be the best in the world such as:
- “The NHS is the best-placed system in the world to harness the advances we are seeing in AI and genomic science”.
- “This plan will put the NHS at the front of the global genomics revolution and make NHS the most AI-enabled care system in the world”.
- “We will make the NHS the most AI-enabled health system in the world with AI seamlessly integrated into clinical pathways”.
The tone “to be the best in the world” is a high goal and is admirable. But I wonder what the government has control over. The government can influence and be leaders in the world, but can they control it all? Would it be better to focus on what the UK can control by being the best in the country, the communities they serve and to provide good leadership and practice in the healthcare system as opposed to saying, “we will be the best in the world”?
As I continued to read the NHS strategy, I wondered where the “person/human” factor is in the plan? The way we engage people within the workforce requires a much more person-centred, compassionate approach, one that respects a person’s morals and values, emotions, culture and spirituality. Are the business ethics and values embedded in the goals of the corporation or in the health of the workforce? What would it look like if we were able to take the whole person to the workplace and the workplace accepted the whole person, especially the double-duty caregivers?
The NHS plan states a reward and punishment system for adherence to quality of care. I wonder if this is the most effective pathway to shift behavioural and cultural change in response to a broken system or broken people? Perhaps incorporating human resource standards of care in the workplace policies might be a better approach to promote the health and wellbeing of the workplace.
How do we harness the power of technology and innovation to benefit the healthcare system? It has been suggested in the NHS strategy that we “empower” patients to have control and influence over their own health and care. This offer to empower patients cannot and should not be done without financial help and supportive resources. Otherwise, we are shifting the responsibility to the patient/caregiver for their own healthcare without the proper training and support.
In conclusion, I think the NHS is on the right track to fix some of their healthcare system problems through innovation and the use of technology. However, it remains to be seen as to whether it will be integrated and inclusive of the person at the centre of care and what matters most to them.
Pamela Barkhouse
Patient Family Advisor NSHEALTH, Central Zone, Quality Team (Canada)
Neighbourhoods and networks: a population health perspective
Author: Rachel Harris, Integrated Care Academy Manager at IFIC who holds a master’s in public health.
Fit for the Future: 10 Year Health Plan for England outlines an ambitious vision for transforming health and social care services across England. The plan is defined by three main changes: moving care from hospitals into the community, using more digital technology and focusing on preventing illness rather than just treating it. When viewed through an integrated care lens, the plan fundamentally alters the current NHS ‘hospital-centric’ model to a ‘Population Health Management centric’ model. The principles of the plan closely align with the Nine Pillars of Integrated Care as defined by the International Foundation for Integrated Care (IFIC) and aims to address systemic fragmentation.
Integrated care and population health are intrinsically linked with one another. Therefore, effective population health management is dependent on the strong integration between all health and social care services. A critical aspect of this 10 Year Plan is the commitment to reducing health inequalities across different socioeconomic backgrounds. The use of population health management through data-management to identify community health risks and allowing communities to target their own specific wider social determinants of health, something the current unintegrated health and social care services currently do not do. The success of this 10 Year plan relies on continued funding, support from both practitioners and communities, political will, coordination between local and national services and an understanding from all involved in the complexities around implementing integrated care.
Arguably, the most promising aspect of this 10 Year plan is the creation of the ‘Neighbourhood Health Service’, which contributes to both moving care from hospitals to community and focusing on prevention at a wider systemic level, rather than dealing with issues at the acute level. Neighbourhood Health Services will manage to tackle the systemic issues, allowing teams from both health and social care services to work together to reduce wider determinants of health while still allowing these initiatives and services to focus on community specific issues. The answer is ‘always in the room’ and one of the key principles of effective integrated care and public health is ‘nothing about us without us’. Therefore, this aspect of the plan is a strong solution which allows local services to tailor their preventative health initiatives to community-centric issues. In doing so, it creates more effective, integrated and community specific health and social care services.
Neighbourhood Health Services are in theory, the perfect combination of integrated care and population health management and offer a strong structural solution to the unintegrated NHS seen today. However, meaningful change also requires strong social will. Members of health and social care services are constantly under pressure, with lack of funding and long work hours. Therefore, it is no surprise that workers become demoralised and potentially resistant to change. When working so hard, service providers may not feel they have the psychological capacity or time to adapt to these changes. Without the full will and commitment from staff, the work may still be siloed, because proximity does not automatically equate to integration or teamwork. While the flexibility promoted across local bodies is positive in many respects, it may lead to uneven implementation. For example, as discussed, the success depends on the commitment of staff and local government and financial backing; some areas may struggle to keep pace and fall behind, while others prosper.
The shift from analogue to digital technology is a central feature of the NHS 10 Year Plan, aligning closely with IFIC’s Digital Solutions Pillar of Integrated Care. The plan will use digital technology such as the NHS app and shared electronic health records to track population health data, allowing local integrated services such as Neighbourhood Health Services to tailor their actions towards community health risks, thus ensuring high-quality and consistent care for the population. This digital shift seems incredibly promising in terms of population health management, having large quantities of data available to make informed preventative healthcare decisions and empower people to control their own health. With many daily activities, such as shopping and banking, now routinely carried out online, it is reasonable to expect that most of the population will adapt to this transition with relative ease. Whilst promising in many respects, this digital shift presents challenges for certain groups who may struggle to navigate digital services, for example, older generations, people with limited experience of technology or people from lower socioeconomic backgrounds. In doing so, it may further the health inequalities that this change aims to dismantle. For many individuals receiving care, particularly those in long-term care, human contact remains essential. Even a simple phone call to book an appointment can provide meaningful social interaction and emotional support that technology alone cannot replace. Therefore, while this digital transformation has the potential to make services more integrated, efficient and accessible, it is important not to neglect those who are less digitally literate or confident. Furthermore, whilst the plan aims to empower individuals to take greater control over their care, it could be seen as transferring responsibility from staff to people, potentially increasing fragmentation further. This is the exact antithesis of what the plan sets out to establish. Achieving success depends on striking a careful balance between digital innovation and person-centred support, to ensure no-one gets left behind.
In principle, this 10 Year Plan provides an integrated care focused response to the fragmentation seen within the NHS. However, questions remain about if this integration is truly achievable or whether it risks reinforcing the very fragmentation it seeks to resolve. If the foundations of integrated care are not aligned across the entire system, efforts toward integration could instead result in further fragmentation in practice. Such fragmentation may lead to disillusionment among practitioners and communities, potentially undermining momentum before the plan can develop. Moreover, the role of political support cannot be overstated. In a constantly shifting political landscape, there is no certainty that future governments will continue to prioritise or invest in the reform of the NHS. Without sustained cross-party commitment, the longevity and success of this 10 Year Plan remain uncertain.
In summary, the NHS 10 Year plan clearly embraces the principles of integrated care and population health management and aligns closely with the Nine Pillars of Integrated Care as defined by IFIC. The digital shift and Neighbourhood Health Services show promise for strong integrated population health management. The success of this policy and its genuine integration depend on strong collaboration, and the collective will of government, health practitioners, management and communities. Without these, the plan risks reinforcing the very fragmentation it aims to address.
Rachel Harris
International Foundation for Integrated Care (IFIC)
Hope and hesitation: A graduate’s view on the future NHS
Author: Shreya Chhugani, recently graduated from Imperial College London with a BSc in Biomedical Science and an interest in health informatics.
As a recent graduate in biomedical science interested in working in health informatics in the NHS, the radical restructuring outlined in the 10 Year Plan promises new hope for the future of the NHS. Its core proposed shifts: community-based care, digitisation and increased focus on prevention, offer to bring the NHS into the modern age and propel it into a global leading healthcare system. While this vision is promising – given the much-needed improvements to quality of care and long overdue modernisation of administrative systems – the Plan lacks clarity in terms of how to implement these ideas. This makes it difficult to see how these changes will be possible within the next 10 years, especially as many of the changes require collaboration with other sectors (education, tech, life sciences, policy, construction etc.).
Given the NHS is at the forefront of the consequences of modernisation, especially regarding chronic illness and poor mental health, its digital infrastructure has yet to catch up. I am optimistic about digitisation, not only to integrate care for improved patient access and experience, but also to explore the possibilities provided by data and the growing field of health informatics. The applications of constant technological advancements and data-driven insights are exciting to consider. Integrating these into the NHS, if done effectively, could transform the way healthcare is delivered and give power back to the patient.
A key consideration for the digitisation shift is the ethical implications of artificial intelligence (AI). Although the Plan briefly mentions the Medicines and Healthcare products Regulatory Agency (MHRA) to facilitate the NHS becoming “a global leader in deploying AI ethically” there is no expansion on how this will be done. AI can be beneficial in certain applications such as diagnostic screening, drug candidate profiling and performing repetitive administrative tasks for improved efficiency and accuracy. This has the potential to accelerate treatment developments and optimise healthcare administration, while reducing the burden of menial tasks from staff which is particularly appealing as someone entering the workforce. AI could potentially help improve continuity and coordination of care if strategically applied to streamlining administrative tasks and collating and updating all patient records/information in one place. This would allow for easy access by all care providers, leading to more joined-up care and reducing the need for patients to constantly repeat their history.
However, there are still many drawbacks which need to be addressed if AI can be successfully and ethically deployed throughout the NHS. A major challenge with AI modelling is bias within data, as training data often underrepresent marginalised populations due to systemic inequalities in medical research and healthcare access. These biases are then perpetuated in the model, reducing the accuracy of predictions for underrepresented populations. This therefore highlights the need for ethical oversight to ensure the health inequality gap is not widened by AI. It is also important to note that AI technology is still in development where it is often limited by poor quality data or disorganised dataset structures that can lead to inaccurate results, which is undesirable in healthcare settings where mistakes can affect someone’s life. As someone passionate about helping people and a member of underrepresented populations, I think it is vital to centre ethics when implementing AI within the NHS.
Additionally, the limitations of AI may consequently create barriers to integrated care, for example, if patient records are incorrectly or only partially collated by the system, patients will still face a lack of continuity between care providers. This may also be detrimental to care coordination if it remains difficult for different care providers to communicate and share notes effectively. Similarly, given that AI chatbots do not always function as intended and often cannot handle complex requests, implementing these for administrative tasks such as support & advice, appointment bookings, digital triage etc. may lead to negative patient experiences and prevent people from accessing the services they need.
Another caution with the increased digitisation of services is accessibility to ensure positive patient and staff experiences: are these tools easy to use, particularly for older people or people with a disability, who are more likely to need access to healthcare? As people who are digitally excluded (no internet access or don’t know how to use digital technology) often belong to marginalised communities, there is a possibility that digitisation will further exclude these groups. I think it is important to ensure that all digital services remain available offline to preserve access for these people, such as making paper copies of available resources and funding in-person (e.g. at local public libraries) digital training and information sessions.
Once these new digital tools are implemented, there is also the question of how we measure their effectiveness, particularly if information on the quality of healthcare providers is to be made available to the public in the NHS App and used to inform funding allocation. This level of transparency requires both quantitative data on measures such as productivity, efficiency, and patient satisfaction scores as well detailed qualitative feedback from both staff and patients to reflect their experiences. How will this data be collected on a nation-wide level? The way the data is analysed and presented also needs to be thought through carefully – when it is made publicly available, is it easy to understand? Seeing how statistics are often misused or taken out of context, I think an emphasis on reducing biases within and around data and making insights as accessible as possible is integral to ensuring these applications are successful in the NHS.
One of the most ambitious aspects of digitisation within the Plan is the future integration of genomic sequencing to guide health predictions and personalised advice within the NHS App. While there are many steps before this becomes possible universally, I’m not sure this would be a good use of NHS spending. Genomic sequencing is greatly beneficial for identifying rare inherited diseases or some types of cancer risk so as scientists continue to identify genes with associated risk, this application in newborns could significantly improve preventative and early-phase treatments. However, I don’t see as much benefit in providing everyone in the UK with their genetic risk, given that socioeconomic status and lived environment are huge health determinants. This means that giving people advice on how to reduce their risk of certain diseases such as cardiovascular disease or diabetes when these are largely influenced by the environment outside of individual control is unlikely to facilitate a healthier population in the way suggested by the Plan. This could better be achieved through policy and increasing spending on public systems and infrastructure such as building more green spaces, eliminating food deserts, ensuring safe and affordable housing for all, making sure salaries match rising costs, and creating better, less stressful working conditions.
Further to this point, the Plan proposes a “moonshot to end the obesity epidemic” outlining several public health policies to target the obesogenic environment, particularly for children. Although these policies will likely mitigate the impact of environment on obesity to some extent, I’m not sure they will have the desired outcome of ending the epidemic given the complexity of the disease. Simply making healthier choices when ultra and highly processed foods are still widely available and much more affordable than healthier, unprocessed foods is easier said than done. This is especially true for people from lower socioeconomic groups, particularly as they are also more likely to be in time poverty so will have less time for cooking and physical activity. Additional barriers, such as the cost of cooking (gas and electricity usage) and travel to supermarkets/whole foods stores which are often less accessible, further exacerbate this inequality. Addressing these issues will likely have a positive impact on health and the obesity epidemic by making healthier choices easier for everyone.
Overall, the 10 Year Plan proposes an ambitious vision for the future of the NHS – one which prioritises patient needs and primary care by harnessing the power of rapidly advancing data and technology. As a recent graduate considering a career in the NHS, I am hopeful about the new direction and its possibilities for revolutionising healthcare. What I need to see in the future is the establishment of clear ethical guidelines and measurable outcomes of effectiveness to ensure the new changes don’t widen the health inequality gap. I also think there needs to be strong support for staff as this Plan is implemented so that the changes are positive to staff, reducing stress and workload and ensuring no one gets left behind as technology continues to advance.
Shreya Chhugani
International Foundation for Integrated Care (IFIC)
