Fit for the Future – Or Stuck in the Past?
- Aug 20
- 4 min read
A deep dive into the NHS’s latest 10-year health plan, and what history tells us about its chances of success.
By Dr Andrew Davies MB ChB
For decades, the NHS has been in a near-constant state of reform. Every few years, a new plan is unveiled promising to transform healthcare delivery in England. The latest, Fit for the Future: The 10 Year Health Plan for England, claims to mark a radical break from the past.
But here’s the question: is this really a bold new direction, or just a remix of old ideas? By examining the history of NHS reform, we can better understand whether Fit for the Future is likely to deliver on its promises — or join a long list of well-intentioned but under-delivered strategies.
A Short History of NHS Reform Cycles (1990–2025)
1990s – The Internal Market
The NHS and Community Care Act 1990 introduced the “purchaser–provider split” to encourage competition. Hospitals became self-governing trusts, and GP fundholding gave practices budgets to commission care. The aim was efficiency and patient choice. The reality? Higher admin costs, limited true competition, and the emergence of a two-tier system.
2000s – Investment and Targets
New Labour kept the purchaser–provider split but replaced market rhetoric with “partnership” and “commissioning.” Massive funding increases (nearly 7% per year in real terms) fuelled record reductions in waiting times and the highest public satisfaction in NHS history. However, a heavy reliance on targets created pressure to “game” the system.
2010s – Austerity and Reorganisation
The Health and Social Care Act 2012 reshaped the NHS into hundreds of GP-led Clinical Commissioning Groups. Funding growth slowed to historic lows, and performance sharply declined. By the late 2010s, policy shifted back toward integration with the introduction of Integrated Care Systems (ICSs).
2020s – Integration Returns
The Health and Care Act 2022 put ICSs on a statutory footing, ending the competition rules of the 2012 Act. But despite structural changes, waiting lists are at record highs and the NHS workforce is under severe strain.
The “Three Shifts” in Fit for the Future – Familiar Ground?
1. From hospital to community
The plan’s vision for a “Neighbourhood Health Service” aims to bring care closer to home. This echoes policies from 1990 onwards, including the 2006 Our Health, Our Care, Our Say white paper and the 2019 Long Term Plan. The barrier then, as now, is the lack of funding and workforce incentives to make community care viable alongside hospital provision.
2. From analogue to digital
A single patient record, expanded NHS App features, and AI-assisted clinical workflows form the plan’s digital promise. These build directly on decades of NHS IT ambitions, from early projects like NHSnet to the digital goals of the 2019 Long Term Plan. The challenge will be moving from pilot projects to nationwide adoption — and ensuring interoperability between systems.
3. From sickness to prevention
Prevention has been a political priority since the early 1990s, but often ends up the least developed part of policy. Tobacco restrictions, junk food advertising bans, and genomics services are part of Fit for the Future, but without sustained investment and social care alignment, prevention risks remaining a slogan.
Structural Changes – Can Competition and Collaboration Coexist?
The operating model in Fit for the Future blends market-style reforms (patient choice, provider autonomy, performance-linked funding) with integrated system planning through ICSs.
This creates a tension: can the NHS drive competition between providers while also expecting them to collaborate on shared population health goals? History suggests these dual aims can send mixed signals, making local delivery more difficult.
The Implementation Gap
Like many reform papers before it, Fit for the Future suffers from what could be called an implementation deficit:
Vague Timelines – Major pledges, like opening a Neighbourhood Health Centre in every community, lack clear start dates, annual targets, or completion goals.
Unclear Funding – The £29 billion investment headline lacks detail on timelines, whether it’s new money, and if it covers both existing pressures and transformation costs.
Workforce Uncertainty – With over 112,000 vacancies, the absence of a credible, costed workforce plan is a major risk. The hope that technology alone will offset staff shortages is optimistic at best.
Lessons from Past NHS Reforms
History shows NHS reforms succeed when:
Funding is sustained (as in the 2000s, when waiting times dropped dramatically).
Political leadership is stable and aligned across government departments.
Clinicians and managers are engaged in shaping changes.
They fail when:
Funding is squeezed.
Large-scale reorganisations distract from service delivery.
Workforce shortages go unaddressed.
Social care is neglected — a recurring problem that undermines hospital discharge and community care capacity.
Recommendations to Make Fit for the Future Work
Prioritise stability over constant reorganisation – Give Integrated Care Systems the time and space to mature.
Commit to sustainable funding – At least match the historic 3.7% annual real-terms growth needed to maintain standards.
Build the workforce first – Address retention, pay, pensions, and working conditions before promising expanded services.
Fix social care – Without a functioning social care system, hospital pressures will remain high.
Test before scaling – Pilot new models in selected areas, evaluate rigorously, and expand only what works.
Final Thoughts
Fit for the Future has big ambitions: closer-to-home care, digital transformation, and a stronger focus on prevention. But ambition alone isn’t enough. Without concrete timelines, sustainable funding, workforce planning, and social care reform, this could become yet another chapter in the NHS’s long history of reform fatigue.
For the plan to succeed, we must break the cycle of overpromising and underdelivering — and instead, focus on steady, evidence-based, and fully funded change.
Because in the NHS, as history shows, the more things change, the more they risk staying the same.