Jun 29, 2025 4 min read

Cowper’s Cut 382: Some questions for successful NHS reform

When all you’ve got is a hammer …

At the launch of the Big NHS Plan, the Prime Minster warns the nation that “our ambitions for the future of the NHS can and should go much further. We can build on its strengths - and make it stronger.

“The NHS of the future will do more than just provide the best technologies to cure: it will also - as our population ages and long-term conditions become more prevalent - be an NHS that emphasises care too.

“The NHS of the future will do more than just treat patients who are ill - it will be an NHS offering prevention as well. The NHS of the future will be more than a universal service - it will be a personal service too.

“It will not be the NHS of the passive patient - the NHS of the future will be one of patient power, patients engaged and taking greater control over their own health and their healthcare too.

“And so if the NHS is to change like this - to meet the challenges of 21st century healthcare and our 21st century lives - we will have to embrace even deeper and wider reform.”

The Prime Minister in question was Gordon Brown: the year in question was 2008, and the Big NHS Plan in question was Lord Darzi’s ‘High-Quality Care For All’.

We’ve survived a busy seventeen years of English health policy and politics since then. Alas, those years have not been full of curiosity about why the promised prevention and person-centred shift so completely failed.

The main reason is because it’s genuinely hard to encourage and support people to want to change almost everything about the way in which they work. And incentives matter. If the money does not shift, the system does not change: the money did not shift.

If anyone really thinks that commissioning is potentially more powerful than provision, they should look around an NHS in England where the provision landscape is virtually unchanged from 2008, while the commissioning landscape is about to undergo yet another of its permanent revolutions. For all the talk of ICBs taking on ‘strategic commissioning’, the current plans will firmly re-establish the Health Secretary atop the Department For Health But Social Care as The Single Commissioner. The abolition of commissioning support units makes this explicit.

2025’s Big NHS Plan currently sits in a liminal, almost quantum state of not yet being officially launched while being almost totally revealed. Health Service Journal’s extensive compendium of leaks and analysis triggered the DHBSC and ministers into a fiesta of briefings. We learned that patients’ feedback is to impact hospital payment (which no other health system in the world seems to do); foundation trusts will be re-liberated (and will be confident that this time, it’s for real because?); robot surgery will be mainstreamed (no extra capital is available to fund this).

It is a valuable index of the system’s confidence in the authority and durability of the current leadership that HSJ obtained the pre-final draft immediately it was circulated. Clearly, journalists love leaks (and other vegetables, too), but the manner of their happening tells both media and political set-ups a lot about the current state of affairs, if they choose to pay attention.

I suspect that pre-reviewing the Ten-Year Plan might not be the right approach. Instead, I’ve tried to come up with a list of questions about the likely characteristics of successful reform. I hope this might be a useful lens through which to read whatever emerges later this week.

Does the plan have a clear, costed and deliverable strategy to fix the system’s obvious, broken basics?
Does it understand that changing how health systems work is a long-term, people-based contact sport?
Does it understand the importance of culture and leadership in the English NHS, including West and colleagues’ work on the culture of high-quality care, specifically around bullying and the perverse incentives of the ‘targets and terror’ 2000s NHS reforms, as explained by Bevan and Hood?
Does it really, though?
Does it make decision-making power national only where essential, and local whenever possible?
Does it convincingly propose to make access easier, and reduce handovers and hand-offs?
How much resource and power does this plan shift to primary, community and preventative care, and how quickly?
How will the plan’s proposed new system make its rationing decisions?
How will this plan move the catastrophe areas of maternity and winter urgent and emergency care access from awful to acceptable?
What does the plan offer in terms of NHS improvement capacity and capability? How will it make national leadership more curious about the root causes of good and bad performance, and what will change as a result of that?
What have these reforms learned from existing NHS lessons on patient choice?
What have these reforms learned from primary care’s spectacular increase of access over recent years?
What will these reforms change around procurement, capital and maintenance?
What is the appropriate data-set to enable meaningful comparison of providers’ performance? (Since 2017, PROMs data collection is only for hip and knee replacement.) What is the role for data around the NHS Staff Survey and retention; financial performance; ‘never’ events, Datix use and payments to NHS Resolution?
What are the plan’s proposals for credible and regularly-published evaluation to iteratively inform its delivery?
What is the impact of the plan on the post-2014 move towards greater integration of health services?
Where quasi-market incentives are suggested, does the plan acknowledge the reality of trade-offs and the importance of avoiding perverse incentives?
Are the plan’s claims about what AI will achieve credible?

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