If the pandemic had not struck in early 2020, the NHS in England would have been into the third year of its 10-year programme of reform and improvements to services set out in the NHS Long Term Plan.

The long term plan was drawn up in response to a 5-year funding commitment made by Prime Minister Theresa May in 2018, on the 70th anniversary of the NHS. In a speech delivered at the Royal Free Hospital in London, May said that past funding increases had been ‘inconsistent and short-term’, and that the NHS needed to be able to ‘plan for the future with ambition and confidence.’ May committed to increase the NHS budget by 3.4% in real terms between 2019/20 and 2023/24, and in return asked the NHS to develop a 10-year plan for reform.

Those plans were developed and consulted on by NHS England over the next 6 months, with the NHS Long Term Plan published in January 2019. The plan sets out a vision for better care in the community, improved treatment for major conditions such as cancer and mental illness, improved waiting times, more action to prevent ill health and reduce inequalities, and better use of technology. This was to be achieved through a mix of policy approaches – including stronger partnerships between the NHS and local government to lead local service changes, and new collaborations of general practices to provide more integrated care.

Overtaken by events

The proposals in the long term plan were built on May’s 5-year funding pledge, and on the expectation that multi-year funding settlements for the Department of Health and Social Care would be set later in 2019 – covering public health, education and capital. The plan also anticipated the reform and investment promised by government for adult social care in England.

But events since the plan published have been turbulent. On 24 July 2019, Boris Johnson was appointed Prime Minister, and in October a general election was called. The Conservative manifesto recommitted the government to the existing NHS funding increases but added more priorities for the NHS, including new hospitals and additional GP appointments. The day after his victory at the polls on 12 December, the re-elected Prime Minister declared the NHS to be ‘this one nation Conservative government’s top priority.’

Less than 3 months later, the UK recorded its first death from COVID-19. By June 2021, COVID-19 had claimed over 150,000 lives in the UK, hospitalised over 460,000 people, and left a million reporting persistent symptoms after infection. Even though the government released billions of pounds to protect people’s lives and livelihoods, the effects of policies to control the virus, including lockdowns and social distancing, have damaged the economy. Employment began to rise as the economy reopened in 2021, but by May 2021 there was still an estimated employment gap of 4.5 million people compared with the pre-pandemic period. The negative impact on people’s finances and wellbeing has been felt most acutely by the most socioeconomically disadvantaged, younger people, and the self-employed.

The disruption to health and care staff and services has been severe. At the peaks of the pandemic, many NHS staff were redeployed to care for COVID-19 patients. Infections among staff have caused illness and death, and exacerbated staff shortages. Infection control measures have required wholesale changes to how services are delivered (and to whom) across the health and care system. The result has been delays to routine care and a rapidly growing backlog of unmet need. In social care, staff have also experienced high mortality and illness from COVID-19, and, like NHS staff, have experienced high levels of stress.

In response to the crisis, the government has spent heavily. The National Audit Office estimates that £172bn has already been spent out of £372bn that government expects to spend (as at May 2021). This includes support for businesses, individuals, and health and care services. Although the government has committed to protect the 5-year NHS spending plans, it is facing additional costs likely to run into billions of pounds over several years to meet new demand arising from the pandemic and to reduce the backlog of care. Economic uncertainty has meant short-term, 1-year funding commitments for public health, capital and education, and similar short-term funding for social care and local government.

The long term plan remains the blueprint for the NHS’s evolution, but the pandemic has dealt a huge blow to both the NHS and social care. In what follows, we assess the overall progress of the main pledges in the NHS Long Term Plan and the impact of COVID-19 on their delivery. We provide a narrative of what was achieved before the pandemic, assemble the evidence of how the pandemic has affected progress against the different components of the plan, and identify implications for the future as the NHS and government plans its recovery from the pandemic.

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