Policy paper

Road to recovery: the government's 2025 mandate to NHS England

Published 30 January 2025

Applies to England

Presented to Parliament pursuant to section 13A of the National Health Service Act 2006.

Foreword from the Secretary of State for Health and Social Care

The government was elected with a mandate to get our NHS back on its feet and to build an NHS fit for the future. Together, we will deliver.

On day one, I was honest with the country that the NHS is broken, because the first step to rebuilding public trust and confidence in the service is to be completely honest about its failings.

The promise that the NHS will be there for us when we need it has been broken for almost a decade. Patients are waiting too long for appointments, treatment and ambulances. Cancer care lags behind other countries. Care for cardiovascular conditions is going in the wrong direction. The NHS budget is not being spent where it should be - far too concentrated in hospitals, too little in the community, and productivity is too low. Patients and staff alike are confronted with these failures, and they are counting on us to act.

Nothing I have experienced in my first months as your Secretary of State has shaken my conviction that, while the NHS may be broken, it’s not beaten. The NHS has extraordinary depth of clinical talent. Staff across every function in every part of the NHS are dedicated to their patients, have an unshakeable commitment to the NHS’s values, and are passionate about bringing about the change we all want to see.

This new mandate for reform of the NHS reflects patients’ priorities:

• cut waiting times
• improve access to primary care
• improve urgent and emergency care

With so many pressures on people’s pockets and the public purse, the NHS must learn to live within its means. We recognise that this will mean tough decisions need to be made and local systems should feel empowered to make them. The government’s investment in the NHS against a challenging economic and fiscal backdrop must be matched with reform to the operating model, with a sharp focus on improving efficiency and productivity. We have a shared responsibility to make sure that every pound is well spent. The public welcomed the Chancellor’s decision to prioritise the NHS, but they remain sceptical about whether the money will be well spent. It is our responsibility to make sure that it is. I will be closely monitoring performance against the budget. The culture of routine overspending without consequences is over.

Our 10 Year Health Plan, to be published in the spring, will deliver the 3 big shifts our NHS needs to be fit for the future: from hospital to community, from analogue to digital, and from sickness to prevention. It will deliver power to the patient and more freedom to the frontline. It will meet the Prime Minister’s challenge, set out in the Plan for Change, for us to deliver the biggest reimagining of the NHS since its birth.

This mandate puts the NHS on the road to recovery. The last Labour government delivered the shortest waiting times and the highest patient satisfaction on record. It won’t be easy, but together we’ll do it again.

The Rt Hon Wes Streeting MP

Secretary of State for Health and Social Care

Our mandate to reform the NHS

Introduction

This mandate represents a critical step in responding to the issues identified by the Darzi investigation and addressing the urgent challenges facing the NHS. The government is committed to ensuring that every individual receives timely, high-quality care, and this requires swift, decisive action now.

In addition to addressing the immediate challenges, the mandate lays the foundation for longer-term reform as part of our health mission, focusing on bringing care closer to communities, prioritising prevention over treatment, embracing digital transformation, and embedding financial discipline within the system.

Ahead of the broad and extensive engagement planned through the 10 Year Health Plan process, it is important to put a new mandate in place to formally communicate the key priorities on which the new government was elected, and signal to NHS England and the NHS the immediate actions needed. Integrated care boards (ICBs) and NHS England need to engage with patients, carers and the public as they discharge their functions, both in relation to clinical and wider commissioning decisions.

In the financial year 2025 to 2026 we will take the first steps to reform the service, so that it delivers the new model of care that the NHS will be working towards over the next decade. Following the publication of the 10 Year Health Plan the government will publish an updated mandate, to support longer-term planning in the NHS aligned with a long-term vision for health.

Through the 10 Year Health Plan, the government will focus on 3 strategic shifts, moving care from:

• hospital to community
• sickness to prevention
• analogue to digital

These shifts will help to:

• cut waiting times for care
• reduce the amount of time spent in ill health
• tackle health inequalities
• reduce the lives lost to the biggest killers - cancer, cardiovascular disease and suicide
• make the NHS sustainable in the long term

Alongside our health mission, our ability to achieve the government’s growth mission is dependent on a healthy, productive workforce. At the start of this year, 2.8 million people were economically inactive due to long-term illness. We know that 4.1 million people are in employment with a work-limiting health condition - an increase of 300,000 in the last year. The NHS plays a vital role in keeping people healthy and in work. Further, the NHS also plays a vital role in delivering our opportunity mission, including through training the staff we need (including health visitors) and the provision of health services to provide babies and children the best start in life.

There are many positive examples of local organisations and systems working effectively to successfully drive progress towards the 3 shifts. Scaling examples of best practice, promoting innovation in delivery and tackling unwarranted variation will be critical as we collectively transform the NHS. The NHS has more pilots than the Royal Air Force (RAF). We need to do more to adopt and scale new approaches, to take the best of the NHS to the rest of the NHS. This applies especially strongly in addressing the stark health inequalities that mean shorter lives in poorer health for far too many people.

Mandate objectives

Objective 1: reform to cut waiting times

High-quality elective care, delivered in a timely way is a top priority for patients and the government. It is simply unacceptable that waiting lists are at record highs and that some patients are waiting over a year for care. We expect the NHS to make progress towards delivering shorter waiting times and to improve performance against the constitutional standards. Patients should be empowered and given more choice and control, and their experience of planned NHS care should be as smooth, supportive and convenient as possible.   

The government will prioritise reducing waiting times for elective care and improving experience of care by empowering patients with greater choice and autonomy over their treatment. We will need to shift culture in the NHS to focus as much on experience as outcomes and safety, making the most of patient voice and involvement in co-design solutions. Making progress will require judicious use of public resources and wide-ranging reforms to delivery by working more productively, consistently and differently. These reforms will be successfully delivered by aligning finance, performance oversight and delivery standards with clear responsibilities and incentives for reform, robust and regular oversight of performance, and clear expectations for how elective care will be delivered at a local level. As part of delivering our Elective Reform Plan, NHS England should:

• support the NHS to ensure that trusts make progress towards the 18-week standard over the financial year 2024 to 2025 and 2025 to 2026 in line with the 2025 Elective Reform Plan, by continuing to maximise elective activity, increasing diagnostic and theatre capacity, and introducing the reforms it outlines
• empower patients with choice and control over where they receive treatment, including from the independent sector
• work with patients and carers to understand their expectations and co-design solutions to improve experience of care
• drive expansion of the NHS App as a key part of the drive to improve communication with patients so that individual needs are better met and patients exercise greater control over their health and care
• continue to support the NHS to maximise performance against the cancer waiting time standards and improve cancer outcomes
• support the NHS to maximise performance on the waits patients experience for mental health services
• continue to reduce the number of long-waiters, including reducing the proportion of people waiting over 65 weeks in the financial year 2024 to 2025 and waiting over 52 weeks in the financial year 2025 to 2026

Objective 2: reform to improve primary care access

Primary care services are the front door to the health service for most people and the key to earlier diagnosis, but too often it is not possible to get a timely appointment, or one at all. Improving primary care access is essential to support a move to a neighbourhood health service, with more care delivered in local communities to identify and manage problems earlier. Bringing care closer to home is important for preventing hospital attendances and admissions, so reducing waiting lists. This will be a focus of the 10 Year Health Plan.

NHS England should:

• enable patients to access general practice appointments in a more timely way
• enable commissioners to tackle unwarranted variation and support improvement in general practice services, including by increased investment to deliver upgrades to GP surgeries
• ensure investment in data and digital to build a more modern and productive primary and community care sector
• ensure a focus on patient access to urgent NHS dental care, including access to urgent care appointments
• develop approaches with relevant partners to improve financial flows within health and social care to provide more co-ordinated services to patients as a step towards building a new neighbourhood health service
• work through the 10 Year Health Plan process to deliver an expansion in primary and community services including dental practices and pharmacies

Objective 3: reform to improve urgent and emergency care

The NHS has been struggling to provide the level of urgent and emergency care the public needs. Ambulance response times and waiting times in A&E are unacceptable. It will take time and transformation for these services to be fit for the future, but a start must be made.

NHS England should:

• support the NHS to reduce long wait times in urgent and emergency care settings with the aim of improving patient safety, experience and outcomes
• improve patient flow through mental health crisis and acute pathways by providing new infrastructure for mental health crisis support to improve patient experience, outcomes and contribute to the avoidance of unnecessary A&E attendance
• make progress towards reducing hospital admissions, especially with respect to emergency bed use, by taking the first steps to building neighbourhood health services
• ensure close working with local government, community partners and social care services to improve discharge in a timely manner with appropriate support
• develop new approaches to financial incentives to support urgent and emergency care performance and improve the use of resources by tackling unwarranted variation in performance
• work with the Department of Health and Social Care (DHSC) to develop a new strategy for transforming urgent and emergency care for publication in early 2025

Objective 4: reform to the operating model

To support delivery of these reforms and to improve performance, changes must also be made to the operating model of the NHS. The top down centralised model of control will, over time, need to give way to a more devolved system where ICBs and trusts have greater freedom and flexibility and where patients have more choice and control.

NHS England should:

• develop an updated NHS Oversight and Assessment Framework
• develop a differentiated approach to supporting ICB and trust delivery, empowering those performing well with a package of freedoms, flexibilities and financial rewards while improving support for those in the middle and offering intensive and focused intervention for the most challenged local systems
• reward the best performing NHS organisations by rewarding them with financial incentives, for example flexibilities such as more capital resources
• get ICBs focused on developing the new neighbourhood health service of the future, with stronger primary and community care services closer to home, through a renewed focus on strategic commissioning

Objective 5: reform to drive efficiency and productivity

The financial position facing the NHS is not easy. The Darzi investigation spoke of a system under huge pressure. The public welcome the Chancellor’s decision to prioritise the NHS in the Budget but want funds to be spent wisely. This will require the NHS to revisit how they can further improve efficiency and productivity in all parts of the system and the choices being made about which services to prioritise. 

While NHS England needs to continue to comply with its existing duties and deliver financial balance, the overarching financial objective for the NHS has to focus on ensuring that the right spending decisions are made to deliver the services patients require.

NHS England should:

• work closely with DHSC to monitor the delivery of spending plans and expected outcomes against jointly agreed metrics, across both revenue and capital funding, including with the aim of delivering a 2% productivity improvement across the NHS
• contribute to a zero-based review of spending, including in NHS England’s resources with a view to making real terms cash-releasing savings
• prioritise digital integration to promote greater efficiency within the system by allowing systems to co-ordinate more effectively to deliver better outcomes for patients
• ensure the right financial management and control frameworks are in place to support the delivery of mandate objectives within the parameters set out in the financial directions, delegated spending authorities and controls issued by the department
• ensure that ICBs and partner trusts exercise their functions with a view to managing within agreed plans, to deliver financial balance across their systems. Where deficits occur, NHS England should work with DHSC to identify potential measures to address systems and trusts with persistent financial issues

Accountability for mandate progress

This mandate will apply from 30 January 2025 until a new mandate is published, following the publication of the 10 Year Health Plan. NHS England has a duty to seek to achieve the objectives in the mandate. The Secretary of State keeps progress against the mandate under review, setting out his views in an annual assessment which is laid in Parliament and published. The government will agree with NHS England how it should report on overall progress against the mandate to support the Secretary of State in keeping this under review.

In seeking to meet the objectives set out above, NHS England will need to act in accordance with the principles and guidance set out in Managing public money, and continue to comply with its delegated authorities agreed by DHSC, and its framework document with the department, which will be published on GOV.UK and sets out how it and the government will work together. NHS England’s statutory obligations under the NHS Act 2006 and other legislation also apply.

The Education Outcomes Framework, as published on GOV.UK (The government’s 2023 mandate to NHS England), remains in place pursuant to Section 100(2) of the Care Act 2014.

As required by the NHS Act 2006, the government has consulted NHS England and Healthwatch England on the objectives set in this mandate.