Key points

  • COVID-19 has been the biggest shock in the NHS’s history and its impacts on people’s health and the health service will be felt for many years. This report assesses progress on the main pledges in the NHS Long Term Plan and the impact of COVID-19 on their delivery.
  • In 2019, the NHS Long Term Plan set out a 10-year strategy for improving and reforming the NHS in England. The plan aimed to expand primary and community services, strengthen action on prevention and health inequalities, and improve quality of care for people with major diseases. Collaboration between local services was to help drive this progress.
  • No part of the NHS’s plan has been unaffected by the pandemic. Unsurprisingly, the overall picture is one of major delay, disruption, and increased demands on services. There have been delays to developing planned new services in primary and community care, and widespread disruption to elective care, cancer screening and treatment, mental health care, and other services, with serious consequences for people’s health and wellbeing.
  • The plan committed to maintaining and improving performance in hospital waiting times, but performance was declining even before COVID-19 hit. The pandemic had a major impact on hospital services, particularly in the first half of 2020. Although many non-COVID-19 services remained open and many others have been restored to pre-pandemic levels, there is a large backlog of unmet health care needs. Waiting lists for hospital care are the worst on record, at over 5.45 million at the end of June 2021, while only two-thirds of community services are reported to have been fully restored.
  • The pandemic has also created new demands for NHS services beyond immediate COVID-19 care, including additional mental health needs and chronic side effects of COVID-19. Previous national targets – such as for expanding access to mental health services for adults and children – will need to be revisited to account for greater need.
  • Some long term plan commitments have been accelerated by the COVID-19 response, such as improving access to remote consultations in primary care and outpatients. But these changes will need careful monitoring and evaluation to ensure that they meet their intended aims and do not exacerbate inequalities.
  • COVID-19 has exposed and widened existing inequalities in health and care in England. The long term plan lacked detail on how inequalities would be reduced – and local plans to tackle inequalities were delayed before the pandemic. A more detailed framework of priorities, interventions, and measures for NHS agencies on tackling inequalities is now needed to ensure greater awareness of inequalities is translated into tangible action to reduce them.
  • New partnership structures have been developed to help local agencies improve care, including integrated care systems (ICSs) and primary care networks (PCNs). PCNs have been vital to delivering the COVID-19 vaccination programme. But COVID-19 has held back the broader process of redesigning care to improve health and reduce inequalities, which is at the core of the NHS Long Term Plan.
  • The Health and Care Bill 2021–22 will introduce changes to NHS structures in England – including formalising local partnerships. But the health system needs an updated strategy for improvement and reform that accounts for the massive disruption caused by COVID-19. This must confront hard trade-offs. Action to address the backlog in elective care must not come at the expense of interventions to prevent disease and reduce inequalities in health and care.
  • Making progress depends on government decisions about investment and reform. Before the pandemic, government failed to provide the NHS with the long-term investment needed to expand the workforce and improve NHS infrastructure. Without enough staff and adequate buildings and equipment, the NHS will not be able to recover services after the pandemic.
  • Significant additional investment has been promised, but major unknowns around the future course of the pandemic mean there is considerable uncertainty over whether this will be sufficient. Projections suggest the NHS England budget needs to increase by at least £7.1bn in 2022/23, not including the substantial additional funding that may be needed to cover any immediate costs of dealing with COVID-19 and the virus having an ongoing impact on the NHS’s ability to deliver care. This is the minimum required to put the NHS on course to tackle the growing backlog of treatment by 2024/25, cover increases in underlying pressures, the costs of implementing existing long term plan commitments, and meet increased demand for mental health services.
  • After repeated delays, plans for a cap on social care costs were eventually announced in September 2021. While a bold and positive step forward that will start protecting people from incurring catastrophic costs, this falls well short of what is needed to stabilise the current system and deliver the comprehensive reform needed to fully deliver the Prime Minister’s promise to fix social care once and for all.
  • Wider reform is also needed to improve population health and reduce inequalities. Government currently has no national strategy for reducing health inequalities in England and public health budgets were 24% smaller per capita in 2021/22 than 2015/16. Increased investment in the NHS must go alongside investment in the wider services that shape health.
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