The government has chosen a return to 18-week waits as the totemic way it will demonstrate recovery to a public aghast at how the NHS is running. This week’s reform plan is the means intended to achieve it. It is a substantial set of policies, and offers a good balance between changes based in evidence and the stability the health service has so often lacked.
But it is not the finished article. A close look shows that some of the knottiest questions about how it will work remain to be answered. Further announcements later this year will decide whether its aims can be achieved, and at what cost.
Where’s the money, and what will it pay for?
The plan features very little information on funding. Recovery in elective care so far has been funded and incentivised through an earmarked Elective Recovery Fund in the region of £3 billion a year, which ties provider trust funding to the achievement of activity growth targets rather than waiting time improvement. In recent years, the Treasury has showed considerable flexibility in how that fund was managed, including this financial year agreeing to supplement it to pay trusts for significant over-achievement of their activity growth targets.
The mood music from Treasury is that it will take a much firmer approach from April. While NHS England claims that ICBs will have sufficient funds to pay their local providers for the activity needed to meet the waiting time target, knowing in practice how much extra activity will be needed to hit a specific waiting time level is not easy. It will be influenced both by the speed at which new patients join the list and the effectiveness of initiatives designed to reduce demand for hospital-based care. In the context of constrained finances, both NHS England and the Treasury will be tempted to be optimistic in their assumptions about the actual level of activity needed to hit the targets. If this is the case, providers will be left uncertain as to where the money to pay for activity above those assumptions will come from.
What about staffing?
The NHS workforce is barely mentioned in the plan. But it comes at a time of rapid change. The workforce has grown very rapidly– for every four professionally qualified staff prior to the pandemic, there are now five (a 138,000 increase in the five years to October 2024). However, there have been growing pains exacerbated by staff burnout and poor industrial relations, and NHSE is now trying to slow down further expansion because there is so little financial room to cover more. Are we confident that, as the dust settles after the hiring spree, there are the right numbers of the key staff groups, in the right places, to deliver the increase in planned care that is required?
The intensified focus on splitting out planned care into community diagnostic centres and surgical hubs will mean more staff are separated out from the places where urgent care and diagnosis happens. This is the intention: to shield booked appointments from the unpredictable demands of emergency care on the same staff. But at a time when it is A&E waits which are heading most worryingly in the wrong direction, what will be the impact on urgent care in specialties where the same clinicians have often covered both?
Will patient-initiated follow-up and other initiatives free NHS capacity?
The plan revives a push for patient-initiated follow-up, where outpatient checks are only conducted at patients’ requests, to apply to 5% of all appointments. This is now to happen by 2029. PIFU showed some successes in our recent evaluation. But we have been sceptical about blanket targets given limited evidence about their effects, notably in inequalities, and that PIFU might make more sense for some clinical specialties over others. We also noted its relatively limited scale, even at the target level, compared to the total amount of outpatient activity.
It is critical that this and other specific changes set out in the plan should be properly and thoroughly evaluated. A common stumbling block has been that data is not good enough to actually tell whether reforms work, particularly where they cross NHS boundaries. The government needs to stay informed and flexible enough to gather as much hard evidence as possible, and then be willing to change course, rather than assume the ideas it has inherited will work – or that they will keep working when applied to a wider range of patients and scenarios.
What is the aspiration on inequality?
The plan is admirable in that it commits to tackling the shocking level of inequality in planned care, where our recent analysis shows that people in the most deprived areas receive 20% fewer hip replacements than average. It has multiple mechanisms to ensure ICBs take this seriously and plan to improve it.
But there is no hard target or indication of the actual level of aspiration – whether ICBs need to make relatively marginal progress, or move significantly towards eliminating the disparities in one of the most unequal parts of the NHS.
What will be the implications for general practice?
My colleague Becks Fisher describes what this plan means from the perspective of a practising GP. The new £20 payments for seeking advice from specialists in the hope of avoiding referrals have wider implications too. Ahead of a new contract trailed as reducing micro-management and specific payments, this seems to illustrate that policymakers still feel the need to use financial inducements outside the general contract to shape general practice. Will it take us again further away from the model of the generalist professional with a generalist budget, providing care based on ethical and professional judgement? Is that what the NHS needs?
Decision points
The rest of the year will see a succession of decision points which start to answer these questions: planning guidance, the Spending Review, the 10-Year Plan for the whole NHS, a refreshed workforce plan, and the publication and use of inequalities data outlined in the plan. Next year, meanwhile, will see medium-term recommendations from Baroness Casey’s social care review. Their ambition, and whether politicians have the courage to follow, will determine whether the level of unmet need for care continues to pressurise urgent care, general practice, and the lives of planned and unplanned patients outside their visits to the NHS.
These will get us closer to understanding what this parliament means for the English health service. Can the staff, money and changes in practice available deliver enough care for the revolutionary recovery the government wants for planned care, without a deeper impact elsewhere?
Suggested citation
Stein T, Dayan M and Gainsbury S (2025) “A partial plan: unanswered questions on reforming elective care”, Nuffield Trust blog