The question on everyone's lips! Did the 10 year plan beat me to having a baby?? Yes but only just..... it dropped as I was in pre-op assessment before having a c-section. Baby Annie is here safe and sound but has needed a veritable buffet of appointments which have delayed this post, hopefully we are at the end of that and we can get into the swing of things as a family now. Fingers crossed.

I've attempted to use voice recognition to do this issue - its unfortunately corrected pseudonomised data to sodomised data among other errors. All hail the saviour of clinical consultations - ambient AI!

10 year plan analysis

The NHS 10-Year Plan: Big Ambition, Missing Foundations

Let’s start with the elephants in the room. The implementation chapter went walkabout (somewhere between author two and three, I’m told) and there are no timelines. So we’re all guessing at priorities and horizons for most of what’s been mooted.

Second, there’s zero evidence of lessons learned. We make clinicians do Learning from Deaths reviews and share the findings in coroner’s court; policy should get the same treatment. Without a formal “why this failed before” loop (hi, care.data), we’re destined to repeat ourselves.

Finally, I'm all for international comparators but Estonia is the size of Birmingham & Solihull ICB with 1.3m. The national model is great and it works well for them but it was built on a greenfield site as a new country....

Data: Great Expectations, Shaky Reality

The plan assumes the data exists, is structured for flexible use, and—most importantly—isn’t rubbish. That last bit is where the wheels come off. Operational data still lives on whiteboards and print-outs; theatre schedules are literally pinned to walls. Meanwhile there’s been cultural resistance to sharing records with patients because GPs—who historically claim ownership of the longitudinal record—aren’t resourced to fix errors or manage legacy diagnoses that were never actually discussed with patients. Primary legislation will force the door open (rightly), but the resourcing and cultural problems haven’t disappeared.

Patient Power, Payment Peril

The proposed payment system needs serious thought. How will people make decisions? Will those choices reflect things a Trust can realistically change? We’ve been round this track with patient choice before—most people choose the nearest site. Worse, if you peg money to satisfaction without nuance, you risk systematically underfunding services whose “poor performance” is driven by… underfunding.

If I were still in ops, I’d be rebuilding PALS from the ground up. Yes, AI can triage, but the real issue in many places isn’t workload—it’s whether PALS understands its own organisation or can act impartially between the Trust and DHSC. Closing Healthwatch in that context is a spectacular own goal.

Social Care: The Dog That Didn’t Bark

Where is social care? You can’t fix A&E unless you sort discharge. Waiting on the Casey commission means the foundational piece isn’t there, and most mentions of social care are just DHSC name-checks.

Maternity: Over-Trialled, Under-Supported

The document piles a lot of trials into maternity at a moment of national safety concern. Where’s the backfill and hands-on support to make those trials safe and useful? This is on top of the Ockenden report recommendations too.

Prevention: Genomics Isn’t The Whole Show

The prevention chapter reads like a genomics brochure. We can already predict risk fairly well; the missing bits are the services that help people act on it—Sure Start, green school spaces, affordable healthy food. Pouring money into ever finer risk-stratification while ignoring the social levers is classic “define the problem, don’t fix it.” Health data is framed too narrowly, too—if you don’t bring in justice, housing, and education, you’re dimming the lights before you start.

Mental Health & Work: Let’s Be Serious

The idea that people out of work due to mental health conditions can be helped back to employment via remote support on the NHS App is… optimistic. It’s a safety net at best. In reality, by the time you’re out of work, acuity is high and IAPT criteria often exclude you. That’s a mismatch between need and intervention, not a UX problem.

Research Signals & Techno-Optimism

There’s a strong (and new) investment signal to industry running through the paper. I don’t hate it—but let’s be honest about what it is.

Predictive genomics makes me uneasy. Women are already under-researched; there’s a real risk this benefits white men disproportionately and bakes in bias. There’s also overtreatment risk in conditions where the “cure” is worse than the disease (some prostate cancer pathways spring to mind). If we’re going to do this, we need a proper feedback loop—linking novel presenting factors to genomics, learning fast about polypharmacy and outcomes, and not pretending GLP-1s don’t interact with the messy reality of people’s lives and existing other medicines.

The tech chapter gallops along, very pleased with itself. If any chapter was written by AI, it’s this one. Ambient voice, RPA, apps, wearables—fine—but none of it is a panacea. RPA is sticking-plaster for bad processes; if we redesign properly, we shouldn’t need it.

Operating Model: Back To The Future?

I had to reread the operating model section and dust off the Health and Social Care Act—never a joyful experience. I’ve worked frontline, commissioning, and ops; no one group has the full picture. Credit where due: the plan says “frontline,” not just “doctors and nurses.” But let’s stop setting professions against each other and start championing good management wherever it sits.

The Daily-Mail-ification of NHS management needs to end. Some reporting is nonsense and should be binned, yes. But overall we’re under-managed, which is why performance lags. Asking ICBs to “market make” when analytics teams are being trimmed and PBR is what it is is a fools errand?

The market has been dead for years—killed by constant reorganisations, loss of strategic commissioning capacity, and austerity. Setting a skeleton-staff ICB a market-making task is pure Apprentice task energy.

FTs, PFI, and Other Ghosts

A return to foundation trusts in all but name? Re-read Francis before we cosplay the 2000s. I was part of the Mid Staffs review. We cannot go back there.

And where’s the national plan for PFI? Local trusts can’t out-lawyer PFI partners. If you want structural deficits to move, that intervention has to be national. Are we… reinstating Monitor? It’s giving retro.

For what it’s worth, the gain/loss sharing methodology we devised via Monitor to solve benefits-vesting still stands up. Dust it off.

Workforce: Big Words, Old Problems

“Modern employer” sounds nice. Then we’re told most savings come from automation—assuming the same tasks, in the same order, just done by machines. That’s a lack of ambition about how care is delivered. Digital staff passport, NHS Staff App—paused. ESR rebuild—five years and counting. Please don’t badge this as “new.”

Training reform? One mention of AHPs, tucked into a nurses/midwives paragraph. That’ll go down like a lead balloon with the third-largest clinical workforce. Modernising medical training is overdue, but The Firm approach had its issues.

And the pointed reference to UK-trained SAS doctors feels like a gratuitous dig at colleagues who keep services running. Why say it? Reform voters aren't reading this so don't pander to them.

Data Quality (Again), Autonomy, and Spread

Even if we park the “anonymised vs pseudonymised” face-palm, the plan ignores the sheer graft required to get data fit for purpose. It also wants to end Not-Invented-Here and increase local autonomy. Fine—but what’s the mechanism for spread without recreating a postcode lottery? National marketplaces and DPSs sound neat, but procurement categories thought up centrally by CCS rarely map to what systems actually need, so people route around them.

Finance: Arithmetic Meets Reality

Multi-year planning and settlements are welcome. But structural deficits don’t vanish because we said “balance.” Some systems can’t live within means short-term: PFIs, recruitment gaps, agency bills (hello, M25 commuter belts which are hotspots for clinical safety issues). Try doing a five-year capital and revenue plan without pay, drift, and borrowing assumptions—you can’t. Moving away from block contracts is also familiar territory; we’ve tried and backslid before.

Tariff “based on clinical practice” is admirable, but do we have the data? I’ve seen 120+ clinically legitimate pneumonia pathways in a single multi-site trust. There isn’t one “best” pathway for everyone; you’ll need an exceptions process. “Year of care” payments borrow from ACOs; maternity shows the edge cases—especially if, like me, you live on a trust border.

“Patient power” payments risk further starving services where quality is poor because resources are thin. The baseline assumption seems to be well-funded services with management obstinacy as the main variable. That’s not today’s NHS. My principle stands: patients are excellent at telling you what’s wrong; it’s not their job to design the fix.

Carr-Hill being revisited—for the fifth time in 20 years— and always tends to return as the least shit option. The £2.2bn overdraft withdrawal will almost certainly need quiet carve-outs (PFI, at minimum). Capital flexibility is genuinely helpful—but we need the “timbers” (rules of the game) to know if it actually unlocks multi-year planning.

Finally given NHSE are taking sorely needed EPR monies to prop up their underlying defecit there needs to be a multiyear view on central monies out to systems and providers too.

So… Now What?

This plan is ambitious and occasionally brave. But too much rests on missing foundations: social care, data quality, realistic finance, and a grown-up view of management. Without those, it’s a glossy re-skin of old problems without reference to the reasons for prior failure.

If I had one plea for the implementation plan: show the timelines, fund the unglamorous plumbing (data and management), stop asking local teams to magic markets into existence, and put social care on level pegging rather than Waiting for Casey. Only then do the shiny bits have a fighting chance.