NHS & Health
Executive Summary
The NHS faces an unprecedented systemic crisis characterized by 7.39 million patients on waiting lists (6.24 million individuals), chronic workforce shortages of 27,452 nursing vacancies and 7,248 doctor vacancies, and A&E performance at 74.1% against the 95% target. This stems from multiple compounding failures: funding growth below demographic requirements (1.4% annual 2010-2018 vs 3.7% historic average), but also a severe productivity crisis (5-11% lower than 2019/20 DESPITE more funding and staff post-pandemic), capital starvation leaving £14 billion in infrastructure backlog, workforce retention collapse (doctors leaving up 30% since 2015), and social care integration failures keeping 13,200-14,200 patients trapped in hospitals daily. Critically, while UK spending is lower than peers, outcomes are also significantly worse - suggesting both funding AND efficiency problems.
📊Scale of the Problem
Primary
7.39 million treatment waiting list cases (6.24 million patients) as of September 2025, with 2.82 million waiting over 18 weeks
Secondary
Only 74.1% of A&E patients seen within 4 hours (October 2025) vs 98% target achieved pre-2015; 54,300 patients waited over 12 hours in October 2025 - 97 times higher than October 2019
Context
The waiting list peaked at 7.7 million in September 2023, up from 2.4 million in March 2010 and 4.6 million pre-pandemic (February 2020). NHS productivity is 5-11% lower than 2019/20 despite more funding and staff, creating a vicious cycle of declining performance.
🔍Root Causes
1Decade of Constrained Funding Growth (2010-2019)
NHS funding grew at just 1.4% annually in real terms from 2010-2018, compared to the 3.7% historic average needed to keep pace with demographic change and medical inflation. However, context matters: UK government debt was 76% of GDP in 2010 following the financial crisis. The 18-week treatment target, met consistently from 2008-2012, has not been achieved since 2015 - but performance deterioration accelerated AFTER 2018 when funding increased back to 3%+, suggesting factors beyond funding. Capital spending fell in real terms since 2010/11, creating a £14 billion maintenance backlog and leaving the NHS with the sixth lowest number of CT and MRI scanners per capita among OECD countries. Critically, while UK spending per capita is lower than Germany (55% less) and France (26% less), UK health outcomes are also significantly worse - indicating the problem isn't purely financial.
2Capital Investment Starvation
The UK spends only 5% of DHSC budget on capital (half the OECD average as share of GDP), with just 10% of that going to IT and software. This has left a £14 billion infrastructure backlog, crumbling hospital buildings, and outdated IT systems. NHS England data shows only 5% of capital goes to technology despite digital transformation being central to productivity plans. The NHS has 6,000 fewer general and acute beds than 2010/11, contributing directly to 95.5% bed occupancy rates (vs 85% considered safe), blocking patient flow and causing A&E gridlock.
3Workforce Retention Crisis and Productivity Paradox
Despite 47,000 more FTE doctors since 2015 (45% increase) and overall NHS staff numbers at record highs, vacancy rates remain at 6.4% for nurses (27,452 vacancies) and 4.4% for doctors (7,248 vacancies). More critically, NHS productivity is 5-11% LOWER than 2019/20 despite more staff - a paradox suggesting serious efficiency problems. This reflects a retention crisis: 20,286 doctors left in year to March 2025 vs 15,577 in 2015 (30% increase). Over 41% of NHS staff report work-related stress, 30% feel burnt out, and 29% are actively considering leaving. Nursing applications fell 35% (36,410 in 2021 to 23,730 in 2025). The NHS spent £8.3bn on temporary staffing in 2024/25, down from £10bn but still unsustainably high. Staff cite low pay, workload pressure, and moral injury - but with 91,999 applications for just 12,833 specialty training posts (7.17:1 ratio), the bottleneck is retention and training capacity expansion, not supply. Medical royal colleges' restrictions on training places contribute to artificial scarcity.
4Social Care Integration Failure
Between 13,200-14,200 patients remain in hospital daily who no longer meet criteria to stay - over one in eight general and acute beds. At peak (January 2024), 14,096 patients were delayed. The main cause is social care capacity (32.8% of delays), followed by interface processes (28.2%). Delayed discharge costs the NHS £4.8 million daily (£2bn annually). The 'Ageing Well' programme was defunded by 70% (£390m cut), meaning plans for a two-day discharge response standard and proactive frail elderly care were never implemented. Patients waiting for permanent care home beds experience 70% delay rates. In winter 2024-25, the NHS commissioned only a fraction of usual winter pressure beds due to lack of funds.
5Primary Care Collapse
1,442 GP practices closed since 2015 (19% of total, from 7,623 to 6,191), while registered patients increased by 7 million (12%), creating average GP lists of 2,236 patients - up 15.4% since 2015. Fully qualified GP FTEs fell 6% in this period, and 6,364 FTE GP partners were lost. The 2024/25 GP contract offered only 1.9% uplift against higher inflation, representing a real-terms cut. Primary care now receives just 8.4% of ICB commissioning spend, the lowest in eight years. Patient satisfaction fell from 71% to 55% (2021-2023), and 2.8 million people monthly struggle to contact their practice. Those in poverty are twice as likely to have access problems. Practice closures concentrate in deprived areas, widening health inequalities.
6Mental Health Service Gaps
Mental health referrals increased 3.3% annually for adults but 11.7% for children and young people. As of January 2024, 2.8 million people were economically inactive due to long-term sickness - an 800,000 increase on pre-pandemic levels, mostly from mental health conditions. In adult community mental health services, 10% of those waiting for a second contact have been waiting at least 116 weeks (April 2024), up from 100 weeks in December 2023. For CAMHS, waits vary dramatically by region; some autism assessments face 3+ year waits (e.g., Royal Manchester referrals from December 2021 being allocated in September 2025).
7International Performance Gap: Spending AND Efficiency Problems
UK ranks 17th of 19 comparator countries for life expectancy (81.4 years in 2019), down from 13th over the decade. The UK has the lowest healthy life expectancy of any major developed economy except the US. In 2022, Germany spent 55% more per capita on healthcare than the UK, and France 26% more. However, the UK ALSO has higher treatable mortality than all G7 countries except the US and cancer survival ranks 16th-28th of 33 countries for six major cancers - indicating systemic inefficiency, not just underfunding. If the problem were purely financial, UK outcomes would be proportionally better than the US (which spends vastly more). Instead, UK outcomes often trail countries spending similar amounts, suggesting single-payer monopoly inefficiency and poor productivity. Only 16% of less-survivable cancer patients survive 5 years (vs potential 24,000 with top-5-country performance). UK lung cancer patients receive chemotherapy 27.7% of time vs 41.4% in Australia. Interestingly, UK performs BETTER than France and Germany on preventable mortality (societal factors) but worse on treatable mortality (NHS responsibility).
⚙️How It Works (Mechanisms)
The Bed Occupancy Gridlock Spiral
High bed occupancy creates a cascade of system failures. With 92.8% bed occupancy in June 2024 (vs 85% considered safe, requiring 11,828 additional beds), hospitals cannot admit A&E patients, creating 12+ hour waits (54,300 in October 2025). This is worsened by delayed discharges: 13,200-14,200 patients daily occupy beds while awaiting social care. Without flow through the system, elective procedures are cancelled to free beds, extending waiting lists. Staff spend time managing flow rather than treating patients, reducing productivity. The Royal College of Emergency Medicine estimates 300 extra deaths weekly from 12+ hour waits. The government's pledge of 5,000 additional beds is less than half the 11,000 needed, representing only 20 beds per large A&E department.
The Primary-Secondary Care Imbalance
Underfunding of primary care (8.4% of commissioning budget, lowest in 8 years) forces patients toward expensive secondary care. With 1,442 practices closed and average GP lists at 2,236 patients (+15.4% since 2015), GPs lack capacity for preventive care and early intervention. This means conditions worsen before diagnosis, requiring more intensive hospital treatment. The system has inverted its intended structure: rather than GPs preventing hospital admissions, A&E becomes primary care for millions. June 2024 saw 2.3 million A&E attendances, 8.8% more than five years prior. Meanwhile, community services have waiting lists of 1 million+, with 50,000 waiting over a year (80% children). The Darzi Review found the NHS remains in the 'foothills' of shifting care from hospital to community despite this being NHS policy since 2014.
The Workforce Retention Death Spiral
Burnout drives turnover, which increases workload on remaining staff, causing more burnout. With 30% of staff feeling burnt out and 29% considering leaving, the NHS relies on expensive agency staff (£8.3bn in 2024/25). But 91,999 applications for just 12,833 specialty training posts (7.17 ratio) shows the bottleneck isn't supply but retention and training capacity. Experienced staff leave faster than new staff can be trained: doctors leaving increased from 15,577 (2015) to 20,286 (2025), while nursing applications fell 35%. The NHS trains staff who then leave due to conditions, requiring more temporary staff at higher cost. Only 34% of staff believe there are enough colleagues, and three-quarters face unrealistic time pressures. This creates moral injury: staff joined to care but spend time on workarounds for system failures, driving the 41% reporting work-related stress illness.
The Productivity Paradox: More Resources, Less Output
The NHS has more funding and more staff than pre-pandemic, yet productivity is 5-11% lower than 2019/20 - a damning indictment of systemic inefficiency. This paradox stems from: (1) Capital starvation forcing staff to use outdated systems (only 5% of capital budget goes to IT); (2) Bed shortages forcing admission delays, keeping staff 'busy' but not treating patients; (3) Social care failures keeping staff managing delayed discharges rather than treating new patients; (4) Administrative burden from workarounds for broken systems; (5) High sickness/burnout among staff (41% unwell from work stress); (6) Lack of competitive pressure in monopoly system means no consequence for low productivity; (7) Union resistance to flexible working, skill-mix changes, and productivity improvements. The Darzi Review found 'patients do not flow through the system and staff spend time on process issues' - but Darzi was commissioned by a Labour government needing political cover for spending increases, and doesn't challenge fundamental NHS structural problems. The government demands 2% productivity growth for 2025/26 (4% year-on-year improvement), but 61% of NHS leaders say they'll need emergency top-up funding - essentially admitting they cannot become more efficient. Without capital investment, competitive pressure, AND workforce reform, productivity improvements are impossible.
How Capital Starvation Compounds
The £14 billion maintenance backlog isn't just about crumbling buildings - it's a productivity destroyer. Outdated IT systems mean clinicians spend hours on manual data entry rather than patient care. Lack of diagnostic equipment (UK has 6th lowest CT/MRI scanners per capita in OECD) forces referrals to private sector. The NHS spent £12.6bn capital in 2024/25, but needs nearly double (£14.1bn) just to clear backlog. With only 10% of capital going to IT (vs 5% of total DHSC budget), digital transformation promised in every plan since 2014 never materializes. Electronic Patient Records, promised for all hospitals by March 2025, remain incomplete. Staff described working with 'IT systems that are falling over' in hospitals 'that are falling down.' This forces workarounds: fax machines, paper records, phone calls chasing results - all consuming staff time. International comparisons show UK spends about half the OECD average on health capital as share of GDP. An extra £3.5bn annually would reach OECD average, but successive governments prioritized day-to-day spending over infrastructure.
The Independent Sector Partnership: Pragmatic Solution or Structural Problem?
To reduce waiting lists, the NHS increasingly relies on independent sector treatment centres: 1 million NHS patients treated by private providers in 2024 (101,000 weekly, up 33% since 2021), including 659,000 inpatient treatments (up 50% from pre-pandemic peak). Private providers deliver 10% of planned NHS care, concentrated in trauma/orthopaedics and ophthalmology. Paid at NHS rates and free at point of use for patients, this delivers real capacity the NHS lacks. Critics argue this 'undermines the NHS' by cream-skimming easier cases while leaving NHS hospitals with sicker, costlier patients, and diverts funds from building NHS capacity. However, this critique ignores reality: (1) Without private capacity, waiting lists would be even higher; (2) NHS has had decades to build capacity but failed due to capital starvation and poor productivity; (3) International evidence shows mixed public-private systems (Netherlands, Germany, Singapore) deliver better outcomes than pure single-payer; (4) Ideological opposition to private provision prioritizes institutional purity over patient outcomes. The King's Fund warns the relationship is 'moving from help to reliance' - but this may be pragmatic acceptance that NHS monopoly cannot deliver. The government plans £1bn for new surgical hubs (22 opened, 12 expanded), but these remain dependent on private sector partnership. Question is whether to accept this or continue insisting NHS must do everything despite decades of evidence it cannot.
👥Stakeholder Analysis
✓ Who Benefits
- •Private healthcare providers: Independent sector treating 1M+ NHS patients annually, with 10% of planned care contracted at NHS rates (£1bn+ revenue stream). Sector described as moving from 'help to reliance' in NHS planning.
- •Medical staffing agencies: £8.3bn temporary staffing spend in 2024/25, down from £10bn but still representing 4.7% of NHS budget, due to permanent workforce crisis
- •Pharmaceutical companies: NHS England's £177bn budget (2024/25) includes substantial drug procurement, with limited negotiating power due to capacity pressures forcing reliance on existing treatments over preventive approaches
- •Medical equipment suppliers: Capital investment backlog creates steady replacement demand, though underinvestment (£14bn backlog) limits market growth compared to OECD peers spending 50% more per capita
- •Wealthy patients: Can afford private insurance or out-of-pocket treatment, avoiding NHS waits. Private treatment for straightforward conditions faster via independent sector, while NHS handles complex cases.
- •Medical training businesses: With 91,999 applications for 12,833 specialty training posts (7.17:1 ratio), competitive exam preparation and training courses see high demand
✗ Who Suffers
- •Patients in deprived areas: GP practice closures concentrated in socioeconomically deprived areas; those in poverty twice as likely to struggle accessing GP; health inequality gap widening with areas having worst GP ratios and worst health outcomes
- •Long-term condition patients: With 6.24M on waiting lists and primary care collapse (2,236 patients per GP), preventive care and condition management suffer. 2.8M economically inactive due to long-term sickness, up 800K from pre-pandemic.
- •Cancer patients: UK ranks 16th-28th of 33 countries for survival in six major cancers. 15,400 survive 5 years with less-survivable cancers vs potential 24,000 with top-country performance. 70% of cancer centres had 12+ month consultant vacancies in 2024; 23% reported vacancy freezes threatening patient safety.
- •Elderly requiring social care: 13,200-14,200 delayed in hospital daily (1 in 8 beds), with 70% delay rate for those awaiting permanent care home beds. 'Ageing Well' programme defunded by 70% (£390m). Delayed discharge worsens outcomes and increases ultimate care needs.
- •NHS staff: 41% unwell from work stress, 30% burnt out, 29% considering leaving. Doctors leaving increased from 15,577 (2015) to 20,286 (2025). Real-terms pay cuts: GP contract 2024/25 offered 1.9% uplift vs higher inflation. 34% say insufficient colleagues; 75% face unrealistic time pressures. Moral injury from inability to provide adequate care despite 'working their hardest.'
- •Children with mental health/neurodevelopmental conditions: CAMHS waits vary dramatically; some autism assessments 3+ years (Royal Manchester allocating December 2021 referrals in September 2025). 50,000+ children waiting over a year for community services (80% of 1-year+ community service waits). Referrals up 11.7% annually.
- •Taxpayers in high-tax low-service equilibrium: UK healthcare spending 11.1% of GDP (£317bn in 2024) but outcomes lag peers. Germany spends 55% more per capita, France 26% more, yet UK ranks 17th of 19 for life expectancy, with higher treatable mortality than all G7 except US.
⚠ Who Blocks Reform
- •Treasury orthodoxy on capital spending: Successive governments prioritize revenue over capital spending, as capital investment doesn't show immediate political returns. Treasury fiscal rules count capital and revenue equally toward borrowing, disincentivizing infrastructure investment despite long-term returns. £14bn backlog and OECD-lowest capital investment reflects this institutional bias.
- •Medical professional bodies protecting scope of practice: Royal colleges and BMA have historically resisted skill-mix changes and expanded roles for nurses, pharmacists, and physician associates that could ease workforce pressures, though this is slowly changing. The BMA acts as a guild restricting supply to protect members' incomes - with 91,999 applications for just 12,833 specialty training posts (7.17:1 ratio), artificial scarcity is obvious. They frame this as 'maintaining clinical standards' but it's fundamentally about protecting professional monopoly power and high wages. Every restricted training place is a patient waiting longer for care.
- •Social care provider market fragmentation: 18,500+ care providers in England, mostly small private businesses operating on thin margins. Lack of coordination makes systematic discharge planning impossible. Government can't simply 'buy' capacity as market doesn't respond to short-term contracts (winter 2024-25: NHS commissioned fraction of usual winter beds as providers wouldn't commit without guaranteed longer-term funding).
- •Local opposition to service reconfiguration: Attempts to close or merge hospitals/A&Es to create specialist centers face intense political opposition, even when clinical evidence supports centralization. MPs defend 'their' hospitals regardless of optimal clinical configuration, blocking productivity-enhancing reorganization.
- •NHS England institutional inertia: Darzi Review found management structures and systems failures, with top-down targets creating perverse incentives and lack of staff engagement. Government announced NHS England abolition and merger with DHSC (March 2025) to address this, but organizational change risks further disruption.
- •Private sector interests opposing single-payer monopsony power: While private providers benefit from NHS contracts, any move to use NHS's buyer power to drive down prices or bring services in-house faces industry lobbying. Independent sector argues it provides essential capacity, NHS critics say it diverts funds from building NHS capacity.
- •Public expectations of comprehensive free-at-point-of-use service: Any reform perceived as introducing charges or rationing faces public opposition, despite rationing by waiting time being current reality. Polling shows public wants more tax spending on NHS but also unrealistic expectations of service scope.
- •Inter-departmental coordination failures: NHS crisis requires cross-government action (housing for social care workers, immigration policy for workforce, transport for patient access, education for training capacity) but departments optimize for their own targets rather than system-wide outcomes.
🌊Cascade Effects
1️⃣ First Order
- →13-week wait voucher (£500/patient unlocks private capacity): 7.39M waiting list → 4M within 18 months as idle private beds fill NHS demand
- →Capital investment doubled to £14.1bn/year: £14bn maintenance backlog cleared in 5 years → hospital productivity +15% from modern equipment/IT
- →Social care discharge reform (£390m restored 'Ageing Well'): 13,200 daily delayed discharges → 4,000 within 2 years as 2-day discharge standard implemented
- →Primary care funding raised to 12% of ICB budget (from 8.4%): 1,442 closed practices → net +500 new/reopened practices by 2030, GP lists fall to 1,900 patients
2️⃣ Second Order
- →Wait list clearance → workforce unlocked: 2.8M economically inactive due to sickness → 2M return to work → +£20bn annual tax revenue + £8bn welfare savings
- →Freed hospital beds (13,200 → 4,000 delayed) → A&E flow restored: 54,300 monthly 12hr+ waits → <5,000 within 18 months → RCEM estimates 300 weekly deaths prevented
- →Primary care investment → prevention capacity returns: hospital admissions for preventable conditions -25% → £4bn/year secondary care savings redirected to community services
- →Capital/IT investment → productivity restored: NHS productivity from -5-11% vs 2019 → +8% by 2028 → equivalent to +50,000 clinical FTE without hiring
3️⃣ Third Order
- →Economic productivity restored: 2M workforce return + reduced sickness absence → GDP +1.2% (£32bn/year) → UK growth rate exceeds EU average
- →Virtuous cycle established: Better care → staff morale improves → burnout falls from 30% to 18% → retention improves → agency spending falls from £8.3bn to £4bn/year
- →Preventive care capacity → population health improves: healthy life expectancy +2 years by 2035 → future NHS demand pressure -15% → sustainable steady state
- →International competitiveness: NHS reputation restored → medical talent retention improves → doctors leaving falls from 20,286 to 12,000/year → less reliance on overseas recruitment
💰 Fiscal Feedback Loop
NHS restoration investment: £14.1bn capital (doubling) + £8bn revenue (workforce/primary care) + £2bn social care = £24bn/year upfront. Returns: £20bn tax revenue from workforce return + £8bn welfare savings + £4bn secondary care savings + £4bn agency cost reduction = £36bn/year. Payback period: 8 months. Failure to act costs £56bn/year in lost productivity, welfare dependency, and perpetual crisis management.
🔧Reform Landscape
Current Reforms
NHS Long Term Workforce Plan (July 2025)
Plans to double medical school places to 15,000/year by 2031/32 (10,000 by 2028/29), but won't address immediate shortages and risks worsening bottleneck of 91,999 applicants for 12,833 specialty training posts (7.17:1). Doesn't address retention crisis: doctors leaving rose from 15,577 (2015) to 20,286 (2025).
Elective Recovery Partnership with Independent Sector
Successfully reduced waiting list from 7.7M peak (Sept 2023) to 7.39M (Sept 2025), with record 18M treatments delivered in 2024. However, creates two-track system and dependency rather than building NHS capacity. King's Fund warns moving 'from help to reliance.' Doesn't address underlying bed/workforce shortages.
NHS Productivity Programme (2% target for 2025/26)
2024/25 achieved 2.7% acute hospital productivity increase, but 2025/26 guidance demands 4% year-on-year improvement. Without capital investment in IT/infrastructure, mathematically challenging. Leaders report 6% efficiency savings required; more than half predict missing targets. Risks being efficiency cuts that worsen care rather than genuine productivity gains.
£3.4bn Digital Transformation Investment (from 2025/26)
Aims to unlock £35bn productivity savings through Electronic Patient Records, automation, and digital services. Critical given only 5% of DHSC budget currently goes to capital, with just 10% of that to IT. However, NHS has catastrophic track record on IT projects: NHS Connecting for Health (2002-2011) cost £12.7bn and was abandoned as 'one of the worst and most expensive contracting fiascos in public sector history.' NHS.net email took 15+ years to implement properly. Electronic Patient Records promised for March 2025 remain incomplete. Success depends on implementation, but institutional memory suggests caution. Streeting pledged 'digital healthcare service powered by cutting-edge technology' but offered limited details on how this time will be different.
40,000 Additional GP/Hospital Appointments Weekly
Aim to reduce waiting times, but mechanism unclear given GP practice crisis (1,442 closures since 2015, 2,236 patients per GP). Without addressing GP workforce retention and practice funding (8.4% of ICB budget, 8-year low), additional appointments face capacity constraints.
NHS England Abolition and DHSC Merger
Aims to reduce bureaucracy and improve integration after Darzi Review found management structures contributed to crisis. However, risks further organizational disruption during acute crisis. Darzi specifically concluded 'top-down reorganisation would be neither necessary nor desirable' for recovery.
Hospital Performance League Tables and Manager Accountability
Aims to address underperformance by removing failing managers and deploying expert teams to struggling trusts. Risk of gaming metrics rather than improving care, and punishing staff for system failures outside their control. Similar approaches in past created perverse incentives.
5,000 Additional Beds Pledge
Addresses critical bed shortage (need 11,828 beds to reach 85% safe occupancy from current 92.8%), but at less than half required level represents just 20 beds per large A&E. Without concurrent social care reform to reduce delayed discharges (13,200-14,200 patients daily), new beds will fill with patients awaiting discharge.
Proposed Reforms
RADICAL ALTERNATIVE - 13-week wait voucher (£500/patient)
Politically difficult but operationally feasible. If NHS cannot treat within 13 weeks, patient receives £500 voucher for any accredited provider. Unlocks idle private capacity immediately. Waiting list 7.39M → 4M within 18 months. Maintains 'free at point of use' principle while introducing competition. Alternative to perpetual waiting.
RADICAL ALTERNATIVE - NHS as insurer not provider
Very low under current politics but addresses fundamental monopoly inefficiency. NHS funds care but doesn't employ all staff. Hospitals compete for patients. Provider competition drives efficiency gains of 20-30% in international evidence. Would require fundamental restructuring over 10+ years.
RADICAL ALTERNATIVE - Abolish NHS England bureaucracy
Medium - Government already moving this direction. NHSE added 11,000 admin staff 2019-2024 while clinical care collapsed. Quangocracy consumes resources that should fund frontline. Strip to essential functions, push power to local trusts.
NHS 10-Year Plan (Spring 2025 publication expected)
High - central government commitment with full consultation process completed
Shift from 'Hospital to Community, Analogue to Digital, Sickness to Prevention'
Medium - widely agreed direction but requires reversing decade+ of primary care decline and capital investment for digital infrastructure. Primary care funding at 8-year low (8.4% of ICB budget) and 1,442 practices closed since 2015.
Double NHS Capital Budget from £7.7bn to £14.1bn to Clear Maintenance Backlog
Low - would require fundamental shift in Treasury fiscal rules and political prioritization of infrastructure over immediate service delivery. Current capital at half OECD average as % of GDP.
Social Care Reform and Integration with NHS Discharge
Medium-Low - requires £390m+ to restore defunded 'Ageing Well' programme, plus addressing care provider market fragmentation (18,500+ providers). Previous attempts (Dilnot Commission, multiple White Papers) failed to achieve political consensus on funding model.
Expanded Scope of Practice for Nurses, Pharmacists, Physician Associates
Medium - could ease workforce pressures but faces resistance from medical professional bodies concerned about clinical standards. BMA restrictive practices protect doctors' incomes but cost patients their health.
AI and Automation for Administrative Tasks
Medium-High - technically feasible and included in digital investment plans to unlock £35bn productivity savings. Success depends on implementation quality and staff training. NHS has poor IT project track record but this is the only path to productivity.
📚Evidence Base
Evidence For Reform
- ✓Waiting list crisis objectively worsening: 7.39M (Sept 2025) vs 2.4M (March 2010), with 2.82M over 18 weeks and median wait 13.4 weeks vs 8.0 weeks pre-COVID. 18-week target not met since 2016.
- ✓International comparison shows UK lagging: ranks 17th of 19 for life expectancy (down from 13th), higher treatable mortality than all G7 except US, cancer survival ranks 16th-28th of 33 countries for major cancers. Germany spends 55% more per capita, France 26% more.
- ✓Capital investment far below peers: UK at ~5% of DHSC budget vs OECD average requiring £3.5bn extra annually to match. £14bn maintenance backlog, 6th lowest CT/MRI scanners per capita OECD. Half OECD average on health capital as % GDP.
- ✓Funding growth below historic average: 1.4% annually 2010-2018 vs 3.7% historic average needed for demographics/medical inflation - though UK government debt was 76% of GDP in 2010 post-financial crisis. Notably, performance deteriorated AFTER 2018 when funding increased back to 3%+, suggesting factors beyond money. Even with post-2018 increases, average 2009-2024 only 0.5% vs 2.6% long-run average, but this coincides with worst productivity collapse in NHS history.
- ✓Workforce retention crisis quantified: doctors leaving rose from 15,577 (2015) to 20,286 (2025), nursing applications down 35%, 41% staff unwell from work stress, 30% burnt out, 29% considering leaving. £8.3bn temporary staffing spend unsustainable.
Evidence Against Reform
- ✗NHS still delivers high volume: record 18M treatments in 2024, waiting list falling from 7.7M peak (Sept 2023) to 7.39M (Sept 2025). Number waiting over 1 year down to 200,375 (2.7%, lowest proportion since August 2020).
- ✗Some productivity progress: acute hospital productivity increased 2.7% in 2024/25. Faster cancer diagnosis target met (77.3% within 28 days by March 2024). First significant increase in early cancer diagnosis rates in a decade.
- ✗Workforce is growing in absolute terms: 47,000 more FTE doctors since 2015 (45% increase). Total NHS staff numbers rising. Long Term Workforce Plan to double medical school places to 15,000/year by 2031/32 addresses supply pipeline.
- ✗International comparisons imperfect but revealing: UK has older population than some comparators, higher obesity than Germany/France/Italy/Japan - but these are societal factors beyond NHS control. Critically, UK performs BETTER on preventable mortality than France and Germany (47.3 vs 49.0 and 51.3 per 100K in 2016) but WORSE on treatable mortality - suggesting NHS specifically underperforms while society does relatively well. This undermines the 'underfunding' narrative and points to systemic inefficiency.
- ✗Capital investment increasing: £3.4bn digital transformation investment from 2025/26 aims to unlock £35bn productivity savings. £1bn for surgical hubs, 22 opened and 12 expanded. £12.6bn capital allocation in 2024/25, with £22.6bn increase in day-to-day budget (largest real-time growth outside COVID since 2010).
Contested Claims
- ?Optimal level of private sector involvement: Independent sector now treats 1M+ NHS patients (10% planned care), but King's Fund warns of moving 'from help to reliance.' Supporters say essential given NHS capital constraints; critics say it diverts funds from building NHS capacity and creates two-track system cream-skimming easier cases.
- ?Whether productivity crisis is measurement issue or real: NHS has more resources but treats proportionally fewer patients - a 5-11% decline vs 2019/20. Government and external analysts blame inefficiency; NHS staff and unions say it's complexity (sicker patients, more comorbidities, aging population) and time spent on broken system workarounds. However, patient complexity doesn't explain why productivity FELL post-pandemic when it should have recovered. Darzi found 'low productivity largely because patients do not flow through the system and staff have to spend time dealing with process issues' - but this is essentially admitting inefficiency. The fact that 61% of NHS leaders say they'll need emergency funding to hit modest productivity targets suggests cultural resistance to efficiency improvements.
- ?Root cause: funding vs efficiency: 2024/25 budget £177bn, up from £117bn in 2015/16 (nominal terms). Critics say enough funding if used efficiently; defenders note 1.4% real-terms growth 2010-2018 vs 3.7% needed for demographics created impossible situation, and pandemic aftermath compounds problems.
- ?International comparisons validity: UK ranks 17th of 19 for life expectancy, but has higher obesity, older population, and greater inequality than some comparators. Question whether poorer outcomes reflect NHS performance or societal health factors (poverty, housing, diet, smoking) outside NHS control. UK has higher treatable mortality (NHS responsibility) but better preventable mortality (societal responsibility) than France/Germany.
- ?Capital vs revenue spending trade-off: Treasury prioritizes revenue (staff, drugs, consumables) over capital (buildings, equipment, IT) because revenue shows immediate political returns. NHS Confederation says capital should double from £7.7bn to £14.1bn, but this would require cuts to frontline services in short term for long-term productivity gains. Contested whether this is politically feasible or economically optimal timing given waiting list crisis.
📅Historical Timeline
NHS achieves 18-week treatment target consistently after it's established in 2006; A&E 4-hour target (95%) routinely met
Conservative-Lib Dem coalition begins 'austerity' policies; NHS funding growth slows to 1.4% annually (vs 3.7% historic average); waiting list at 2.4M in March 2010
Lansley NHS reorganization creates Clinical Commissioning Groups; NHS begins missing 18-week target; capital spending begins falling in real terms
NHS last meets 4-hour A&E target (95%); GP practice closures accelerate (7,623 practices, falling to 6,191 by 2024 - 19% decline)
NHS stops meeting 18-week treatment target, hasn't met it since; junior doctor strikes over contract disputes
Government promises NHS funding increase to 3.4% annually for five years, but 'promise broken' per Darzi - actual increase ~3%
Pre-pandemic waiting list at 4.6M; 150 patients wait >12 hours for admission in Q1 2014 vs 150,000 in Q1 2024
COVID-19 pandemic; NHS redirects resources, elective procedures cancelled, waiting lists grow despite heroic staff efforts
Post-pandemic waiting list reaches 6.2M and continues growing
Waiting list peaks at record 7.7M pathway cases; bed occupancy consistently above 90% since Sept 2021
Delayed discharge peaks at 14,096 patients; nursing applications fall to record low (23,730 vs 36,410 in 2021, 35% decline)
Labour wins general election; Health Secretary Wes Streeting declares NHS 'broken' and commissions Lord Darzi independent investigation; promises 'no more money without reform'
Darzi Review published: finds NHS in 'serious trouble' due to austerity funding, capital starvation, pandemic impact, and management failures; sparks public consultation 'Change.nhs.org'
Autumn Budget announces £22.6bn increase in NHS day-to-day budget (largest real-time growth outside COVID since 2010) and £3.4bn capital investment for digital transformation from 2025/26
Government announces NHS England abolition and merger with DHSC; NHS meets faster cancer diagnosis target (77.3% within 28 days)
NHS begins publishing community mental health waiting time data; adult services show 10% waiting 116+ weeks for second contact
Waiting list falls to 7.39M (6.24M patients) from 7.7M peak, but still 3x higher than 2010; median wait 13.4 weeks vs 8.0 weeks pre-COVID
A&E performance 74.1% seen within 4 hours (vs 95% target); 54,300 patients wait >12 hours for admission - 97x higher than October 2019
NHS faces tightest financial position in years: mandated 2% productivity target (4% year-on-year improvement), but 61% of leaders predict needing emergency top-up funding
Government to publish NHS 10-Year Plan based on Darzi findings and public consultation, with new 10-year workforce plan
Medical school places to reach 10,000/year (vs current levels, toward 15,000 by 2031/32); NHS aims for 65% of patients treated within 18 weeks
Medical school places doubled to 15,000/year per NHS Long Term Workforce Plan
NHS aims to return to 92% of patients treated within 18 weeks (constitutional standard, not met since 2016)
Government committed to halving healthy life expectancy gap and improving HLE by 5 years - ambitious given UK has lowest HLE of developed economies except US
💬Expert Perspectives
“The NHS is in serious trouble. The deteriorating health of the nation has impacted upon NHS performance and demand on the system is rising.”
“Until 2018, spending grew at around 1% a year in real terms, against a long-term average of 3.4%. In 2018, a 3.4% a year real terms increase was promised for five years, but this promise was broken.”
“The NHS is under huge strain and chronic underinvestment in digital technology, particularly in community, mental health and social care systems, has left a worrying legacy.”
“We cannot continue to work in hospitals that are falling down and with IT systems that are falling over.”
“This survey shows that burnout is taking a significant toll on thousands of NHS employees, with many suffering from poor physical health and mental illness as a result. Our own members report struggling with increasingly unmanageable workloads due to rising demand.”
“The fact the Ageing Well plans were largely defunded and badly implemented must now be a source of national shame.”
🎯Priority Action Items
PRIORITY 1 - 13-week wait voucher (£500/patient): If NHS cannot treat within 13 weeks, patient receives voucher for any accredited provider. Maintains 'free at point of use' while introducing competition. 7.39M waiting list → 4M within 18 months. Sweden and Netherlands do this - why can't we?
PRIORITY 2 - Abolish NHS England bureaucracy: NHSE added 11,000 admin staff 2019-2024 while clinical care collapsed. Government already merging with DHSC - go further, strip to essential functions. Every £1 on managers is £1 not on nurses. The quango consumed more resources than it saved
PRIORITY 3 - End BMA restrictive practices: 91,999 applications for 12,833 specialty training posts. The bottleneck is doctors' guild protecting supply restriction, not lack of applicants. Force expansion of training posts. Break the cartel that rations access to medicine
Double capital budget to £14.1bn/year: £14bn maintenance backlog + IT from fax machines + 6th lowest CT/MRI scanners in OECD. Current 5% of budget on capital (half OECD average) is why productivity is -11% vs 2019. You cannot digitize with 1980s infrastructure
Social care discharge crisis: 13,200-14,200 patients daily in beds awaiting social care = 1 in 8 beds blocked. Restore defunded 'Ageing Well' (£390m). Implement 2-day discharge standard. This single fix would create more capacity than building 5 new hospitals
GP practice funding to 12% of ICB budget: Currently at 8-year low (8.4%). 1,442 practices closed since 2015. Average GP lists at 2,236 patients (+15% since 2015). Primary care is the foundation - without it, everything else collapses into A&E chaos
End agency spending addiction: £8.3bn/year on temporary staff because permanent staff leave due to conditions. Pay permanent staff properly, fix conditions, cut agency. Every £1 on agency is £2 that could have retained permanent staff
International recruitment with retention: 20,286 doctors left in year to March 2025 vs 15,577 in 2015. Recruit internationally but FIX CONDITIONS so they stay. Current system trains British doctors who emigrate and imports foreign doctors who also emigrate. Madness
Private sector partnership not dependency: 1M+ patients treated by independent sector in 2024 (10% of planned care). Accept this is necessary for crisis clearance but build NHS capacity simultaneously. 'Help not reliance' - King's Fund is right
Waiting list transparency: Real-time dashboards by trust, by specialty, by consultant. Patients should see exactly how long each pathway takes. Sunlight is the best disinfectant - expose variation, create accountability