Research and analysis

Chapter 3: what success looks like for the 10 Year Health Plan, and what needs to change to achieve this

Published 17 December 2025

Applies to England

Summary of findings in this chapter

The public’s priorities for change speak directly to the challenges they face using the NHS. Overwhelmingly the public prioritise access to care, particularly primary care. Those who interact more with the NHS, including seldom heard audiences in the community engagement, are also more likely to prioritise improving co-ordination between services.

Staff prioritise changes that will improve their working life and that they think have been barriers to reform in the past. This includes structural and cultural changes, such as making the health and care system more integrated and addressing insufficient and inconsistent funding. It also includes making the NHS a great place to work, such as by valuing and developing its staff.

For the 10 Year Health Plan to be a success, staff believe it is crucial to address these structural and cultural problems which have been a barrier to reform in the past. For example, staff feel that without addressing workforce capacity issues in the system, staff will not have the bandwidth to successfully adapt to change.

Staff think it is essential for the public to buy in to any change for the 10 Year Health Plan to be a success. This includes understanding and adapting to new models of care and taking more ownership over their health. While the public agree they have a responsibility to the NHS and their health, they place greater emphasis on the role of government and the NHS. For example, the public say education and signposting is required about the availability of NHS services, and the government has a responsibility to make it easier to be healthier.

To understand what success looks like for the 10 Year Health Plan, we explored the questions below:

• what are the public and staff’s priorities for change, which they want to see addressed in the 10 Year Health Plan?

• how do they think that change can be delivered?

• what are the systemic and cultural changes needed to deliver change and to support staff to adapt and innovate in their roles?

• how does the relationship between the public and the NHS need to change?

• what would make the NHS a great place to work so it can successfully recruit and retain a happy workforce?

Summary of staff and public priorities

Public priorities were:

• improving access, particularly to primary care
• improving co-ordination and communication from NHS services
• reduction in waiting times for hospital procedures and A&E
• improving access and waiting times for mental health services
• reducing health inequalities

Staff priorities were:

• improving the daily life of the workforce - for example, through increasing capacity
• resolving challenges which have impeded reform in the past - for example, through investment in resource (including technology) and creating a more integrated service

These priorities are not mutually exclusive. Staff recognise that resolving challenges which have impeded reform will also improve their experience at work.

Summary of views on what will enable change in the NHS

When it comes to changes to the structure and culture of the NHS, specific themes from this engagement were:

• adequate resources, funding and infrastructure to underpin change efforts
• a more integrated service allowing a genuine shift to a culture of collaboration across boundaries
• effective leadership with a clear vision that engages and listens to staff
• an environment that fosters innovation, empowerment and effective change management
• freedom from unnecessary bureaucracy

When it comes to changes to the relationship between the NHS and the public, specific themes from this engagement were:

• in the deliberative events, staff said it would be essential for the public to buy in to any change for it to be a success
• across the engagement, staff also stressed the importance of the public being empowered to behave responsibly, both with regards to their own health and in relation to their use of the NHS
• the public were open to new ways of engaging with the NHS, including greater use of digital channels and accessing a wider range of healthcare professionals - albeit with important caveats
• in the summit, the public were open to the idea of having a responsibility toward the NHS, focusing primarily on not misusing services
• that said, public participants at the summit tended to place a greater emphasis on NHS and government action to support them to stay healthy than on personal responsibility

When it comes to changes to make the NHS a great place to work, specific themes from this engagement were:

• appropriate recognition and reward
• training and development
• improve workload and staffing levels
• policies which support work-life balance
• an open and collaborative workplace culture
• action to address racism, bullying, sexism and discrimination

3.1 The public’s priorities for change

We explored the public’s priorities for change through the deliberative events and the Change NHS website. On the Change NHS website, participants were asked to select the top 3 priorities that it is most important for the 10 Year Health Plan to address, from a pre-coded list. During the public deliberative events, participants were asked to categorise several priorities (taken from the Change NHS website and warm-up events) as either short or long-term priorities. In the community engagement, priorities for change surfaced through discussion of the challenges participants face when using the NHS.

Across the engagement, the public had 3 short-term priorities for change:

• to improve access to the NHS, particularly to primary care but also A&E and elective care
• to improve co-ordination between NHS services
• to improve aftercare in the community

In the long term, the public wanted to prioritise reducing inequalities in health and increasing the amount of time people live in good health.

Importantly, the public thought an increase in funding is necessary to deliver these priorities. They wanted funding to be long term and ring-fenced to improve the NHS.

Access to care, particularly to GPs

Overwhelmingly, participants in the public deliberative events identified access to care as the most immediate priority the 10 Year Health Plan should address. Of various access points in the system, participants in the deliberative events were most likely to prioritise GP access. This was mirrored on the Change NHS website where improving access to GPs was the most commonly selected option when participants were asked to choose their top 3 priorities - over half of participants (53%) selected it. Half of participants (50%) also selected it as a top 3 challenge to address in the nationally representative survey.

Figure 3: chart showing public priorities for change on the Change NHS website

Shows percentage of participants on the Change NHS website selecting answers to the question: ‘Which of the following challenges do you think is most important for the 10 Year Health Plan to address? Please select up to 3 options.’

	Percentage
Difficulties getting a GP appointment	53%
Long wait times for a hospital procedure	43%
Long wait times in A&E	37%
Poor co-ordination between different services	34%
Delays in being referred for treatment	31%
Waiting to access mental health services	28%
Poor-quality care	19%
Poor communication with patients	15%
Waiting to access community services	13%
Treatments or services not available on the NHS	9%
Other	7%

Base: all those who answered this question in the ‘Start here’ survey (number equals 62,493). The survey was live between 21 October 2024 and 14 April 2025.

Discussion in the public deliberative events showed that the public prioritised resolving access to GP appointments in the short term for 3 reasons.

Firstly, the public felt it would directly address the most common challenge they face with the NHS. As noted in section 2.2.1 of chapter 2, challenges with access were the most widespread challenge and something which caused a deep sense of frustration.  

Secondly, they said that improving GP access would relieve pressure elsewhere in the system. Participants felt that some of the pressure in A&E is due to people who cannot get a GP appointment turning to A&E for help. Moreover, participants said awareness of challenges with GP access means that some people delay seeking care until their condition has deteriorated, resulting in avoidable additional care needs, including avoidable hospital referrals. As a result, participants felt that improving GP access would have positive consequences for access more broadly.

Finally, it would improve health outcomes. Given the perception of GPs as the gatekeeper of healthcare, there was a strong sense that if the public cannot access a GP appointment, they cannot be referred to other services (for example, diagnostic testing and secondary care). The public felt that improving access to GPs would expedite access to other services too.

If you see a GP and can get a problem sorted, it saves the trip to the hospital. If things get worse and you cannot get to see a GP and I do not know, an infection gets worse and worse, you end up in A&E. And possibly stay in the hospital. So more GP [appointments] could perhaps stop things before they get too bad.

(Public deliberative event participant, South West)

Although less commonly selected than GP appointments, participants on the Change NHS website also prioritised addressing challenges with other points of access to the NHS. These included (in order of most selected on the Change NHS website ):

• waiting times for hospital procedures
• waiting times in A&E
• waiting times for mental health services

Table 3: proportion of participants on the Change NHS website who see challenges as a priority for change, compared with the nationally representative survey

	All public participants on the Change NHS website	Nationally representative sample
% prioritising addressing waiting times for hospital procedures	43%	56%
% prioritising addressing waiting times in A&E	37%	48%
% prioritising waiting to access mental health services	28%	18%

Base: all participants on the Change NHS website who answered this question in the ‘Start here’ survey (number equals 62,493). This survey was live between 21 October 2024 and 14 April 2025. All those who answered this question in the nationally representative ‘Start here’ survey (number equals 2,025). This survey was live between 12 and 17 December 2024.

This was echoed by participants in the deliberative events who identified these other access points as elements to address in the short term. Many participants had experienced challenges trying to access A&E, or experienced long waits for elective care and mental health services. Access to NHS dentists was also raised as a challenge by many participants in the deliberative events (this was not provided as an option on the Change NHS website).

In the deliberative events, the rationale for prioritising waiting times for hospital procedures, A&E, dental services and mental health services was based on 2 considerations.

Firstly, it will improve the patient experience and their health outcomes. For example, participants noted that patients are often waiting for a long time in A&E in pain and distress. Similarly, they said that there is an extremely high number of people waiting for hospital procedures whose condition is worsening while they wait. Improving access would make the experience less challenging and improve the health of patients.

I went into hospital and was sat there 3 or 4 hours in complete pain. Eventually when I did get seen it was great, but you’ve got to go through that loop before you get there. It’s a knock-on, you have got ambulances queuing up because of the people in A&E.

(Public deliberative event participant, South East)

Secondly, it will help to relieve pressure elsewhere on the system. Although less commonly mentioned as a benefit, participants expected that improving access would help the health system as a whole function smoothly. For example, improving waiting times in A&E would help to improve the ambulance service who are often also delayed by the waiting times, and addressing access to mental health services would help to relieve pressure on primary care as patients will be healthier.

However, despite being perceived as important challenges to address, improving access to A&E, dental care, mental health services and for elective care was felt to be less important than improving access to GP appointments. In part, this was because difficulties accessing GP appointments were felt to be a more common experience among the public.

Addressing poor co-ordination between different health and care services

Addressing poor co-ordination between different health and care services was consistently listed as a short-term priority by participants in the public deliberative events. This view was shared by many participants on the Change NHS website. Just over a third (34%) selected it as one of their top 3 priorities, following GP access and waiting times for hospital procedures. This theme also came out strongly in the community engagement among those with experience of drug and alcohol dependency, children and young people, and people with learning disabilities and/or autism.

Table 4: proportion of participants on the Change NHS website who see addressing poor co-ordination between services as a priority for change, compared with the nationally representative survey

	% prioritising challenge
All public participants on the Change NHS website	34%
Nationally representative sample	14%

Base: all participants on the Change NHS website who answered this question in the ‘Start here’ survey (number equals 62,493). This survey was live between 21 October 2024 and 14 April 2025. All those who answered this question in the nationally representative ‘Start here’ survey (number equals 2,025). This survey was live between 12 and 17 December 2024.

The public, particularly those with long-term or multiple health conditions and seldom heard audiences in the community engagement, prioritised this action due to their own experiences of using the NHS. Many had experienced challenges with poor co-ordination, including:

• having to repeat themselves to different healthcare professionals
• difficulties co-ordinating appointments across different services - for example, no option to book all their appointments on the same day
• delays in referrals as a result of falling through gaps between services and between paediatric and adult care

Not only did these challenges cause huge frustration but they also undermined participants’ confidence that they were receiving the best possible care. Therefore, there was a strong desire to improve co-ordination in the short term.

As someone with a chronic, progressive genetic condition, people with cystic fibrosis require care from healthcare professionals from across the NHS. Good communication and co-ordination of care is a cornerstone.

(Community engagement, multiple long-term health conditions)

Reducing health inequalities and a focus on prevention

Despite often not including them as short-term priorities, the need to reduce health inequalities and increase the amount of time people are living in good health resonated strongly with participants in the public deliberative events and community engagement.

A large proportion of public participants in the public deliberative events and community engagement were aware of inequalities in health access. This was often discussed in relation to location (for example, variation in ease of getting a GP or dentist appointment across England or differences in proximity to specialist treatment centres). It came out particularly strongly for participants living in coastal communities in the community engagement. There was a strong sense that this ‘postcode lottery’ is unfair and needs addressing - participants felt everyone should have the same opportunity to access healthcare regardless of where they live.

A smaller proportion of participants in the public deliberative events acknowledged that some groups experience worse health outcomes than others. However, this concern came out strongly in the community engagement among participants with lived experience of inequalities, including people from ethnic minority backgrounds, children and young people, those who have been in contact with the criminal justice system and those living in less affluent areas. As with location, there was a strong sense among those who raised this issue that it is unfair and needs to be addressed.

I know a lot of […] young women are feeling that the inequality in healthcare is a huge issue […] there has been this thing where young women have been experiencing treatment very differently when they go to a hospital or see a doctor. I do not know if that is really a 5 year [priority]. I think it is more distant future, a longer-term goal.

(Public deliberative event participant, North East and Yorkshire)

There was also a strong feeling among the public in both the deliberative events and the community engagement that reducing the amount of time people live in ill health and reducing the number of people who get sick is critical to address. The public felt this goal is of the utmost importance, both to reduce overall pressure on the health service and increase quality of life for all.

However, after discussion, the public in the deliberative events identified both issues as longer-term priorities. They did this because they believed that implementing some of the short-term priorities outlined above would contribute (after some time) to reducing inequalities and the amount of time people live in ill health. For example, they felt that improving access to GPs and dentists and reducing the waiting times for hospital procedures would go a long way towards keeping people healthier for longer. In addition, those in the community engagement felt that better co-ordination would help to make healthcare more inclusive, contributing to a reduction in health inequalities.

This [prevention] needs to be a long-term goal. To get to this point all of [the other priorities] need to be dealt with, like dentistry.

(Public deliberative event participant, South West)

Moreover, despite recognition of the importance of these issues, the other priorities usually felt more pressing in the short term. The impact of not being able to access care and poor co-ordination felt much more closely aligned to the challenges participants face when using the NHS.

In contrast to the public, reducing health inequalities was the priority the majority of partner organisations wanted the 10 Year Health Plan to address. On the other hand, partner organisations were less likely to prioritise access, which was consistently listed as a short-term priority by the public.

3.2 Staff’s priorities for change

Staff responding through the Change NHS website were asked to select which of a list of challenges are the most important for the 10 Year Health Plan to address. Participants were able to select up to 3 options. In the deliberative events, staff were asked about the single biggest challenge the shifts will need to overcome if the 10 Year Health Plan is to succeed.  

Figure 4: chart showing workforce priorities for change on the Change NHS website

Shows percentage of workforce participants on the Change NHS website selecting answers to the question: ‘Which of these challenges do you think is most important for the 10 Year Health Plan to address? Please select up to 3 options.’

	Percentage
Unmanageable workload or demand	45%
Staff shortages	44%
Inefficiencies in connecting services	41%
Complex administrative processes	31%
Growing complexity of patient needs	28%
Low levels of job satisfaction or morale	22%
High levels of staff turnover	19%
Poor mental health or burnout	18%
Problems with workplace culture	16%
Poor equipment	14%
Stressful working environment	13%
Other	9%

Base: all those who answered this question in the ‘Your Experiences - Workforce’ survey (number equals 3,618). The survey was live between 21 October 2024 and 14 April 2025.

The consistent message from staff was to focus on making the workforce feel valued and on removing barriers to holistic care for patients. In the deliberative and online events, staff noted that failure to deliver these has hindered change in the past. For example, failure to address fragmented services has in turn made it more challenging to deliver truly collaborative care.

As a result, staff prioritised systemic and cultural changes (outlined in section 3.3 of this chapter) and changes which would make the NHS a great place to work (outlined in section 3.5 of this chapter). Staff felt these changes would both create an environment where change can be delivered, as well as demonstrate value to the workforce.

3.3 Systemic and cultural changes needed in the NHS to deliver change

Staff across the engagement pointed to the 5 themes listed below as the most significant systemic and cultural changes required to enable change. They are listed in order of priority:

• adequate funding, staffing and infrastructure to underpin change efforts
• a genuine shift to a culture of collaboration underpinned by a more integrated system
• effective leadership with a clear vision that engages and listens to staff
• an environment which fosters innovation, empowerment and effective change management
• freedom from unnecessary bureaucracy

Adequate funding, staffing and infrastructure to underpin change efforts

Across the staff deliberative and online events and the health system leader engagement, participants consistently emphasised the critical importance of providing appropriate resources to deliver effective care while also implementing meaningful improvement. For participants, ‘appropriate resources’ had 3 elements: funding, staffing and infrastructure.

Radical systemwide overhaul to create an NHS framework that illustrates the shared goal of the shift. Being bold enough to make radical change while still trying to deliver a functioning health service.

(Staff deliberative event participant, North East and Yorkshire)

When discussing funding as part of this priority, staff in the deliberative events and health system leaders advocated for strategic funding enhancements. In particular, they called for improvements to the financial model. For example, there was strong support for transitioning to multi-year contracting and funding cycles, which would enable more effective long-term investment and planning, particularly for prevention initiatives.

There was also support for moving investment to settings outside hospitals to avoid reinforcing existing imbalances. This included alternative funding models specifically for primary care and increased investment in community care and social care to alleviate system pressures. Health system leaders advocated shifting capital from secondary care towards community settings through specific financial mechanisms, including direct budget transfers and multi-year funding approaches. While ‘double running’ both systems during transition received support, staff participants recognised this requires careful trade-offs and cannot be universally applied.

The funding model needs to change to move money away from being so acute centred. [We] would welcome a percentage shift of money from acutes from annual budgets. [However,] double running is not a wholesale option, and so trade-offs will be needed.

(Health system leaders, South West)

The second element of this systemic change - staffing - was a strong theme for frontline clinical staff in particular. In the deliberative events, there was a high level of concern about staffing shortages. In this context, staff were apprehensive about being expected to maintain service delivery while also engaging in change and improvement initiatives. They said that increasing staff capacity was essential for change to succeed.

Staff are willing to make these changes, but there is a lack of capacity within the system to make them when the frontline services need to be delivered.

(Staff deliberative event participant, North West)

Finally, both workforce and health system leaders said there needs to be improvement in the NHS’s infrastructure. This included both digital and physical infrastructure. All staff and health system leaders said there needs to be an improvement in digital infrastructure, but with different emphases. Clinical and managerial staff focused on resolving the daily inefficiencies of fragmented systems. There were consistent calls for a single patient record and reliable shared systems. On the other hand, health system leader participants focused on strategic considerations around interoperability, purchasing power and procurement.

Is the purchasing power of the NHS as good as it needs to be? There almost seems to be a mistrust of it. We want to do things right for patients, but could we use the commercial sector better to bridge the gap? Can we buy better? Can we get the commercial sector to come in and front this shift (from analogue to digital)?

(Health system leaders, North West)

Improving the physical infrastructure was emphasised by staff in the deliberative events. This included optimising clinical spaces, improving storage solutions and providing well-designed workspaces. They felt this could positively transform both operational efficiency and staff wellbeing.

Improvements to the physical infrastructure in community settings was particularly identified as essential to create more effective working environments. A range of suggestions was proposed, including the creative repurposing of existing buildings (such as vacant shopping centres for outpatient services) and strategic investment in local facilities to enable hyper-local care.

Time, space, support, a realistic end point that is achievable and gives benefit to both patients and staff. [We need] money, more rooms for clinics, more storage [and] a digital system fit for purpose.

(Staff deliberative event participant, Midlands)

A genuine shift to a culture of collaboration underpinned by a more integrated system

To support genuine collaboration, staff across the engagement emphasised the importance of a more integrated service. Participants in the staff deliberative events wanted to break down silos and foster integration between:

• different staff groups within a setting, building knowledge of the challenges and pressures they face in their role
• traditionally separate parts of the health and care system, including primary, acute, community, dental, social care and local authorities

Staff said that the current fragmented structure creates barriers to delivering seamless, effective care for patients and delivering the ambitions of the 10 Year Health Plan. Where collaboration does exist, staff said that it can feel like it happens despite the system, rather than being enabled by it.

[We need] to break down barriers: cultural, managerial, financial, between services that prevent collaboration. The hurdle to implement change across these barriers is too great.

(Staff deliberative event participant, London)

The perspectives from different staff groups in the deliberative engagement and from the health system leaders events revealed complementary priorities for integration. They called for the following.

Firstly, a more integrated service within the NHS. Staff in the deliberative events and health system leader participants advocated for a singular NHS model that moves away from ‘us and them’ dynamics between organisations.  

We need to join forces all together collectively as a health care service.

(Staff participant, Change NHS website)

Secondly, a ‘whole-system approach beyond the NHS’. Staff also highlighted the vital importance of cross-sector partnerships with local authorities, voluntary organisations and to a lesser extent the private sector. Integrated neighbourhood teams were seen as central to community models, requiring alignment with primary care networks.

Better collaboration of services to deliver the best care to patients. Without a joined-up approach, change cannot be embedded […] Bold decisions [are needed] to drive real change.

(Staff deliberative event participant, North West)

Thirdly, effective information sharing to enable truly collaborative care. Staff felt that improving the current IT infrastructure would help achieve integration and seamless service delivery. Health system leaders advocated for a unified digital infrastructure with standardised national protocols and interoperability. Throughout the engagement, there was a clear recognition of the benefits of implementing systems that communicate effectively across acute, mental health, community and primary care settings, as well as with education and social care. Staff said this would ideally be through a single portal rather than numerous disparate systems.

[We need to prioritise] communication across primary and secondary care. It needs to be consistent, easy to navigate and effective to improve delivery.

(Staff deliberative event participant, South East)

Effective leadership with a clear vision that engages and listens to staff

Staff consistently emphasised the importance of effective leadership in tackling change fatigue and creating environments where positive change can flourish. Current leadership approaches were often identified as barriers to improvement and innovation. Across online and deliberative events, many staff expressed frustration with hierarchical leadership styles that fail to incorporate frontline perspectives.

Staff in the deliberative and online events felt that the effective leadership needed for the 10 Year Health Plan to succeed has 3 components.

Firstly, a clear, stable national vision with space for local decision making. Health and care staff across the engagement expressed a shared desire for a clear national vision and direction of travel for the NHS, particularly for digital and service transformation. Within this, participants emphasised the importance of political stability and cross-party consensus on long-term NHS planning to avoid disruptive reorganisations.

Staff emphasised that the national vision needs to be balanced with local needs. For example, they discussed the importance of setting national targets to signal political intent and influence market development, while enabling local leaders to focus on core priorities with appropriate support.

As a priority, we need a clear national ambition […] [We] need a direction of travel, a destination. […] Create the political environment to enable system leaders to focus on the core priorities (urgent and elective care, access etc.) with the air cover and support from media and NHS England that will clear space for progress to be made.

(Health system leaders, South West)

Secondly, staff emphasised the importance of engaging and listening to staff throughout the change process. Across the staff engagement, participants highlighted the benefits of collaborative change design, rather than top-down implementation.

Staff felt engagement is required before change has been delivered, to provide a transparent rationale for change and win support. This would also provide an opportunity to ensure transformation design is rooted in an understanding of operational realities. They then emphasised the importance of continuous open and honest communication and a feedback loop that demonstrates the impact of staff’s input.

[We need to] create environments where staff feel empowered to participate in change, have protected time to engage with innovation and are genuinely involved in decision making.

(Staff deliberative event participant, East of England)

Finally, staff in online and deliberative events spoke of the need to foster collaboration rather than competition. In particular, staff felt that leaders should model this approach and demonstrate the collaboration that is needed to deliver change across the system. Within this more collaborative approach, they recognised the importance of clear accountability frameworks and developing the skills to integrate different parts of the health and care system.

Collaboration, not competition. Articulate the shared purpose and work together to alleviate it.

(Staff deliberative event participant, North West)

An environment which fosters innovation and empowers staff

Staff were keen to adapt in their roles to deliver change. However, they stressed that to be able to do this, they need to be working in an environment that empowers them to adapt and innovate. Staff in online and deliberative events said that such an environment would have multiple elements, including the following.

Firstly, allowing time and space to embrace change. This was the most commonly mentioned environmental change staff called for. Staff said that to be able to embrace and drive change, they need to be able to balance operational demands on their time with being able to protect mental bandwidth for innovative thinking and supporting implementation. This would help to alleviate the barrier of ‘lack of time to change’ that many said they currently experience. One common suggestion of the best way to free up this time was by streamlining administrative processes.

[We need to change] bureaucracy - committees and meetings with too many members offering little input

(Staff deliberative event participant, online event)

Secondly, celebrating success and sharing learning. This emerged as a requirement for sustaining positive momentum. Health and care staff consistently called for approaches that recognise small improvements, share successes across organisations and the wider NHS, and build confidence in the change process.

Thirdly, empowering staff to make decisions at a local level. Many frontline clinical staff participants, including nurses, doctors and allied health professionals, felt constrained by the current decision-making structures and wanted space to adapt at a local level.

Fourthly, listening to and learning from staff. Many highlighted the critical importance of establishing ‘safe spaces’ where staff feel able to share ideas, raise concerns and learn from mistakes without fear of blame.

Understanding when things don’t work, we can start again. Getting feedback on change and admitting if it doesn’t work.

(Staff deliberative event participant, Midlands)

Lastly, placing patients at the head of change. Across the engagement, health and care staff emphasised a shared commitment to patient-centred approaches as a driver for positive change. There were consistent calls for focusing transformation efforts on delivering the right care in the right setting and improving outcomes that matter to patients.

Freedom from unnecessary bureaucracy

Staff in the deliberative and online events consistently highlighted the overwhelming burden of excessive administrative tasks and unnecessary bureaucracy. The impact of this ‘red tape’ on frontline care delivery was seen as a top challenge requiring urgent attention. This challenge was also prioritised by almost a third (31%) of staff participants in the Change NHS website.

Both frontline clinical staff and health system leader participants recognised the potential for automation and digital solutions to streamline workflows and reduce administrative burden.

Long time doing admin tasks - writing clinical letters / referrals / risk assessment, could [we] use AI? Poor experience of ‘staff effectiveness’ and diary monitoring. [There is] no time to put things in a diary!

(Staff deliberative event participant, South East)

At the governance level, staff identified opportunities to streamline multi-layered approval processes to speed up improvement initiatives. Many advocated for nationally led procurement of digital systems and standardised processes that could reduce local variation and create clearer pathways for innovation.

Large unified system rollout needs to be nationally led. Locally-led initiatives have led to huge differences in systems based on cost and preference.

(Staff deliberative event participant, Midlands)

3.4. Changing relationship between the NHS and the public

The issue of the relationship between the public and the NHS came up regularly - both prompted and unprompted - throughout Change NHS. Staff in the deliberative events stressed that for the 10 Year Health Plan to succeed it will be essential for the public to accept and adapt to a new model of care. In the national summit we specifically explored the idea of responsibility and what the public, staff and the government would need to do differently for the 10 Year Health Plan to be a success.

The staff perspective

In the staff deliberative events and through the Change NHS website, staff highlighted the importance of public support for the successful delivery of change. They also said that the public’s behaviour in relation to the NHS would need to change. They felt that generating buy-in for both of these would be difficult but essential. Staff highlighted the risk of public resistance undermining transformation efforts.

The narrative around health and social care is negative and deteriorating. Being transparent about change, inclusive and open will help embed what to expect and ease the change transition.

(Staff deliberative event participant, North West)

To generate the support and drive the behaviour change they felt was essential, staff in deliberative and online events recommended a number of steps including the following.

Firstly, clear, open and proactive communication about the need for change to drive public support and understanding.

Secondly, proactive education about service design and appropriate usage. Frontline clinical participants particularly emphasised the need for a comprehensive approach to helping patients understand when and where they should seek care, how services are designed to function and which healthcare professionals are able to help them. They felt this would have the dual benefits of enhancing both patient experience and system effectiveness.

[Building] public understanding of what’s available and what we actually do. For example, pharmacists aren’t just ‘glorified shopkeepers’.

(Staff online event participant)

Thirdly, empowering patients to look after their health. There was a view among staff that the public needed to take greater responsibility to ‘stay healthy’, thereby reducing overall demand on NHS services. This included both behavioural changes (such as diet and exercise) as well as engaging with secondary prevention services.   

Education for the public about changes, and how they can help make the NHS better.

(Staff deliberative event participant, South East)

More generally, the overwhelming message from frontline clinical staff participants in the deliberative events was about the need for a more positive narrative about the NHS from politicians, to build a more positive public image. Staff felt that a negative portrayal of the NHS in the media is damaging to both public trust and staff morale. Primary care staff felt especially targeted in this respect.

The public perspective

In the public deliberative events and the national summit, we explored what the public, workforce, NHS and government need to do differently if the NHS in England is to successfully transition to a new model of care. Within this, we explored to what extent public participants thought individuals have a responsibility towards the NHS.

Overwhelmingly, participants thought the public have a responsibility not to waste NHS resources. For example, expectations included attending appointments, following the advice of healthcare professionals, and not overusing NHS services when they could self-care.

Less commonly (and much less frequently than staff participants), some public participants said the public has a responsibility to look after their health. This included factors such as a healthy diet and exercise, as well as engaging with NHS preventative care programmes like screening. Finally, a minority of participants said the public has a responsibly to embrace a new model of care, working with the NHS to ‘give it a go’, even if it feels different to the past.

I think there is onus on us as the public to look after our own health. I think you tend to rely on the NHS to cure us and fix all. I think there’s that perception that the NHS is going to do everything in its magic. I think we need to actually have greater responsibility for our own health as well.

(Public deliberative event participant, South West)

Importantly, public participants emphasised they would need support from the NHS and government to behave in this way. They often felt that the state has a greater role than the public when it comes to enabling a new model of care. They emphasised the importance of education - for example, about what service misuse looks like and the wider role of healthcare professionals in primary and community care beyond the GP. They also said the NHS has a responsibility to reach out to communities to encourage uptake of services through effective engagement and signposting.

Public participants in the deliberative events and the community engagement also stated that not everyone is equally capable of taking actions to stay healthy due to structural barriers (such as the cost of healthy food and access to green spaces), as well as personal circumstances (such as caring responsibilities). In this context, participants said that the government has a responsibility to make it easier to be healthy.

It’s cheaper to eat unhealthy than healthy. It needs to be easier to eat healthy food, not having chicken shops every 5 minutes.

(Public deliberative event participant, East of England)

3.5. Making the NHS a great place to work 

In the staff deliberative events, we discussed what changes could be made to make the NHS a great place to work and address challenges relating to recruitment, retention and burnout. Staff identified 6 themes that they said are the most significant systemic and cultural changes required to achieve this ambition:

• recognising and rewarding staff
• training and development
• workload and staffing levels
• policies which support work-life balance
• an open and collaborative workplace culture
• addressing racism, bullying, sexism and discrimination

Recognising and rewarding staff

Staff in deliberative events said that appropriately recognising and rewarding staff is the most important thing the NHS could do to become a great place to work. This included recommendations by staff to improve pay and progression opportunities.

I work as a theatre nurse with 20yrs experience, the only career progression I have is to be promoted to a manager band which I don’t like because my passion is clinical patient care but for me to get better remuneration I have to leave that.

(Staff participant, Change NHS website)

Staff said that the first step to valuing staff is putting in place structures to recognise their contribution. This has 2 interconnected dimensions: being fairly compensated, and management approaches that show staff they are valued and appreciated.

In the context of perceptions of pay inequity, the idea discussed in the deliberative events that areas of the country that struggle to recruit should get additional funding to offer higher salaries was contentious. Some participants supported the idea as a pragmatic solution to capacity issues and felt it could help resolve disparities in the cost of living. However, most participants expressed concerns about fairness. In addition, there was a sense that while this idea might be a ‘quick fix’, it does not address other issues about culture and leadership and therefore may not be effective in the long term.  

I think it could be considered, but not in isolation - £15,000 would not be compensation for working somewhere that made me feel miserable or unsafe […] It should be considered alongside working conditions, progression, recognition, and quality of life.

(Staff deliberative event participant, London)

Notwithstanding the emphasis on pay, staff across roles also consistently stressed that recognition includes more than just pay. They said it includes visible appreciation for hard work, the celebration of excellence and recognition of staff’s passion. Many staff in the online and deliberative events felt that the perceived failure to value their work is leading to low morale.

In the staff deliberative events, managerial staff participants recognised the importance of showing staff that they are appreciated. They said that fostering a culture that empowers staff, celebrates and shares success, and acknowledges sacrifices, was essential to making the NHS a better place to work.

People should feel valued and appreciated, which is not happening in some areas. Regardless of your role, you should feel appreciated because the NHS is a whole system. If a room doesn’t get cleaned, the doctor cannot do their job; if a porter doesn’t move patients, they won’t get seen by clinicians.

(Staff deliberative event participant, London)

Training and development

Alongside recognition, staff participants in the deliberative and online events emphasised the importance of opportunities to develop professionally, advance their careers and acquire new skills.

Frontline clinical staff in particular emphasised a need for skills training to keep pace with evolving roles, drive change, improve patient care and to complement their clinical training. They felt digital education could help make training more accessible. All staff - but particularly frontline staff - also called for protected time to ensure staff can take up training opportunities.

Time needs to be built into job planning for every role to do a diverse range of development activities.

(Staff deliberative event participant, South West)

Additionally, staff emphasised the importance of clear progression pathways across roles and sectors. Staff consistently mentioned unclear or limited career progression pathways beyond management ‘tracks’, particularly for clinical roles. They wanted to see an expansion of opportunities to help retain the existing workforce.

There is inconsistency in what you need to do to progress and what the standard is for a B2 vs B3. It seems different in different wards and specialties.

(Staff deliberative event participant, Midlands)

Participants in the focus group held with healthcare assistants (HCAs) raised concerns over a lack of career progression pathways for unregistered clinical staff. They highlighted limited opportunities to acquire new skills necessary for advancement. HCAs reported feeling undervalued when overlooked for advancement opportunities, with inconsistent routes to progression between specialisms and departments. There was a call for a comprehensive development and progression offer to give HCAs career growth.

Staffing levels and workload

As described in section 2.2.2 of chapter 2, staffing shortages and an unmanageable workload were some of the most common challenges staff experience. Staff also identified these as priority issues for the 10 Year Health Plan to address. Staff in the deliberative events therefore saw a significant opportunity to improve staffing levels and workloads to ensure they are achievable and sustainable. They felt this would enhance their ability to deliver high-quality care and improve their wellbeing.

As a doctor, the inadequate levels of staffing have meant unsafe patient care. It also means poor job satisfaction. Stress, burnout, reduced wellbeing.

(Staff deliberative event participant, Midlands)

Policies which support work-life balance

Across the engagement, staff consistently expressed frustration with inflexible scheduling and poor work-life balance, saying these contribute to stress, drive dissatisfaction and undermine efforts to retain staff.

Staff in the deliberative and online events therefore wanted to see flexible working arrangements across the NHS to promote work-life balance and support wellbeing, and for all colleagues to flourish, regardless of their personal circumstances (for example, caring responsibilities). Staff said implementing policies of this nature is fundamental to creating sustainable working environments and would demonstrate that they are valued as ‘whole people’ within the NHS.

I want flexibility to be present in my life and responsibilities outside of work. I want to [have time] to exercise. I want to be able to eat my lunch away from the desk.

(Staff deliberative event participant, South West) 

Staff in the deliberative events suggested numerous initiatives to increase flexible working. These included:

• greater control over rotas
• individualised working patterns
• partial or semi-retirement (to help retain experienced staff)

I should be able to self-roster and be able to work only [specific] days due to health issues. [The NHS should] listen to staff preferences and give opportunities to change working patterns. Make sure it takes into account personal circumstances and flexible work [should] be fair with staff as much as possible.

(Staff deliberative event participant, South East)

Many emphasised the need for inclusive policy development to ensure all staff can benefit from flexibility initiatives, regardless of role, setting or pay band. However, staff also acknowledged that the scope of what can be offered will vary between clinical environments, with notable differences between community and hospital settings, and between clinic and ward-based roles.

Employers offer flexibility, but the impact on others is not considered. The night shift runs short to support flexible working […] leaves those who cannot afford to work less unsocial hours with less work-life balance and more stress.

(Staff deliberative event participant, East of England)

Staff participants in the deliberative events also emphasised the importance of leadership modelling flexible working practices and setting the tone from the top.

An open and collaborative workplace culture

Staff stressed the importance of a workplace culture built on values of openness, inclusion and collaboration. This culture would support staff to thrive and deliver high-quality care. There were significant concerns about the current workplace culture, with many staff reporting ‘toxic’ environments characterised by blame, fear and hierarchical divisions that inhibit their ability to speak openly.

Staff in deliberative and online events felt there needs to be 2 changes to bring about a more positive and collaborative culture.

Firstly, a closer connection between leadership and the frontline, to bridge the gap between NHS leadership messaging and day-to-day realities. There were consistent recommendations for leadership practices that actively engage with staff perspectives and build environments founded on trust in the workforce’s expertise and capabilities.

Offer truly compassionate and caring leadership / management that will bring out the best in staff, foster collaboration, boost morale and lead to better, safer care. We were too scared to adopt real change and have failed to unshackle ourselves from policies and processes.

(Staff deliberative event participant, South East)

Secondly, change to a culture where failure is seen as an opportunity to learn. The need to replace blame with learning was frequently emphasised. Staff called for environments where ‘mistakes are seen as learning opportunities’, creating space for both improvement and ‘smart failure’.

Be an open and transparent place to work, encourage openness and honesty and learn from this, do not judge. Shift from a culture of ‘blame’ to a culture of ‘same’ [not singling out individual staff]. People working in fear of making a mistake do not encourage openness or learning. Those working under the threat of litigation will practice defensively and not holistically. We have not supported staff enough to allow them to be heard and allow them to be open. We have instead continued to foster a culture of blame and scapegoating not support.

(Staff deliberative event participant, East of England)

Addressing racism, bullying, sexism and discrimination

As set out in section 2.2.2 of chapter 2, staff expressed profound concern about persistent racism, bullying, sexism and discrimination within the NHS. These themes were raised across the staff engagement and were a strong theme in a focused online session held with over 100 staff from ethnic minority backgrounds. To make the NHS a great place to work, staff said this issue requires urgent attention.

I’ve experienced bullying from managers and witnessed harassment between staff members. I’ve also heard of sexual harassment from colleagues.

(Staff deliberative event participant, East of England)

Staff in deliberative and online events called for 5 actions.

Firstly, stronger accountability. Many highlighted the importance of genuine zero-tolerance policies with meaningful consequences, rather than superficial statements without enforcement. They particularly emphasised holding senior leaders responsible for addressing discriminatory behaviour.

Secondly, safe, supportive reporting systems that protect those who speak up. There was recognition that proving discrimination can be challenging, particularly when it occurs ‘behind closed doors’. Staff said this makes psychological safety and whistleblower protection essential.

Thirdly, comprehensive structural reforms including integrating anti-discrimination standards into regulatory frameworks and establishing independent bodies to address complaints.

Fourthly, education and training, including mandatory training on what discrimination looks like in practice.

Finally, leadership that reflects the diversity of the workforce. Staff were concerned about the underrepresentation of people from ethnic minority backgrounds in senior positions. They emphasised that this creates barriers to addressing systemic issues and perpetuates existing inequalities.

A coherent and deliverable strategy for addressing endemic racism. Instead, we keep asking the same questions and pretending we don’t know the answers.

(Online staff event participant)

See a list of all chapters