Like many others, I have been waiting with eager anticipation for the NHS Ten Year Health Plan. A plan that promised to transform healthcare in England with a health service “fit for the future”, says Christus Ferneyhough, Public Health Registrar ST3
While the plan champions a shift from hospital to community care, embraces digital transformation, and (very welcomely) stresses the importance of prevention, there are notable gaps and potential pitfalls that could hinder true progress, particularly in addressing the persistent and widening health inequalities across the country.
Having discussed the plan with public health colleagues, the overwhelming feeling towards it seems, well, rather underwhelming. We all recognise the difficulties and challenges in developing a plan as important as this. It could certainly be worse, but it could also be much better.
I’ve structured this blog into sections of the good, the bad, and the ugly (still a movie I’ve never actually seen). Each section is prefaced by the words ‘some of’. The reason being is twofold. First, I’ve written this based on what I’ve read, which at this point, admittedly, is not all 168 pages in detail. With that, there may well be brilliant or terrible things I’ve omitted. Secondly, there’s a lot to talk about, much of which will be important for some but less so for others.
Some of the good
Improving access to healthcare is a good thing. Neighbourhood Health Centres could bring diagnostics, post-operative care, and rehabilitation into local areas, reducing the need for hospital visits and the barriers that come along with that. Then there’s primary care – often the marker of what people think about when it comes to healthcare. Everyone wants it to be easier to see a GP – so plans to do just that are very welcome.
The plan also commits to addressing bottlenecks in medical training by creating 1,000 new specialty training posts over the next three years, focusing on areas with the greatest need – I wonder if public health is one? Regardless, this is a step towards ensuring a more robust and adequately staffed public health and healthcare workforce for the future.
With the success of the existing Soft Drinks Industry Levy (SDIL) in driving reformulation and reducing total sugar sold in soft drinks since its introduction, the commitment to uplift the rate and explore expanding its scope to include milk-based drinks and reducing minimum sugar thresholds demonstrates a willingness to strengthen a proven public health intervention. In a similar vein, banning the sale of energy drinks to under-16s is the type of intervention that directly addresses a source of sugar intake among young people which contributes to obesity and oral health. These are strong evidence based public health interventions that I would have loved to have seen more of.
In a “world-first,” the plan commits to introducing mandatory healthy food sales reporting for all large companies in the food sector. This initiative is designed to establish a “robust baseline” for future policies and improve transparency in the food industry. By using this data to set new mandatory targets on the average healthiness of sales, the plan aims to drive reformulation and encourage companies to offer healthier products across their portfolio. This is a potentially powerful mechanism for shifting the food environment towards healthier options on a large scale. This is based on a policy developed by Nesta, whose modelling on retailers suggests that this single policy could reduce obesity by around a fifth, helping over three million people reach a healthier weight. Again – I was very happy to see this.
I also liked the commitment to fairer distribution of funding – by providing extra funding to areas with disproportionate economic and health challenges. It demonstrates a recognition that achieving health equity requires proactive and differentiated funding strategies. That said, details of how this will be done and what metrics will be used are not included in the plan itself.
Some of the bad
One striking omission in a plan aiming to redefine the nation’s health is the absence of a dedicated chapter on health inequalities. Apparently, a full chapter was written, but did not make the final draft. If that is true, it was a bad decision.
The word ‘inequalities’ appears 20 times in the plan and there is the stated ambition to “tackle inequalities in both access and outcomes“. But despite this, there is no blueprint or explanation as to how and why inequalities will be reduced. It feels somewhat tokenistic. So much so that the great Michael Marmot is cited briefly, acknowledging that social determinants explain our countries wide and widening health inequalities. But simply acknowledging the problem is not enough. We need that chapter. We need clear direction. In its absence the plan just nibbles tentatively around the edges of a deep-rooted systemic problem that is worsening.
Furthermore, some aspects of the plan, while well-intentioned, could inadvertently exacerbate existing inequalities. The emphasis on “digital by default” and moving as much as possible to the NHS App, risks leaving behind individuals with lower digital literacy, limited internet access, or those who prefer in-person interactions. For some, the shift from analogue to digital could create new barriers. And it is likely that those ‘some’ are some of the most disadvantaged and vulnerable groups in society.
One of the three shifts perhaps most pertinent to those like me working in public health, is that of sickness to prevention. We love prevention. We want to look upstream and address the ‘causes of the causes’.
Unfortunately, I can’t help but feel that the plan’s interpretation of ‘prevention’ lies heavily on screening and vaccination. While undeniably crucial for public health, these are often categorised as secondary prevention – detecting and acting on early signs of disease. The focus on conditions like cancer and cardiovascular disease through genomic testing and earlier diagnosis is valuable, but it overshadows the deeper, systemic issues and societal conditions that drive ill-health in the first instance.
True primary prevention, which tackles the root causes of poor health like poverty, poor housing, and limited access to healthy food, receives less concrete strategic attention, despite being acknowledged as critical for long-term sustainability (and are akin to Marmot’s work on the social determinants of health mentioned above).
There are some positive commitments within this chapter which will undoubtedly benefit public health. But many are nothing new, are already underway, or have already been announced. For example, the Tobacco and Vapes Bill, restricting junk food advertising, the Soft Drinks Industry Levy (although the uplift is very much welcomed). Although strong interventions, none of these are new.
Some of the ugly
When I read these words, red flags were raised.
“Danone has committed to never introducing a high fat, salt or sugar product targeted at children. Sainsbury’s run a ‘Great fruit and veg challenge’, where customers can win bonus Nectar points by shopping for fruit and vegetables, as well as offering £3 off fruit and vegetables as a weekly top-up for very low-income customers during key holiday periods. Jaguar Land Rover has established wellbeing centres for its staff, alongside an enhanced mental health offer. Apple is helping us track health information.”
For-profit companies are inherently driven by increasing shareholder value and market share. While some of their initiatives might align with public health goals these are often strategic moves that also benefit brand image, customer loyalty, or market position.
When the government forms private sector partnerships, there’s a risk that industry interests can subtly, or overtly, influence public health policy and priorities. This leads to less impactful, voluntary initiatives favoured by industry, rather than robust regulatory measures that are highly effective but less palatable to corporations. We’ve seen this happen repeatedly across industries such as food, gambling, tobacco, and alcohol.
A quick note on gambling – I was quite surprised to see the term ‘big bets’ used to describe five key technological investments. The term “bet” inherently suggests risk, chance, and the possibility of failure, and I found it quite odd to associate healthcare with terminology of the gambling industry – an industry that is incredibly harmful to health.
The plan announces, “we will also work with the Great Run Company to set up a campaign to motivate millions to move more”. Even if we look past the well-established fact that mass media health campaigns have very little impact on population health behaviour, can be very expensive, and can even do more harm than good – particularly when it comes to stigmatising individuals, there is another concern.
You can imagine my joy when I clicked on the Great Run Company’s list of partners, which includes businesses from airline (Tui), car (Nissan), financial (AJ Bell), and food (Greggs, Arla) industries.
I have no doubt that the intentions of the Great Run Company are to encourage people to be more active and the events they put on facilitate that for many (not all). But the core business of Greggs involves selling products that are high in fat, sugar, and salt, which directly contributes to the very obesity epidemic that the plan aims to combat. The core business of Tui is air travel, a significant contributor to carbon emissions and air pollution, which sort of contradicts the plan’s ambitions of “cleaning up our air”. The core business of AJ Bell is managing investments, with its success tied to market performance. It is inevitable that their portfolio will include investments in various sectors that may indirectly or directly contribute to ill-health – for example, industries involved in the production of tobacco, unhealthy foods, gambling, alcohol, and fossil fuels. These industries are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity.
Therefore, the plan’s statement that “it will be by working with these partners that we will make all our efforts more than the sum of their parts” seems to overlook the potential for these partnerships to actively work against public health goals due to their conflicting interests.
Conclusion
Ultimately, for the NHS to truly be “Fit for the Future” it needs to move beyond rhetorical flourishes, the re-packaging of existing initiatives, or campaigns that shift responsibility onto individuals. It must confront the systemic drivers of ill health that Marmot has brilliantly articulated for years, invest comprehensively in proper primary prevention -not just screening and vaccination, and ensure that all partnerships align with, rather than undermine, core public health principles. For this, we need a clear legislative pathway that transforms our systems, structures and environments from ones that fuel ill health to ones that champions good health, ensuring equitable access to healthcare and opportunities to live well, regardless of postcode or income. I hope when the plan is delivered, this comes to fruition.