The NHS 'Ten Year Plan': Addressing Symptoms, Not the System

Strategy sets conditions. The notion that ‘strategy is as much about deciding what not to do as it is about deciding what to do’ is attributed to Michael Porter and is echoed by Richard Rumelt in his book, ‘Good Strategy, Bad Strategy’. Rumelt highlights that bad strategy often stems from an inability to make hard choices and a tendency to try to accommodate too many conflicting demands, leading to a lack of focus. However this process is approached, whether deliberate or not, and whatever the merits of the product that is derived from it, strategy therefore carries the function of settling the parameters, or boundaries, for subsequent decision-making at all levels of an organisation.

The concept of boundaries plays a major role in systems thinking. A boundary is an intellectual concept rather than a physical demarcation, and even then must be acknowledged as porous. A boundary does not necessarily ‘protect’ a system or shield it from external influence. This seemingly simple provision has profound implications for how we understand a system's behaviour, however and, critically, for how we design effective strategies. Boundaries matter because they determine the scope of interest for a strategy; the boundary depends entirely on the problem being addressed and the desired scope of intervention.

A strategy must, by its very nature, delineate the scope of interest and intervention. Without this, it risks becoming a diffuse collection of good intentions that lacks the focus required to translate into meaningful action.

Boundaries therefore impact problem definition and solution generation. The way a boundary is regarded directly shapes how a problem is understood and, consequently, the types of solutions considered. Effective strategy design, therefore, requires a conscious and iterative process of boundary setting, challenging initial assumptions, and expanding or contracting the boundary as understanding of the system deepens.

The concept of boundaries draws systems thinking and strategy design together. Recognising their arbitrary nature whilst consciously defining them is critical to developing strategies that are both focused and holistic, capable of addressing complex challenges without creating new, unforeseen problems. Without clear boundaries, a strategy risks becoming a diffuse collection of good intentions, lacking the necessary focus to translate into meaningful action. The boundaries of a strategy shape the internal culture and decision-making processes, ensuring that daily actions align with the overarching strategic intent. Without the framing function of boundaries, deliberate or emergent, an organisation risks dissipating its energy, losing its competitive edge, and ultimately failing to realise its full potential. Part One of this paper took the view that the NHS 10-year plan fell into this trap, treating the NHS as a ‘closed’ system whilst many of its challenges are interconnected with wider society.

Integrated Systems: Words Without Substance?

Before its publication, The King’s Fund looked forward to the 10-year plan setting the conditions for coherence with wider social care reform, currently under review by the Casey Commission’s report due next year. Its commentary stated, “Policy incoherence fuels implementation coherence” and saw the plan as “a huge opportunity to reignite the health mission”. A potential lever with which to approach this challenge was by developing the concept of Integrated Care Systems. In fact, the plan makes no mention of their role and function, a very noticeable absence indeed.

ICSs have been under development now for around ten years, having been born as ‘sustainability and transformation partnerships’. Formed in 2016 as geographically grouped representatives of health and social care organisations, STPs were encouraged to focus ‘place-based planning’ for health and care services in their areas. Whilst the basis was established in 2016, ICSs were subsequently established as legal entities under the Health and Care Act 2022, which reorganised the structure of the NHS. Each of the 42 ICSs is composed of a statutory Integrated Care Partnership (ICP) and an Integrated Care Board (ICB). This framework constituted a major new approach to the management and oversight of health provision in England.

In 2022 Dame Patricia Hewitt, a previous Secretary of State for Health, led an independent review of the ICS approach. Her report highlighted three pressing reasons for this new approach: increasing pressure on NHS provision, especially following the pandemic; the growing population with complex, long-term physical and mental health conditions; and the deteriorating general health of the nation. ICSs were designed to address all three of these challenges and provide the integrating function between the NHS’s internal and external environments that is sorely needed. Given the observations about boundaries above, the absence of any mention of ICSs in the 10-year plan is an obvious flaw.

The Integrated Care System construct offered a tangible opportunity to bind the aspirations of the 10-year plan together. That it is entirely ignored by the strategy is instructive and represents a very significant missed opportunity.

The ICS experience throughout has illustrated how aspiration and intent does not realise policy by itself. There is much talk of ‘integration’ and ‘the system’ with very little focus on how those constructs will be delivered to address value demand. In fact, the ICS framework was established in a way that allowed for significant variance across all 42 organisations. The New Operating Framework for the NHS, published less than three years ago in October 2022 stated, “This requires a cultural and behavioural shift towards partnership-based working, creating NHS policy, strategy, priorities, and delivery solutions with national partners and system stakeholders; and giving system leaders the agency and autonomy to identify the best was to deliver agreed priorities in their local context”.

By July 2024 The King’s Fund was reporting that it found “evidence of ICSs beginning to build a whole-system approach to…develop new solutions that better meet the needs of the local population”. However, it also stated:

“Despite these signs of progress, some of the more transformative work planned by ICSs is proceeding at a slower pace than intended as a result of the extremely challenging circumstances in which ICSs have been introduced. There is widespread concern that ICSs may not achieve their full potential unless more is done to create an environment conducive to their success. The behaviours of national, regional and local leaders will make or break ICSs. There is an urgent need to ensure that accountability arrangements drive behaviours that reinforce system working rather than undermine it. Success depends on supporting people at all levels to think, plan and act in ‘system-focused’ ways.”

One of the most significant failures in supporting Integrated Care Systems (ICSs) has been the government's tendency to focus on short-term, acute problems at the expense of long-term strategic goals. While ICSs were designed to improve population health and prevention, national targets have consistently prioritized addressing immediate issues like elective care backlogs and waiting lists. This pressure, combined with inadequate and fragmented funding - particularly for social care - has hampered the ability of ICSs to invest in the preventative measures and digital infrastructure needed for genuine integration. Furthermore, a lack of clear national leadership on how the NHS and local government should work together has created an environment of ‘micromanagement’ and conflicting priorities, preventing local ICSs from having the autonomy to innovate and build truly connected services that address the wider social determinants of health.

In February 2023 the House of Commons Public Accounts Committee reported on the establishment of the integrated care system as follows:

“The ‘Integrated’ element of ICSs as well as their accountability arrangements appear under-developed: there is a concerning lack of oversight for ICSs. …The lack of leadership from the Department on the relationship between health and social care is worrying and could mean ICSs become a missed opportunity to make meaningful progress on how the NHS and local government work together. It is not clear who will intervene if joint working between the NHS, local government and other partners breaks down, and local health bodies’ responses to concerns raised by MPs on behalf of their constituents have been very patchy. In short, on ICSs, the jury is clearly still out."

Integrated care systems were designed to integrate, and yet they have not been supported in trying to do so. The intention was clear, and yet the ways and means of their operation has been made far less so for a number of reasons in addition to those outlined above. Most agree that it was the right thing to do, and yet the right thing has been done in the wrong way. The 10-year plan further reinforces the confusion and indeed the undermining of the ICS construct.

Effective strategy design, therefore, requires a conscious and iterative process of boundary setting, challenging initial assumptions, and expanding or contracting the boundary as understanding of the system deepens.

As has been widely commented on, the aspiration to shift from hospital to community care, accompanied by a desire to shift from sickness to prevention, is entirely laudable, but the 10-year plan is short on the ‘how’ to address this intent. As we have noted above, strategy needs boundaries, and there is little in the 10-year plan to indicate how the NHS’ internal and external environments are to be connected. In both these respects, integrated care systems, re-addressed under the 10-year plan, would have provided what is a now absent focus to delivering the strategy. That they are entirely ignored by the strategy is instructive and represents a very significant missed opportunity.

The Well-Trodden Path

Sadly, we have been here before. The last 10-year plan for the NHS, ‘The Long Term Plan’, was published in 2019. At its heart it had prevention, community care, digital access and health inequality. What it did not have was a clear statement of purpose, conceptual boundaries, or a delivery mechanism. In fact, since 2000, successive visions, strategies, policies, and plans, as well as at least six White Papers, have addressed prevention and community care as priorities.

The NHS occupies a unique and revered place in British society, yet for the past quarter-century, it has been subjected to a relentless cycle of policy reform and strategic reorganisation. While each successive government has presented its vision as the definitive solution to the service's perennial challenges - rising demand, financial pressures, and long waiting lists - the outcomes have consistently fallen short of their ambitions. Their persistent failure stems from a flawed approach that prioritises structural reorganisation and market-based solutions over addressing the fundamental and long-standing issues of workforce, funding, and the social care crisis. Unfortunately, the most recent 10-year plan looks like keeping us to a familiar, well-trodden path.

The first major wave of reform began in 1997, defined by the NHS Plan 2000. This strategy sought to modernise the health service through an unprecedented injection of public funding, combined with the introduction of market-style mechanisms. The core pillars of this approach were performance targets, patient choice, and a greater role for the private sector, notably through the creation of Foundation Trusts and the Private Finance Initiative for new hospital construction. The policy's aim was to create a ‘quasi-market’ where competition would drive efficiency and quality, thereby reducing waiting times. Initially, this model saw some success in meeting specific targets, such as the four-hour A&E waiting time. However, these ‘improvements’ came at a cost. The focus on top-down targets lead to ‘gaming’ the system, where resources are diverted to meet metrics rather than genuinely improving patient care. Furthermore, the introduction of multiple competing providers and the PFI model fragmented services and left some NHS trusts burdened with crippling long-term debt, increasing fragility in the system rather than strengthening it.

The cycle of structural change is only one of the systemic issues largely unaddressed by successive governments and most recently by the latest 10-year plan.

This market-driven approach was further accelerated and formalised with the Health and Social Care Act of 2012. This was arguably the most radical and disruptive reorganisation in the NHS’s history. The Act abolished Strategic Health Authorities and Primary Care Trusts, replacing them with a vast array of new bodies, including the NHS Commissioning Board (now NHS England) and over 200 GP-led Clinical Commissioning Groups tasked with purchasing services. The central idea was to put clinicians in the driving seat and create a more competitive environment, with NHS Monitor (now NHS Improvement) acting as an economic regulator to promote choice and accountability. The Act was widely criticised for being an expensive and unnecessary structural shake-up that wasted billions of pounds and caused immense disruption. Rather than simplifying the system, it created new layers of bureaucracy and further fragmented care, making collaboration between different providers more difficult. The promised shift of power to local clinicians was often undermined by the sheer complexity of the new structures, leading to a system that was more opaque and less accountable.

Since the 2012 Act, the focus has gradually shifted away from competition and towards integration, culminating in the Health and Care Act of 2022 and the formation of ICSs. While the aim of integration is laudable, this constant reorganisation is itself a key reason for failure. Each new reform requires significant time and resources to implement, diverting attention and money away from frontline care. The institutional memory is repeatedly reset, and the focus shifts from long-term strategic planning to managing a new set of structures.

This cycle of structural change is only one of the systemic issues largely unaddressed by successive governments and most recently by the latest 10-year plan. First, there has been a chronic failure to provide adequate and consistent long-term funding. Long-term funding is a product of long-term vision and consistency. Political imperatives – at all levels – and inadequate strategy has prevented a sustained focus on the purpose and priorities of the NHS in keeping pace with rising demand from an ageing population and advances in medical technology. Second, and perhaps most critically, is the persistent workforce crisis. As a labour-intensive service, the NHS requires a stable and well-supported workforce. However, a lack of a credible, long-term workforce plan has led to critical shortages across a range of clinical roles, from doctors to nurses. Finally, the perennial failure to properly fund and integrate social care has placed an enormous and unsustainable burden on the NHS. With thousands of patients unable to be discharged from hospital due to a lack of social care provision, the entire system becomes gridlocked, compromising performance across all areas.

NHS policy and strategy over the last 25 years has largely been unsuccessful because of its repeated reliance on structural reorganisations, market-based reforms, and ‘good ideas’ as panacea. Rather than addressing the core issues of purpose, value demand, and true integration, successive governments have instead chosen to engage in a politically expedient cycle of rebranding and restructuring. This perpetual motion has served to create instability, fragment the service, and distract from the real, underlying problems that continue to plague the nation’s most cherished institution. The present government’s 10-year plan is no exception and represents only yet another turn down an already well-trodden pathway.

On Demand

Much of the conversation about the operational challenges faced by the NHS is focused on funding, staff shortages, and waiting times. While these are critical factors, they address the symptoms rather than the drivers of systemic inefficiency. Management theorist John Seddon offers a powerful lens through which to view these problems, arguing that a significant portion of an organisation's activity is consumed by what he has termed Failure Demand.

Seddon says that failure demand would not exist if a service is delivered correctly the first time. It’s distinct from value demand, which is the legitimate, first-time request for a service - for example, a patient’s initial visit to a GP. Failure demand, in contrast, is caused by subsequent, avoidable contact: a patient calling the surgery again because their test results were not communicated, or being re-admitted to hospital because their discharge plan was inadequate. Seddon argues that traditional management, focused on targets and cost reduction, often misinterprets failure demand as a problem of volume, leading to reactive measures that only exacerbate the issue. Instead of addressing the systemic failures that create this demand, managers create new processes, checklists, or targets that simply manage the symptoms, trapping the organisation in a cycle of firefighting and ‘wasted’ resources.

The NHS is a prime example of an organisation plagued by a high proportion of failure demand. A common and highly visible instance is the use of accident and emergency departments by patients whose needs could have been met by other primary care services, such as a GP or even a pharmacist. While some of these visits are for genuine emergencies, a substantial number are driven by a failure of the broader system – the inability to get a timely GP appointment, confusion over where to seek help, or a lack of clear signposting. These avoidable visits represent a perfect case of failure demand, consuming highly specialised resources for non-urgent care.

Failure demand permeates the entire patient journey. When a patient is discharged without a robust follow-up plan - perhaps lacking a clear understanding of their medication, without a district nurse arranged, or with a social care package that fails to materialise - they are at a significantly higher risk of a rapid decline in health and re-admission to hospital. Similarly, the administrative burden of chasing up delayed referrals, correcting inaccurate patient records, or handling complaints about poor communication all constitute failure demand, draining staff energy and valuable time that could be dedicated to direct patient care.

The NHS is a prime example of an organisation plagued by a high proportion of failure demand, which permeates the entire patient journey.

To address this, Seddon's approach advocates a fundamental shift in management philosophy. Instead of a top-down, command-and-control model focused on arbitrary targets, he proposes a systems-thinking approach that identifies the core drivers of failure demand. The solution, therefore, lies not in creating more targets or pursuing efficiency but in empowering front-line staff to design and improve their own processes. By giving staff the autonomy to identify and eliminate the sources of failure demand, the NHS can begin to free up its capacity, reduce its costs, and, most importantly, improve the quality and experience of care for every patient. Address the system, says Seddon, and ‘the culture changes for free’.

A Well-Trodden Path to a Flawed Strategy

This paper has argued that the most recent 10-year plan for the NHS is fundamentally flawed, not because of its stated aspirations, which are largely laudable, but because of its strategic design. It is much less a strategy for the nation’s health and more a plan for a health service, reflecting an inward-looking, closed-system perspective that fails to engage with the complex and interconnected reality of modern public health. This failure is a consequence of three critical shortcomings: a lack of clear strategic boundaries, the outright neglect of existing mechanisms for integration, and a continued reliance on a politically expedient cycle of rebranding and restructuring that has plagued NHS policy for a quarter of a century.

The foundational flaw of the plan lies in its inability to define effective strategic boundaries. A strategy must, by its very nature, delineate the scope of interest and intervention. Without this, it risks becoming a diffuse collection of good intentions that lacks the focus required to translate into meaningful action. By treating the NHS as a self-contained entity, the 10-year plan fails to acknowledge that many of its deepest challenges - from waiting times to the backlog of elective care - are driven by factors outside its direct control, most notably a chronically underfunded and fragmented social care system. The conceptual boundary of the strategy is drawn too narrowly, leading to a myopic focus on internal NHS metrics and a neglect of the wider social determinants of health.

Political imperatives – at all levels – and inadequate strategy has prevented a sustained focus on the purpose and priorities of the NHS in keeping pace with rising demand from an ageing population and advances in medical technology.

The most glaring manifestation of this strategic error is the plan’s conspicuous silence on the role of Integrated Care Systems. These bodies were designed to be the very mechanism for connecting the porous boundary between the NHS and its external environment, including local government and social care providers. Their purpose was to foster place-based planning and develop a whole-system approach to meet the specific needs of local populations. By ignoring the ICS construct, the 10-year plan not only misses a significant opportunity to bind its aspirations together with a tangible delivery mechanism but also undermined the very principles of partnership and autonomy that are essential for successful system working. The plan’s failure to acknowledge and leverage ICSs represents a profound lack of strategic coherence, leaving a critical void in the ‘how’ of its delivery.

This strategic misstep is, regrettably, not an isolated incident. Instead, it is the latest chapter in a long and unfortunate history of NHS policy. For the past twenty-five years, at least, successive governments have been trapped on a ‘well-trodden path’ of structural reorganisation. From the market-based reforms of the NHS Plan 2000 to the disruptive changes of the 2012 Health and Social Care Act, the pattern has remained consistent: a belief that a new organisational chart or a fresh set of top-down targets will serve as a panacea for deep-seated problems. This perpetual motion has served only to destabilise the service, fragment care, and distract from the core, enduring issues of inadequate long-term funding, a persistent workforce crisis, and the failure to properly integrate social care. The current 10-year plan, by continuing this cycle, ensures that the NHS remains focused on managing its own internal structures rather than addressing the health of the population it serves.

Ultimately, the consequence of these strategic failings is an NHS that is increasingly consumed by failure demand, as framed by John Seddon. The absence of a systems-thinking approach, the lack of strategic boundaries, and the cycle of ineffective reforms all contribute to a system that is trapped in a reactive loop, spending vast amounts of time and money rectifying problems that should have been solved correctly the first time. The plan's laudable desires to shift care from hospital to community and from sickness to prevention are rendered hollow without the strategic discipline to identify and address the systemic drivers of this failure.

The NHS 10-year plan, therefore, represents a significant missed opportunity. It had the potential to be a defining strategy for national health, equipped with the conceptual clarity and delivery mechanisms to address the interconnected challenges of our time. Instead, it has settled for being a plan for the health service, a document that promises much but, by perpetuating the same strategic errors as its predecessors, risks delivering very little. It is a document that, like many before it, is destined to be judged not by its intentions, but by the very real and avoidable problems it fails to resolve.