Fever dream

The NHS over the next decade and the bonfire of expectations

You could be forgiven for thinking the fireworks of this summer’s 10-year Health Plan and Life Sciences Sector Plan have turned into damp cardboard.

For the 10-year big one, there’s been no delivery plan for how everything is going to fit together and the operating model seems to be in a state of perpetual ‘emerging’.

We’re not sure how the money is going to work long term and there doesn’t seem to be a clear roadmap to nationally onboard the preventive, digital and community healthcare the plan envisions – yet.

And then the life sciences plan – which seeks above all else to promote a positive investment and R&D environment for pharma and the other industries – has taken a severe knock with AZ, Lilly and Merck all pulling exactly the kind of presence government desperately wants.

That’s why it’s helpful being Content Director at HSJ, with access to so many events, opinions and a pretty good view of the grassroots initiatives and local progress that don’t make the headlines.

When you look at these, you see there is a good deal happening on the ground. Providers are grouping, pathways are being transformed and the NHS is being reimagined – but in a quiet, local way and perhaps this is the real learning of the plan – we need to go up close to benefit from what is still a market with huge potential and hunger for innovation.

I attended HSJ’s 10-Year Plan Summit last week – under Chatham House rules – and over the course of two days I learned the following home truths about the NHS.

1. The gap between vision and capacity is widening
The NHS 10-Year Plan runs to 171 pages, but the delivery bandwidth to match its ambition is shrinking. Leaders described ‘’a system at full stretch’’ trying to operationalise long-term reform on short-term budgets and contracts. We’re going to have to be patient.

2. Policy is catching up with practice
The integrated care model is no longer an experiment. Cheshire & Merseyside – nine places, 55 neighbourhoods – was cited repeatedly as proof that genuine place-based partnership can outpace national policy. Systems are building the NHS England vision from the ground up, not the top down and there’s a lot for pharma to explore here.

3. The digital front door is finally open
For the first time, more people contacted the NHS online than by phone (September data). But as one speaker warned, ‘’we’re putting more doors on the bus without putting any seats on it.’’ Expanding access must not dilute continuity or overwhelm clinical capacity. Pharma needs to be aware of the constraints as well as the possibilities.

4. From pilots to permanence
Somerset’s seven-year journey to integrate two hospitals, mental health, community and 16 GP practices was described as ‘integration by attrition’. The lesson: progress sticks only when it changes contracts, staff terms and culture – not just governance charts. Watch out for such systems, when everyone is on the same page it can make it easier to achieve results.

5. The ageing paradox
Older people in US integrated care systems spend 40% less time in hospital than in the NHS. Our system still incentivises admission over prevention. The ‘frailty premium’ is emerging as a big new battleground for value. How can pharma think in NHS terms like this, and really look at the reality of what it’s like to treat – and be – these patients?

6. Prevention remains rhetoric without fiscal realism
One delegate quipped: ‘’At current rates, it’ll take 250 years to close the life expectancy gap.’’ Everyone agrees prevention is cheaper – but no one’s funding it at scale. The Treasury model remains geared towards acute demand, not future savings. Pharma’s job will involve pressing the arguments for more preventive healthcare with its offerings – and possibly re-imagining what prevention means.

7. Localism or nationalism?
The quiet consensus is the next decade will be defined by how much localism can prevail. One system leader summed it up: ‘’There’s a real limit to how much nationalism we will tolerate.’’ Flexibility, not uniformity, is driving local results, so keep an eye on individual areas that are making progress.

8. Genomics and AI are tools, not panaceas
AI is transforming radiology – ten times faster than cardiology – but tech in itself isn’t a strategy and investment in people and workflow redesign comes before algorithms. As one speaker said: ‘’Genomics and AI won’t fix broken operating models.’’
Pharma needs to remain circumspect about its new wave of genomic-powered treatments as the NHS may need some time to catch its infrastructure and funding model up. And so much truck has been put on AI it risks overemphasising what it can change, quickly.

9. Community-based mental health is maturing
In Birmingham, a 24/7 mental health hub run from a mosque is redefining ‘access’. It’s not just a story about managing exclusion, but about system design – meeting people where they are, not where the NHS is comfortable. Are there win-wins aplenty here for industry seeking to widen access?

10. The power of precision partnerships
The near-eradication of communicable HIV in Greater Manchester was hailed as proof that radical goals can be achieved when science, local government and voluntary services, with the right data, act as one. What else can pharma transform in such a dramatic way, with the right approach?

11. Procurement must grow up
With 90% of purchasing happening at system level, ICSs must become informed customers. The old ‘national framework’ mentality is incompatible with modern innovation. Systems are learning to behave like investors, not buyers. What from pharma should they be investing in?

12. Workforce reform is service reform
The blunt truth: ‘’The business, operating and care models are all broken.’’ Workforce redesign – advanced practitioners, shared staffing, new roles – was cited as the only lever powerful enough to reset the model. Be prepared for lots of new roles bobbing about the NHS.

13. End-of-life care is the hidden drain
Thousands of hospital bed-days each year are consumed by people who would prefer to die at home. This is a human and financial failure – and an area where integrated care can make visible, measurable gains. What can pharma do to align? Medicine clearly has a role in management – what might be the system gains from better EoL care?

14. Primary care is reorganising from the inside out
Lincolnshire’s 22 PCNs show what mature primary care integration looks like. Ten of 14 neighbourhoods now focus on frailty, using shared physio and pharmacy staff and experimenting with continuity models that restore personal care to industrial-scale systems. Pharma can reflect on the wider needs of the patient groups that take its medicines and the systems that serve them, here.

15. Public, private and third sector
The CQC’s 36,000 registered providers illustrate the fragmented landscape of organisations charged with realising the plan. More than before, treatment is going to involve combinations of these sectors and intricate, granular stakeholder mapping.

16. The digital divide mirrors the social one
Digital engagement is soaring, but exclusion remains entrenched. One ICS mapped that its heaviest users of A&E are least likely to access the NHS app. Technology without inclusion widens inequalities by design. Ensure your wraparounds are NHS-interoperable, but be aware of the current limitations of the strategy.

17. Housing, planning and health are merging agendas
Health is moving onto the high street and into planning codes. Cheshire & Merseyside’s work embedding well-being into town regeneration was showcased as a prototype for the ‘healthy place’ approach the NHS Long Term Plan promised. Are you familiar with how provision is changing locally?

18. Obesity is the new tobacco
Public health leaders warned that obesity, not smoking, now drives the largest preventable disease burden. Yet the system still invests more in treating diabetes complications than in community weight management. How is your approach going to reduce demand through your product’s prevention attributes and ability to stem upstream costs?

19. The culture shift is from heroics to humility
‘’If you really want to understand something, try to change it,’’ said one system CEO. The mood has shifted from command-and-control to inquiry and iteration. Leaders are learning to test, adapt and share challenges faster. Industry can definitely help catalyse this with its own data-driven inquiry.

20. Integration’s real measure is belonging
Beyond data and dashboards, the most powerful theme was identity. Staff who feel they belong to ‘the system’ rather than a single Trust or practice deliver better outcomes. Integration isn’t structural – it’s emotional. Talk to your NHS customers about this – where do they feel they belong?

I hope you get the idea: there is much work to be done on the preventive, digital and community-based pathway ideals of the NHS, but it is itself ‘forming’ on a lot of this. Often the reach is farther than the grasp. Systems are variable in how connected they are. Progress is patchy. Progress is often about staying afloat effectively rather than grand change.

The NHS is struggling with some conditions such as frailty and end-of-life care, which are massively and disproportionately affecting capacity, but succeeding, with the help of modern medicine, in others such as HIV.

For companies that make the right approach, similar achievements are there to be made, and the time is full of opportunities to make real gains in conditions the NHS has been struggling to manage for decades – if pharma can find the right stakeholder groups, address the pressing need of the area and message it in a way that hits the right buttons. In this case that’s an absolute focus on the outcomes that it can give the NHS.

Oli Hudson is Content Director at HSJ Information. Go to hsjinformation.co.uk