Summary

The NHS has a healthcare budget that represents c.11% of GDP.

Managed the COVID-19 pandemic, record levels of inflation and industrial action from multiple staff groups.

Mortality rate in England has fallen every year since the peak during the COVID-19 pandemic.

Delivered record numbers of general practice appointments with 369 million appointments (12 months to February 2025).

Operationalised urgent community response teams giving 720,000 people with an alternative to going to hospital in 9 months.

A&E attendances are +6.9% higher in 12 months to January 2025 compared to same period in 2024.

Cancer survival in England is at an all-time high.

Doubled the number of community diagnostic centres (CDCs) from 77 to 170 in less than 2 years.

Successfully implemented Martha’s rule in 143 acute providers.

Established more than 110 elective surgical hubs.

Rolled out 24/7 all-age mental health crisis lines.

Created more than 12,000 virtual ward ‘beds’ from a baseline of 0, allowing patients to receive hospital-level care at home.

Delivered a break-even position across the NHS, and improving productivity growth year on year since 2019/20.

Sequenced over 125,000 whole genome equivalents.

Procured the Federated Data Platform with 27 ICBs and 90 trusts signed up in November 2024.

Exceeded NHS App targets – with over 34 million users, 17.4 million record views and 4.9 million repeat prescription orders in December 2024.

Mobilised the Long Term Workforce Plan which is the most ambitious, far reaching workforce plan ever developed for the NHS.

Established the new NHS England as a streamlined organisation, 35% smaller than legacy organisations combined and resulted in £500 milliom being released to support frontline services.

Defined the framework for improvement across the NHS through the NHS Improving Patient Care Together (IMPACT).

Context

1. The mission of NHS England is to deliver high quality healthcare for all, train and support NHS staff and to deliver value for money for taxpayers. We share, with the Secretary of State for Health and Social Care, the legal duty to promote a comprehensive health service in England. We set the national direction, allocate resources, ensure accountability, and define the national strategy for supporting and developing people, making the NHS a great place to work.

2. The NHS is a large and complex system. It is one of the world’s biggest employers with over 1.5 million members of staff, delivering around 1.7 million patient interactions every day, with healthcare budget that represents c.11% of GDP and delivers a number of large scale national digital channels – including the UK’s biggest health website and the NHS App which has twice as many users as Netflix in England.

3. This is a large and increasingly complex task. Rising demographic pressures and a changing burden of disease are increasing demand for NHS services. Since 2011, the population has grown by 11%, with growth in people over 65 of 28%. An ageing population is a significant driver of increased healthcare needs as it is associated with the development of long-term conditions. With patient needs changing as a result of increasing levels of multimorbidity and frailty, the complexity of service delivery increases in step with this.

4. An ageing, frailer and more complex population is increasing the costs for care, as well as medicine and technology being increasingly able to deliver more – which comes with additional costs. For example, older people with frailty and dementia account for only 1.3% of the population but per capita use ~40 times the acute resources of a generally well older person.

5. This trend is set to continue. Over the next 15 years, the population of England is projected to increase by 4.2%, but the number of people aged over 85 will grow by 55%. By 2037, unless more is done to moderate current trends, two-thirds of those over 65 will have multiple health conditions and a third of those people will also have mental health needs.

6. In addition, trends for some risk factors are going in the wrong direction. Rates of childhood obesity in England have risen sharply in recent years, alcohol-related deaths are increasing, and physical activity levels are lower than in the past. We have seen sharp increases in mental health needs – particularly in children and young people.

7. Poverty has continued to deepen as a result of the cost of living crisis. Whilst the proportion of children living in poverty fell from 31% to 27% between 2007 and 2010, it has been steadily rising since then. 30% of children are now living in poverty according to the Joseph Rowntree Foundation’s UK Poverty 2025 report.

8. The NHS since its inception has grown and evolved to meet changing needs – and changes to its role and structures – reflect the growing complexity of need. But we know that good health depends on a broader set of factors beyond health care, like income, employment, housing, and the range of public services on offer. Over the last decade, people’s diets now incorporate more sugar and ultra-processed foods, and daily lives have been changed through increased use of social media.

9. In the last 5 years, short-term challenges have added further complexity to the operating environment of the NHS, including managing:

• the COVID-19 pandemic, with a peak of 1 in 13 people infected in England in March 2022. The pandemic, recovery from it and the additional ongoing major winter pressure the virus puts on the system – over and above usual seasonal illnesses – has been significant
• the highest inflation rates in a decade – inflation soared in 2022 hitting 11.1% in October 2022, which was the highest rate for 40 years. It remained above the 2% target contributing to a £2.3bn increase over funded levels in operational costs for the NHS over 2022/23 and 2023/24
• unprecedented levels of industrial action including by resident doctors between December 2022 and July 2024 resulted in over a million staff days lost as well as almost 1.5 million rescheduled appointments
• substantial legislative changes and organisational re-structure, including the transition from 220 clinical commissioning groups (CCGs) to 42 integrated care boards (ICBs) as a result of the 2022 Health and Care Act
• establishing the new NHS England as a single, streamlined organisation, building on the strengths and expertise of its legacy organisations (NHS Digital, Health Education England and NHS England), while avoiding duplicate activities. The organisation is 35% smaller that the legacy organisations combined and resulted in £500 million being released to support frontline services. This included NHS England:
  • assuming responsibility for planning, recruiting, educating and training the health workforce, and leading work to ensure it has the right numbers, skills, values and behaviours in place to support the delivery of excellent healthcare to patients and the public
  • becoming the custodian of national health and social care datasets and the single executive non-departmental public body with responsibility for digital technology, data and health service delivery in the NHS
• significant political changes (including 6 secretaries of state and 4 prime ministers) and a general election leading to a change of government.

10. The NHS entered the COVID-19 pandemic after a period of austerity in the decade before with the 2010s being the most austere decade since the NHS was founded.

• over the last 5 years overall NHS England funding has grown broadly in line with historic trends, with 3.5% average annual real terms growth between 2019/20 and 2025/26 on a like for like basis (including the COVID-19 period)
• the pattern of and drivers of growth have been unusual though, with the COVID-19 pandemic driving a 14% real terms increase in expenditure in 2020/21, followed by negative or much reduced growth in the subsequent 2 years as the NHS has been expected to recovery productivity and make internal efficiencies
• in 2024/25 the combination of significant pay reforms to consultants and resident doctors, plus additional funding for additional elective activity has increased spending alongside a further stretching challenge to improve underlying performance
• relatively lower growth and/or high levels of efficiency requirement in the years from 22/23 to 25/26 have challenged systems and providers to strip out the additional costs they incurred during and after the COVID-19 pandemic. The result has been some organisations operating with a deficit in 22/23, growing into 2023/24 (net system deficit £0.6 billion 22/23 rising to £1.4 billion in 2024/25)
• although these overspends have been offset through underspends elsewhere in the overall NHS budget, a financial regime based on deficit support is not sustainable. Action to support system and provider financial improvement has been successful in reducing the net deficit in 2024/25.

11. Capacity in both physical infrastructure and workforce has been impacted by a decade of underinvestment. As a result, as Lord Darzi’s Independent Investigation stated, the NHS entered the pandemic with chronic underinvestment in its infrastructure. So now key constraints include:

• a £37 billion capital investment shortfall – which would have been invested if the NHS had matched peer countries’ levels of capital investment in the 2010s. That sum could have prevented the significant growth in backlog maintenance, modernised technology and equipment, and paid for the 40 new hospitals that were committed to. It could have rebuilt or refurbished every GP practice in the country (Lord Darzi review, 2024)
• this shortfall in investment also means buildings and equipment degrade over time which impacts productivity. For example the Health Foundation reported that maintenance backlog (the estimated cost of bringing NHS estates or buildings back to a minimum expected standard) more than doubled in real terms between 2015/16 (£6.4 billion) and 2023/24 (£13.8 billion), with the fastest growth in the highest risk category (urgent repairs to prevent catastrophic failure or disruption to clinical services). Since 2021/22, the backlog has grown by £2.1 billion. Over the same period, investment to reduce the backlog fell by £707 million in real terms, contributing to this growth
• fewer scanners than peer countries– the UK had 16.1 CT and MRI scanners per million head of population in 2019 – fewer than any of the 19 countries examined in a report by the King’s Fund in 2023. The US has 5 times as many scanners per person and Germany has 4 times as many. While there is no ‘right level of diagnostic equipment, too few scanners can lead to longer waiting times, and there have been recent moves to improve diagnostic infrastructure in the NHS.
• fewer nurses and fewer doctors per capita compared to peer countries, for example the UK, prior to the LTWP, had 8.7 nurses and 3.2 doctors per 1,000 population compared to 12.0 and 12.8 nurses and 4.5 and 4.0 doctors per 1,000 population in Germany and Australia respectively (2021 data)
• a 29% reduction in general and acute (G&A) beds (from 137,000 in 2001 to 96,000 in 2021)

12. An NAO report in 2023 found that the social care sector remains challenged by chronic workforce shortages, long waiting lists for care and fragile provider and local authority finances.

• demand for care services among working-age adults is growing quickly: the number of new requests for support from individuals aged 18–64 grew by 18% between 2014–15 and 2022–23 (more than three times faster than population growth for that age group) and the Association of Directors of Adult Social Services estimated that in England around 250,000 people were waiting for a care assessment in August 2023
• there is also significant pressure as a result of needs of children and young people growing for example as rates of assessment and diagnosis for ADHD and Autism have been growing

Social care constraints have put further pressure on the NHS – particularly impacting flow through acute and community hospitals, where an average of 13,700 beds per day were occupied by patients who are ready for discharge in February 2025.

Delivery record

14. To meet these challenges, NHS England worked with the government and the wider NHS to manage the pandemic, recover services, start to deliver reform and set the foundations for future transformation. Achievements include:

• managing the COVID-19 pandemic
• increasing activity, improving access and reforming the way care is delivered
• delivering better, more equitable outcomes and safer care
• improving productivity and financial management
• laying the foundation for future transformation

Managing the COVID-19 pandemic

15. Responding to COVID-19 (which was declared a level 4 national incident – the highest category of emergency on 30 January 2020) has placed extraordinary pressures on the NHS.

16. NHS England and Improvement initiated a rapid repurposing of NHS services, staffing and capacity to meet the expected surge in COVID-19 demand. Urgent actions were enacted to free-up the maximum possible inpatient and critical care capacity; prepare for, and respond to, the anticipated large numbers of COVID-19 patients who would need respiratory support; support staff and maximise their availability; stress-test operational readiness; and remove routine administrative burdens. Example impact includes:

• expanding critical care capacity by around 50% above their usual capacity, with some areas surging to over 80% above their usual capacity. At the peak of the pandemic in January 2021, around 4,000 COVID-19 patients were being looked after in critical care every day
• increasing Advice & Guidance services to enable secondary care provided clinical advice to support to primary care elective services. Annual activity increased from 647k in 2019/20 to 2.4 million in 2023/24. This transformation in practice was further accelerated in the Elective recovery plan – published in February 2022
• rapidly moving to implement innovative ways of delivering care for example rolling out COVID Oximetry @home and COVID virtual ward (CVW) models to allow identification of silent hypoxia and supported discharge of COVID inpatients respectively
• establishing 24/7 mental health crisis support phone lines nationally by May 2020 – one year ahead of target. By July 2020, almost 100% of Improving Access to Psychological Therapies (IAPT) appointments were delivered virtually
• recruiting into and delivery of clinical trials which have identified effective COVID-19 treatments, including use of dexamethasone, benefitting patients across the NHS and around the world
• being the first health service in the world to deliver the Pfizer and Oxford Astra-Zeneca vaccines outside of a research trial. NHS England and Improvement led the largest and most precise vaccination programme with the programme delivering 175 milliom vaccinations since December 2020, bringing hope to millions. Within 10 weeks of the first person being vaccinated, all people in the top 4 priority cohorts (c.12 million people) had been offered a vaccination. 

Increasing activity, improving access and reforming the way care is delivered

17. To support the recovery of service from the pandemic and to meet growing demand – in the context of constrained capacity – the NHS has stepped up activity and has gone some way to reform service delivery to meet population needs in a more productive way.

18. We have delivered record numbers of general practice (GP) appointments with 369 million appointments – excluding those for COVID-19 vaccinations – delivered in the 12 months up to January 2025, an additional 58 million appointments than before the pandemic. This includes 3 in 5 GP appointments delivered face-to-face, over half booked and attended on the same day or next day, and nearly 9 in 10 appointments attended within 2 weeks of booking (for appointments not usually booked in advance). The monthly results of the health insights survey shows that patient satisfaction has improved since the survey began with 75% of patients reporting that their overall experience of their GP practice was good.

19. This has been enabled by the actions committed to through the Primary care access recovery plan (2023) and more recent investment, which to date has:

• empowered patients through increased use of NHS App and other digital channels to enable more patients to access and book appointments (currently at 94.3%), see medical records including test results (84.1%) and manage their repeat prescriptions (98.9%), expand self-referral pathways and increase scope of role for pharmacies including being able to supply prescription medicines for 7 common conditions
• modernised general practice including moving all GP practices from analogue lines to move to digital telephony by May 2024, including call back functionality which has enabled effective triage and call-redirection
• built capacity including 36,000 additional direct patient care roles compared to 2019
• cut bureaucracy including streamlining the Investment and Impact Fund (IIF) from 36 to 5 indicators – re-target £246 million – and protect 25% of Quality and Outcomes (QOF) clinical indicators and taken forward the Red Tape Challenge to improve the interface between primary and secondary care, specifically for onwards referrals, complete care (fit notes and discharge letters), call and recall, and a point of contact for clinicals
• enabled primary care networks (PCNs) to recruit more than 1,000 GPs via Additional Roles Reimbursement Scheme (ARRS) through additional £82 million funding

20. Urgent and emergency care (UEC) pathways have been busier than ever – A&E attendances are +6.9% higher in 12 months to January 2025 compared to 12 months up to January 2020 and emergency admissions are 0.7% higher. The target of 95% of patients waiting 4 hours or less in accident and emergency (A&E) has not been met since 2015 as services experience growing pressure from rising demand and capacity constraints across the health and social care sector. Since 2010/11, the number of people accessing UEC services has risen by 90%, and the number seen by the ambulance service has risen by 61%.

21. Winter continues to be a challenging period for the NHS. In winter 2024/25, there were 13,000 admissions and 25,600 attendances at A&E for influenza-like illness. Although the NHS delivered more flu vaccinations this year than last year (18.35 million doses), and a high proportion of older people took up their flu vaccination, vaccination rates for other at-risk groups and health and care workers have declined.

22. Despite these pressures, there has been some improvement in A&E 4 hour performance and Cat2 ambulance performance – although access is still not nearly where it needs to be, and 12 hour performance is particularly challenged. A&E performance is better than same point last year, 73.0% in January 2025, compared to 70.4% in January 2024 whilst Cat 2 mean response time is 35:40 in January 2025, compared to 40:06 in January 2024. The Delivery plan for recovering urgent and emergency care, delivered from April 2023 drove key reforms that have enabled this stabilisation and gradual improvement in performance including:

• meeting the target of 5,000 additional core general and acute beds, against previously planned levels
• ensuring all hospitals have a care transfer hub, which works across the NHS and social care to manage discharges for patients with more complex needs
• operationalising system co-ordination centres in all areas of the country to help hospitals and other services have the right capacity in the right places
• continuing to build up new services in the community, which can provide an alternative to ambulance call-outs or trips to hospital – including consistently exceeding the standard for 70% of requests for an urgent community response (UCR) to receive one within 2 hours (at 84% in November 2024). New models of directly diverting 999 calls from the ambulance stack to UCR teams are also being deployed. These teams provided 720,000 people with an alternative to going to hospital between April 2023 and January 2024
• officially launching Pharmacy First on 31 January 2024 with uptake faster and broader than planned, with 98% of pharmacies now signed up with 1.7 million consultations taking place in the first 10 months
• creating almost 12,000 virtual ward ‘beds’ allowing patients to receive hospital-level care at home, with 73% of this capacity used in March 2024 – the equivalent of 20 hospitals’ worth of beds
• standardising operations of same day emergency care services, with all hospitals with major A&Es now operating one and 84% of them operating for over 12 hours a day/7 days a week, enabling people to avoid an overnight admission where this is not necessary

23. These steps have been important foundations. In January 2025, NHS England published neighbourhood health guidelines for 2025/26, outlining the priority areas and objectives for moving towards a neighbourhood health service. This is a stepping stone ahead of the 10-Year Plan and there is a focus on the role of neighbourhood teams in urgent care, management of conditions and demand – drawing together much of the shift in care delivered achieved to date. It lays the groundwork for a more ambitious focus on healthier communities, proactive and preventative care and tackling health inequalities.

24. The NHS has made significant improvements on long waits for elective care caused by the pandemic. NHS England’s ambition, agreed with the government, to eliminate almost all waits of more than 2 years by July 2022 was achieved and 78 week waits and 65-week waits have been bought down by 98% and 93% respectively from their peaks – now at c. 2000 and 15,5600 at March 2024. In addition, the number of people waiting over a year for treatment has reduced by 50% and the waiting list has reduced consistently over the last 5 months. This has been achieved through:

• successfully delivering an offer of alternative choice to 400,000 long waiting patients to receive earlier treatment which commenced in October 2023
• agreeing £1.5 billion capital funding as part of the Targeted Investment Fund with £537.3 million drawn down in 2022/23 and £509 million in 2023/24
• establishing more than 110 elective surgical hubs in England, with more planned over the next 3 years. Supported by GIRFT day case surgery rates exceeded national targets, consistently achieving 88% by year-end
• establishing 170 community diagnostic centres (CDCs) by March 2025 that have cumulatively delivered 8.54 million tests since the first CDC opened in July 2021, with locations selected with a consideration of accessibility and addressing inequality and deprivation
• incentivising the NHS to achieve 119% value weighted activity levels (including advice and guidance) in the 6 months to November 2024, compared to pre-pandemic levels through an Elective Recovery Fund (ERF)

25. To meet the government’s mandate to achieve 65% RTT within 18 weeks in 2025/26, considerable effort and focus will be needed as performance is currently at 58.9% in January 2025. We have set out what will be required in the plan for ‘reforming elective care for patients’ including focus on empowering patients, reforming delivery by working more productively, consistently and in many cases differently, delivering care in the right place and aligning funding, performance oversight and delivery standards.

26. Despite growing levels of demand, with cancer referrals doubling from 1.6 million in 2013/14 to 3.2 million in 2024, we have also recovered the number of patients waiting >62 days on the cancer pathway to pre-pandemic levels. Progress has also been made in recovering performance against the existing Cancer Waiting Times Standards, alongside the introduction of a new constitutional standard, 28 day Faster Diagnosis Standard. In relation to this standard, performance is on track to exceed the target of 77% by March 2025, having improved to 78.1% in December 2024 from 74.1% in December 2023.

27. The mental health sector continues to transform and grow services across the country, within the context of continuously rising prevalence. In 2023/24, 5 million people were in contact with NHS mental health, learning disability and autism services, compared to 4.8 million contacts the year before, and 4.1 million contacts in the pre-lockdown year of 2019/20. By February 2024, approximately 52% more children and young people (CYP) had accessed support since 2019/20. To meet increased demand, the NHS has:

• rolled out 24/7 all-age mental health crisis lines, now receiving 220,000 calls every month
• increased access to NHS Talking Therapies with 1,200,000 people starting treatment in 2022/2023 (compared to 950,000 in 2016/2017)
• established specialist community perinatal mental health services in all parts of England, which saw 58,300 women in 2023/2024
• established 37 new dedicated mental health services for rough sleepers
• ensured 361,210 people living with severe mental illness received a full annual physical health check in the year to March 2024, compared to 159,312 checks delivered in 2019/20

28. Demand for autism assessments has risen rapidly over the past 20 years. New autism referrals have risen sharply since April 2019, even without additional funding, the NHS has stepped up activity, though the gap between demand and supply is very substantial. The NHS closed an estimated 6,800 referrals in December 2024, compared to 4,850 in December 2022; it closed an estimated 100,000 in the last 12 months compared to c. 20,000 in 2019/20 full year.

29. NHS England has produced a national framework to deliver improved outcomes in all-age autism assessment pathways that sets out general principles to be applied during the commissioning cycle for an autism assessment offer in each area of the country.

30. NHS England’s Transforming Care Programme is focused on improving health and care services for people with a learning disability or autism. Progress includes ensuring 255,145 people with a registered learning disability (77.6% of the eligible population) had received an annual health check, exceeding the 75% national commitment as of Mar 24. 75% also had an accompanying health action plan, compared with 64% in February 2023. There has been a strong focus on reducing inappropriate inpatient stays for people with a learning disability and people with autism, with a 29% decrease since 2015 though there is much further to go here. National investment of £121 million in 2023/24 supported delivery of services, including Care (Education) and Treatment Reviews, community infrastructure and key workers for children and young people. Keyworker services for autistic children and young people at risk of admission to, or in a mental health hospital are now operational in all ICB areas. By the end of 2023/24 keyworkers had supported over 2,600 children and young people.

31. In maternity, the 3-year maternity improvement plan has focused on improving outcomes and reducing inequalities for women. Although we know there is more to do to improve, particularly for women from ethnic minorities and those who experience health inequalities particularly through deprivation, early steps include:

• a record number of midwives are now in post, with 24,403 FTE midwives substantively employed as of October 2024 – an increase of over 10.29% (+2,276) since March 2023
• the neonatal nurse workforce has also seen substantial growth, rising from 6,486 in March 2023 to 7,182 FTE in October 2024
• NHS England are developing the Maternity Outcomes Signal System. This tool monitors trends in near-real time to identify potential declines in the safety of care during labour, enabling timely actions to reduce harm. A version is currently being piloted in each region
• NHS England developed the Saving babies’ lives care bundle (SBLCB), which has been implemented to reduce variation and improve care standards. As of April 2024, 87% (104/120) of services were compliant with SBLCBV3
• to increase and align neonatal cot capacity, £45 million in capital funding has been allocated over 3 years, resulting in an overall increase of more than 50 cots, with 10 cots already operational
• 86% of trusts now provide 7-day bereavement services, up from 70% in July 2024
• over 200 staff from Black and Asian minority ethnic backgrounds have been supported in developing leadership skills to increase the diversity of maternity leadership teams

Delivering better, more equitable outcomes and safer care

32. Overall mortality rate in England has fallen every year since the peak during the COVID-19 pandemic – and we have improved quality and outcomes. This has been achieved in part due to focused efforts to improve prevention of ill health, make care safer, access new technologies and medicines, and target health inequalities.

33. Cancer survival in England is at an all-time high due to the speed and scale of advances in diagnosis and treatment across the NHS. 1-year survival for those diagnosed in 2020 at 74.6% and 5-year survival for diagnosis in 2016 at 55.7%. Early diagnosis rates also are 2.4% above pre-pandemic levels. Key actions have included:

• targeted interventions such as the Targeted Lung Health Check (TLHC) Programme which helps to find cancers in those most at risk by offering checks in the local community. Since April 2019 more than 1.5 million people have been invited for a check and over 3,600 lung cancers have been diagnosed – three quarters at stage 1 or 2. The Rapid Cancer Registration Dataset shows that people from disadvantaged areas are now most likely to be diagnosed with lung cancer early
• screening: in 2022/23 we sent out 4.6 million invitations for cervical screening and almost 3 million women were invited for breast screening in 2022/23 and over 2 million women came forward for their mammogram. The phased extension of faecal immunochemical test (FIT) kits to over 50s, a national bowel cancer screening campaign aimed to increase the number of people returning a completed bowel cancer screening home testing (FIT kit) and the introduction of a more user-friendly test have helped to increase coverage to a record 72% as of March 2023
• referral pathways: in July 2023, the first small scale pilot of a direct referral route from community pharmacy started in Cornwall, and projects in other alliances are now underway
• innovation: NHS England’s Innovation Open Call is providing financial backing to exciting new technologies to support the early diagnosis of cancer. These include DERM (Skin Analytics) – an AI tool used to diagnose or rule out skin cancers; and Endoscope-I – a smartphone adapter that can turn an iPhone into diagnostic equipment for head and neck cancers

34. Heart, lung and liver disease: NHS England has prevented ill health through delivery of key programmes including:

• over 1.6 million referrals have been made into the NHS Diabetes Prevention Programme. Independent evaluation has found people who complete the programme reduce their risk of developing type 2 diabetes by 37%
• the NHS Type 2 Diabetes Path to Remission Programme is now available across England and over 25,000 referrals have been made. Early data indicates on average participants lose 13.4kg in 3 months and 50% put their type 2 diabetes into remission
• over 375,082 referrals have been made into the NHS Digital Weight Management Programme since launch in April 2021
• opening 30 complications from excess weight clinics, which take a holistic approach to treating conditions related to obesity in children and young people
• treating more people with lipid lowering therapy, with 62.1% of people with a high-risk score being treated in in March 2024, achieving 2023/24 Operational Priorities and Planning Guidance targets
• 7 in 10 hypertension patients in England being managed to target in March 2024 (representing a 3% improvement to March 2023)
• launched alcohol care teams in 47 hospitals with the highest needs, with an increase of 241 WTE specialist staff working across these sites

35. The NHS has also been at the forefront of therapeutic innovation ensuring patient access to clinically and cost-effective new treatments and technologies including:

• being world leading in genomics and making continual advances in genetic testing:
  • the NHS Genomic Medicine Service has sequenced over 125,000 whole genome equivalents (WGE) since the inception of the Whole Genome Sequencing Service in November 2021, and this consists of more than 21,000 cancer genomes and more than 104,000 rare disease genomes
  • the National genomic test directory currently includes genomic tests for 7,000 rare and inherited diseases and over 200 cancer clinical indications. Since 2018 there have been over 350 changes to the National genomic test directory, including 12 directly in response to industry led innovative newly licensed precision medicines, as well as over 2,500 changes to clinical indications following the use of Panel App
  • in 2024, the NHS Genomic Medicine Service delivered over 810,000 genomic tests for patients across the life course in England. This has continued to increase year-on-year since the NHS Genomic Medicine Service was established, and increased by 8% compared to 2023. Examples include the roll out national genetic test to reduce risk of donor kidney failure for people from Black African and Black Caribbean heritage
  • the National Genomic Research Library (NGRL) has also been initiated and populated to enable approved researchers to access de-identified genomic data, health data and samples
• setting up new services, for example the roll out of up to 6 new specialist centres by 2026 to provide tailored gender services for children and young people, based on recommendations in the Cass Review
• finding and delivering a range of savings opportunities for NHS medicines, including through the rapid adoption of lower cost generics and new biosimilars, creating the financial headroom for the health service to commission cost-effective advanced therapy medicinal products (ATMPs), including personalised gene therapies

36. The scale of the NHS commercial sector is huge. We are one of the biggest commercial organisations in the country, responsible for around £30 billion of spend every year, with over 80,000 suppliers. We are the largest area of government procurement spend, fulfilling 8 million orders annually.

37. NHS England has leveraged this scale to continue to drive value for money access to medicines and therapies such as:

• direct oral anticoagulants (DOACs) – since January 2022 around 460,000 more people have started taking anticoagulant drugs with more than 24 million prescriptions given to patients – preventing an estimated 17,000 strokes and 4,000 deaths
• CAR-T, or chimeric antigen receptor T-cell therapy, which is a potentially life saving treatment for some types of B-cell lymphomas
• the first-ever therapy for Wolman disease, a life threatening genetic condition in babies and children under the age of 2
• new combinations of treatment for advanced womb cancer that between 500 and 750 women a year would benefit from

38. The NHS patient safety strategy launched in 2019 with a target of saving 1,000 additional lives and £100 million annually. Enhanced patient safety initiatives include landmark new ways of delivering care are:

• roll out of Martha’s rule in 143 acute providers to date – with early data showing that 1 in 5 reviews have led to a change in patient care
• launch of new national system for recording and learning from patient safety events in near real-time, fully implemented across all NHS trusts in November 2024
• 1,499 neonatal lives saved through safer care bundle interventions, including improvements made in optimal cord management and antenatal steroids
• 1,900 deaths prevented through medicines safety initiatives and £9 million saved in admission costs
• developed a national medical examiner system in September 2024 that provides enhanced support for bereaved families.

39. The NHS has also delivered more equitable outcomes with significant focus on reducing inequalities worsened by the COVID-19 pandemic including development of the Core20PLUS5 framework – based on evidence and embedded with 543 Connectors – those with influence in their community who can help engage local people with health services, and 245 ambassadors – people working within the NHS and wider systems who are committed to narrowing healthcare inequalities.

40. NHS England established the NHS Race and Health Observatory(NHS RHO). Over the last 3 years the NHS RHO has (i) developed a significant evidence base, (ii) overseen major policy change based on this evidence, and (iii) initiated new and innovative implementation and improvement interventions.

41. The NHS recovered services and built capacity with a specific focus on reducing health inequalities. For example, in implementing CDCs, systems will have fully and thoroughly evaluated where these should be sited with consideration of accessibility and addressing inequality and deprivation.

42. This progress represents not only decisive action and prioritisation by NHS England, but also the daily efforts of the 1.5 million people working within NHS organisations. This effort and progress should not be undermined or diminished by the challenges that remain, which are considerable. Across all points of delivery, there are further opportunities for improvement:

• service gaps and growing community waiting lists for services such as audiology, podiatry and speech and language therapy, with almost 68,000 people in England waiting longer than 2 years
• too many people have experienced unacceptably long waits in emergency departments, care in corridors, or waiting in a hospital bed for services to be available outside of hospital. Some people needing mental health support have waited in environments that were not suitable for them, sometimes for many days
• between 2020 and 2022, at least 7 million fewer patients saw an NHS dentist compared with pre-pandemic levels (24 months to March 2019). As those patients have returned to dental practices, they have found it difficult to get the care they need. Our commitment, shared with government, to provide 700,000 more urgent dental appointments will need focus and attention alongside further work to reform the dental contract
• there is more to do to support low volume, highly complexity fragile services to work together, to benchmark and improve outcomes
• we need to go further to improve outcomes and experience in maternity and neonatal care including a focus on equality of care and outcomes for mothers and babies – and developing a long-term sustainable model for maternity estate
• people who need treatment for cancer are still waiting too long with the 62-day referral to treatment cancer waiting times standard at 67.3% in January 2025, but remains well short of the 85% target
• there are also long waits for children and young people who have mental health conditions, with nearly 250,000 more children supported through NHS funded mental health services

Improving productivity and financial management

43. There was a significant drop in productivity as a result of COVID-19 – the drivers of which are complex including:

• imbalance of inputs such as workforce, infrastructure and technology
• capacity constraints going into the pandemic
• more complex and acute population needs
• loss of staff discretionary effort
• loss of experienced staff
• measures of productivity that did not capture output growths of recently expanded services such as virtual wards, same day emergency care or advice and guidance

44. Multiple and far reaching actions as described above to deliver care differently, improve staff retention and drive commercial excellence, have been taken to improve NHS productivity, enabling us to deliver more care for patients through a clear delivery framework for productivity. This has already begun deliver results:

• over 2023/24, NHS providers delivered around 5% more activity year-on-year, for 0.12% more income. In the first 9 months of this year, the acute sector improved productivity by 2.3% based on NHS England estimates – double the improvement rate pre-pandemic. The NHS is on track this year to surpass the £7 billion of efficiencies delivered in 2023/24 – achieved through innovation and reform, continuous improvement, investment in technology, data and new capacity, and better workforce retention
• for 2024/25 systems planned to deliver efficiencies totalling £9.3 billion (equivalent to 6.2% of their total allocation); and an aggregate reduction in WTE staffing of 1.2% compared to 2023/24. At month 11 systems are forecasting to deliver £9.0 billion of savings which is only £0.3 billion lower than plan. This represents a 25% increase compared to the £7.2 billion of efficiencies delivered in the prior year
• agency spending has reduced significantly in the last 2 years and is continuing to fall in 2024/25. Cash spending on agency staff is lower now than at any point in recent years and as a percentage of total pay is lower than at any point since 2017 (when the current data goes back to). Cash spending on agency staff is currently forecast at £2.1 billion for 2024/25, which would be a reduction of £1.4 billion from 2022/23 (~38% reduction)

45. NHS England has created new measures of productivity in non-acute settings, as well as refined its existing measure of acute productivity. Initial estimates of non-acute productivity show positive productivity growth in 24/25 compared to 23/24.

46. The forecast outturn for 2024/25 is net breakeven position overall. Compared to plan, the aggregate system position shows expenditure to be above plan, including pre-agreed deficit support, by £582 million (0.3% variance versus allocation). Whilst still being an overspend, this is a significant improvement on the position for the previous financial year, with a total of 26 systems expected to hit plan and a further 4 with an overspend of 0.5% or less. Underspends against centrally managed budgets are forecast to be sufficient to deliver a net breakeven position overall.

Laying the foundation for future transformation

47. These achievements have been made through reforming the way care is delivered including by bringing care closer to home, providing a springboard for us to reimagine services as part of the 10 Year Health Plan. Across the NHS, we have also set the foundations for further transformation that will continue to have significant impact.

48. Strengthening our workforce: Against a backdrop of concerns about a workforce crisis in the NHS, NHS England mobilised a programme of work to develop the first ever comprehensive workforce plan for the NHS. The Long Term Workforce Plan is the most ambitious, far reaching workforce plan ever developed for the NHS. Based on NHS workforce demand and supply modelling over 15-years it sets out actions to help deliver a sustainable NHS workforce that meets the changing needs of patients.

• in 2023, when the NHS Long Term Workforce Plan (LTWP) was published, the service was relying on temporary staffing and recruits trained overseas. Since NHS England published the LTWP, significant progress has been made, with staff retention rates lower than any time since the pandemic, vacancy rates falling, and more staff now working in the NHS that at any point in its history. For example, by boosting flexibility in roles and supporting the wellbeing of our staff, we are ensuring that fewer staff leave the NHS now and over the next 15 years
• since the LTWP’s publication, we have seen an improved leaver rate which means around 1,600 more FTE staff are choosing to stay in the NHS every month. Progress on reducing expensive agency spend, from £3.5 billion in 2022/23 (4.5% of total pay) to £3.0 billion in 2023/24 (3.7% of total pay), and is currently forecasted to brought down to £2.2 billion by end of 2024/25
• 205 additional medical school places were created in September 2024, and a further 350 places allocated to begin in September 2025
• in total that means there are now more staff working in the NHS than ever before, and the government’s commitment to refreshing the LTWP later this year, aligning workforce planning with the priorities and direction of the 10 Year Health Plan, will enable further steps to be taken to deliver the right people, in the right places, with the right skills to deliver the care patients need, when they need it
• in addition, NHS England continues to strengthen and support the workforce. For example, every trust in the country has now signed up to the Fit and Proper Person director requirements and the launch of a first ever sexual safety charter in 2023, in collaboration with key partners across the healthcare system. NHS England was a founder signatory of the charter and by the end of 2024 all NHS trusts and ICBs had signed up. Signatories to the charter commit to taking and enforcing a zero-tolerance approach to any unwanted, inappropriate and/or harmful sexual behaviours within the workplace, and to 10 core principles and actions to help achieve this

49. Digitise the health service and use data in new ways: data and technology are crucial to the ongoing evolution of the NHS. Over the last 3 and half years, a number of important improvements and investments have been made to support and enable local systems to work in more efficiency ways, improve diagnosis and treatment and improve services.

• the 90% target for NHS trusts to have an electronic health record was hit in November 2023, a month ahead of schedule, and the 2025/26 planning guidance sets expectation for all trusts without an EPR to procure and implement
• similarly currently 75% of care providers have a digital social care record system – a 12% increase since May 2024 – and we are on track to achieve 80% by March 2025
• new features are being added to the NHS App regularly as the NHS encourages more people to use the app in their everyday lives
  • the 75% target for adults registered on the NHS App was achieved in December 2023, 3 months ahead of schedule, over 34 million registered users
  • 4 million NHS App record reviews in December 2024, which is above the 15 million per month ambition and achieved three months ahead of target
  • 9 million repeat prescriptions were ordered via the NHS App (December 2024), above the 3.5 million ambitions and achieved 3 months ahead of target.
• in November 2023, NHS England delivered a comprehensive procurement of a Federated Data Platform (FDP). The NHS FDP is a software platform that enables NHS organisations to bring together operational data, which is currently stored in separate systems. This supports staff to access the information they need in one safe and secure environment and use it to improve how they work and deliver care for patients. As of November 2024, 90 Trusts and 27 Systems are signed up to the FDP
• The use of artificial intelligence (AI) including artificial intelligence as a medical device (AIaMD) is also being adopted across the NHS including:
  • use of deep ensemble for the recognition of malignancy (DERM) to diagnose skin cancers in the face of rising demand, with initial estimates thought to deliver a £2.3 saving for every £1 spent
  • piloting of software to reduce did not attends (DNAs) by predicting likely missed appointments through algorithms and anonymised data, breaking down the reasons why someone may not attend an appointment using a range of external insights including the weather, traffic, and jobs, and offering back-up bookings
  • rolling out AI decision support tools in stroke care by reducing the time it takes to process and interpret brain scans, supporting clinicians to make faster treatment decisions. An early-stage analysis of this AI technology has demonstrated an association with a reduction in the time between someone presenting with a stroke and receiving treatment by more than 60 minutes, and it is correlated with a tripling in the number of stroke patients recovering with no or only slight disability – defined as achieving functional independence – from 16% to 48%
• this is underpinned by strong target architecture and engineering principles. Agreed for the first time, 2020, these principles define how best to use information technology to improve health and social care services in England, and set out the standards all products and services must adhere to

50. Driven significant changes to the national size and operating model:

• merging NHS Digital, Health Education England and NHS England which have already generated nearly £500 million of savings to support frontline services – and an organisation almost 35% smaller than its predecessors
• developing a refreshed approach to oversight built around the NHS Long Term Plan, NHS People Promise and local strategic priorities, and to reflect the significant changes enabled by the Health and Care Act 2022including the formal establishment of integrated care boards and the merging of NHS Improvement (comprising of Monitor and the NHS Trust Development Authority) `into NHS England. In recognition of the evolving operating model, we consulted on a refreshed performance assessment framework, which will be tested from April 2025, and launched in July 2025
• launching the national Recovery Support Programme (RSP) in July 2021, which provided to all trusts and integrated care boards (ICBs) in segment 4 of the NHS Oversight Framework 2022/23 to replace the separate quality and financial special measures programmes that were in place between 2013 and 2021. As a result of the intensive support provided, since 2021, a total of 14 organisations have successfully exited the programme after meeting the agreed exit criteria in their improvement plans
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51. Defined the framework for improvement across the NHS through the NHS Improving Patient Care Together (IMPACT) Programme: with the aim of becoming the fastest improving healthcare system globally. The 5 major components are building a shared purpose and vision, investing in people and culture, developing leadership behaviours, building improvement capability and capacity and embedding improvement into management systems and processes. Efforts have included:

• establishing the National Improvement Board to set the direction of system wide improvement by bringing in the right stakeholders to achieve our shared aims through collaboration and co-design
• supporting all organisations to understand their starting point in implementing the 5 components of NHS IMPACT through the baseline for improvement and self-assessment maturity matrix
• publishing 4 improvement guides on improving flow through the emergency care pathway (reducing avoidable admissions and optimising admitted care), generating greater value for patients from theatres, elective surgery and perioperative care, generating greater value for patients from outpatient services, and improving medical consultant job planning
• setting up 16 learning and improvement networks, which bring clinical and operational leaders together to learn from each other and share best practice
• planned to train up to 22,000 operational managers, to drive improvement locally, going beyond the commitment made in the Elective reform plan to train 8,000 clinical and operational leaders in how to manage elective pathways effectively

52. In October 2020, the NHS became the world’s first health service to commit to achieving carbon net zero. Since then, the NHS has made significant progress in a number of key areas:

• in 2021 there were no zero emission ambulances and less than 1% of the NHS fleet were fully electric. Now 93% of the NHS fleet are low emission vehicles, 10% are fully electric and zero emission ambulances are being piloted across the country
• for the first time in 2022, every trust in England had a green plan in place. Together, these board-approved plans will save more than 1 million tonnes of carbon over the next 3 years. This is the same as taking 520,000 cars off the road

Conclusion

53. The reforms to service delivery and strengthening of the enablers of care achieved in the last few years – were integral to meeting the challenges of the day. They have been critical to enable stabilisation and recovery post-pandemic and put the building blocks in place for transformation of the NHS in line with the ambitions of the 10 Year Health Plan.

54. This is an opportune moment for the next leaders of NHS England, with the government, to take the NHS to the next phase and build on the learning and achievements from managing and recovering from a pandemic – and to set the path for further transformation.

Publication reference: Public Board paper (BM/25/16(Pu)