The newly released NHS 10-Year Plan lays out bold ambitions for the future of healthcare. As we digest its vision, we must also examine the practicalities—particularly the opportunities and challenges it presents for how care is delivered and funded.
Building on the NHS Long Term Plan, the 10-Year Plan aims to improve health outcomes and ensure long-term sustainability. At its core is a focus on prevention, reducing health inequalities, and creating integrated, personalised care. It envisions empowered citizens and neighbourhood teams working within accountable, integrated health organisations—focused on population health, patient experience, and responsible financial stewardship.
To achieve this, the plan calls for targeted investment in primary and community care, greater access to local mental health support, strategic use of digital technology, workforce development, and financial sustainability.
Across professional networks, two themes dominate discussions: contracts and funding. The Plan mentions “contract” 35 times and “funding” 52. Underlying both is the deeper social contract—delivering timely, effective care when it’s needed most.
Where are we now?
The General Medical Services (GMS) contract forms the foundation of general practice. It’s a nationally negotiated, long-term agreement typically held by GP partnerships. Additional funding flows through a patchwork of mechanisms: Directed Enhanced Services (e.g. immunisations), locally negotiated contracts via Integrated Care Boards (ICBs), Primary Care Network (PCN) agreements, and local authority commissioning for public health services.
This complex web creates a heavy administrative burden. NHS providers must juggle numerous contracts—often tied to proxy metrics rather than meaningful outcomes. The result is a workforce overstretched by compliance, leaving less time for patient care. Until we shift to a trust-based model focused on what matters most, this complexity will continue to hinder transformation.
What does the Plan say about contracts?
The 10-Year Plan introduces several changes aimed at streamlining and strengthening neighbourhood services:
- New contracts: One for single-neighbourhood providers (~50,000 population), and another for multi-neighbourhood providers (250,000+) responsible for broader services and strategy.
- Integrated Care Boards (ICBs): Greater flexibility to contract with NHS and independent providers.
- Dental contracts: Reform to address complex needs and attract new dentists to NHS roles.
- Employment contracts: Modernisation to boost productivity, with poor performance triggering termination.
- Block contracts: Phased out in favour of performance-linked funding.
- Integrated Health Organisations: High-performing Foundation Trusts may evolve into these, with control over local budgets and multi-year contracts.
- Year of Care Payments: Pilots from 2026–27 will introduce annual, capitated budgets to promote prevention and community-based care.
- Funding: Redistribution based on need, with greater investment in out-of-hospital care and reduced reliance on deficit bailouts.
Threat or opportunity?
System-wide changes to funding and contracting naturally provoke mixed reactions. Some see an opportunity for primary and community-based organisations to lead innovation and redesign care. Others worry—particularly about the risks for smaller, less-resourced providers.
A financially struggling NHS trust may receive system-level support. In contrast, a GP practice, charity, or SME provider might face closure. This asymmetry raises serious questions about equity and the future shape of healthcare delivery.
The future of contracting
The form of contract matters less than the content and intent behind it.
We’ve been here before. The Vanguard Programme (2015–18) introduced similar contract models—like alliance contracting and APMS. Much can be learned from that experience: what worked, what didn’t, and why.
Burn the proxies—focus on what matters
Whether you’re an Acute Trust CEO, a community nurse, or a practice manager, most of us want the same thing: a simpler system, fewer forms, fewer meaningless targets, and a shared focus on outcomes that really matter.
Align resources with ambition
Integrated neighbourhood services must be resourced properly. That means investing in workforce, supporting new team roles, and ensuring the promised technological tools are actually available and usable. Transformation won’t happen without capacity.
Measure what matters
Improving access to urgent care, diagnostics, and elective procedures—including cancer pathways—remains a priority. But so too is responsible use of people and financial resources.
To integrate care, improve productivity, and boost quality, we need real, high-performing teams. These teams thrive with enabling leadership, a supportive culture, and empowered citizens. Our metrics must evolve to reflect this reality.
Activate staff and citizens
Measuring staff activation and applying Net Promoter Scores to organisations are already standard in other systems. Imagine if we applied the same thinking here—creating national metrics for citizen activation. It could revolutionise personalised care.
Contract for prevention and inequality reduction
If we’re serious about preventing illness and reducing health inequalities, our contracts must reflect those priorities.
Take obesity: it disproportionately affects our most deprived communities, fuelling chronic disease, mental health issues, and cancer. Yet, it remains peripheral in NHS funding and planning. Without a contractual framework for population health, we’re left relying on informal relationships and goodwill to drive integration.
A call to action
We need bold implementation to match bold ambition. Leaders must learn from past experiments and today’s frontline realities. A contract should enable—not complicate—care delivery. It should foster collaboration, reward outcomes that matter, and treat all providers fairly.
Above all, contracts must become bridges, not barriers—linking people, teams, and services with a shared mission: better health for everyone.
