Taking the bait - has the government choked on health reform?

There was a watershed moment in UK health policy thinking before the election. The most comprehensive collection of reform proposals since the NHS's founding was presented to the government-in-waiting.

Today was the test. Would Keir, Rachel and Wes take the bait?

The convergence of thinking across diverse organisations early last year suggested genuine potential for sustained, cross-party commitment to health system reform. It's just what our poor health system needed, a bit of grown-up consensus-building.

I sat on several of these commissions. It was striking how a consensus built around these major themes.

• Economic framing: Prevention as an investment, not a cost (IPPR, Milken Institute, Demos)
• Localism: Devolve power and resources to communities (Reform, Demos, The King’s Fund)
• Data-driven accountability and patient-engagement: Transparency in spending and outcomes (Demos, The King’s Fund, TBI)
• Structural NHS reforms: Shift from acute to community care (SMF, The King’s Fund, IPPR)

And how the same policies kept recurring: for instance, digital neighbourhood health centres in every community, a national health metric akin to GDP, investment in GLP-1s, and levies on tobacco, alcohol and unhealthy food to fund prevention.

CSR - the results

Several core foundational recommendations get a big nod from the Chancellor in the Spending Review 2025. Especially digital transformation, prevention, shifting care to community, and workforce expansion. A very big nod. Warm words. Jazz hands. But not more than that.

The overall picture is bitterly disappointing. #SR25 prioritises stability over transformation, with modest increases for key services and heavy reliance on efficiency savings.

Despite a huge engagement exercise, a big £20bn top-up last year and a 3% settlement this year, ambitious proposals that might move the needle of the nation's health are ruled out. It was the dustbin for anything requiring systemic overhauls, universal entitlements, fiscal or regulatory interventions, social infrastructure investment, a prevention-first pivot or re-writing the social contract on health. In other words, anything brave or effective.

The watchword is ❌ no change.

⚠️ Resource shift to a "Health Creation" model: Requires systemic shifts in NHS spending from treatment to prevention, which conflict with ambitious productivity targets focused on acute care

⚠️ Harm levies on unhealthy products: Only tobacco cessation is funded. No new "sin" taxes or levies on alcohol, ultra-processed food, social media, gambling, etc to tackle the addiction economy, or to raise money for abatement services.

⚠️ Radical social care overhaul: The £4 billion uplift focuses on "making the most of existing resources", suggesting limited scope for transformative change

⚠️ Community-based prevention models: Some devolution is included, but not as radical as some think tanks proposed. The SR25’s centralised Growth Mission Fund and reliance on mayoral structures shows what government thinks of grassroots innovation

⚠️ Patient empowerment initiatives: Digital transformation is included, but not all specific patient empowerment tools such as digital health passports

⚠️ Universal free school meals: Only partially included for children with parents on Universal Credit. The childcare expansion aligns with think tank proposals but may struggle to meet demand if provider capacity or workforce shortages are not addressed

⚠️ Cross-government health strategy with cabinet-level committee: Not explicitly established. Prevention is a theme but not institutionalised at cabinet level. The PM is not engaged

⚠️ Prevention-first fiscal framework: Not introduced. Prevention is funded, but not structurally embedded in budgeting. No big settlement around obesity.

📉 The stark story is that the NHS’s 2 percent annual productivity target (£17 billion savings over three years) assumes significant efficiency gains from existing budgets. This will shut the door on new prevention initiatives.

But this is not the end of the story.

There is plenty that could be achieved within these funding limitations, workforce shortages and fragmented system in the NHS Ten Year Plan later this month. I would like to see basic secondary prevention prioritised. That means catching up on vaccination rates, restoring screening targets and showing more ambition for population health.

But to really move the needle, we have to go beyond the NHS.

Here is a handy list (clue ... social contract, outcomes data and incentives are the most important):

✅Re-writing the social contract. Giving taxpayer-patient-voters more agency over their health; working with communities to improve environments; and asking individuals for more responsibility for their behaviours.

✅ Integrated data around determinants, outcomes and incentives: Link NHS records with housing, education and welfare data to proactively address root causes of ill health. Publicly track metrics like smoking rates, childhood obesity and mental health referrals to ensure accountability. Put outcomes at the heart of incentives.

✅Local Health Levies: Empower local authorities to pilot health impact charges on businesses contributing to health harms, such as fast-food outlets near schools, with revenue reinvested in preventive services

✅ Social Impact Bonds: Partner with private investors to fund preventive interventions such as childhood obesity programs, with returns tied to measurable health outcomes

✅ Social Prescribing Expansion: Mandate that 20 percent of GP appointments focus on non-clinical interventions such as exercise programs and financial advice by 2030

✅ AI-Powered Risk Stratification: Use the NHS’s £10 billion digital transformation fund to deploy AI tools identifying high-risk populations such as pre-diabetic patients for targeted interventions

✅"Health Creation" Hubs: Co-locate GP practices with job centres, debt advisors, and community kitchens in the 20% most deprived areas, funded by repurposing NHS estates.

🚨 The NHS is going to struggle to stay afloat. The best assessments, reflected in OBR forecasts, predict more sickness, more disease, more people on benefits, more pressure on the workforce, more appointments needed.

More of the same is not an option. If we do not bend the curve on our rising disease burden, we risk collapsing public confidence, melting down national finances, compromising national security and blighting our children’s futures.

Key contributors now in government: Sally Warren Warren (Director General, 10 Year Health Plan, DHSC) Christopher Thomas Thomas (likely policy lead, IPPR) Axel Heitmueller Heitmüller (policy and data strategy), Paul Corrigan (strategic adviser, DHSC) and Tom Kibasi Kibasi (Senior advisor to the Secretary of State).

Think tanks and commissions referenced: IPPR Social Market Foundation The King's Fund The Times Demos Re:State Tony Blair Institute for Global Change Nuffield Trust Centre for Policy Studies Milken Institute Health The Health Foundation Simon Radford

#SpendingReview2025 #HealthPolicy #NHS #PublicHealth #PreventionFirst #DigitalHealth #SocialCare #HealthInequality