Rethinking NHS Spending: Insights on What Government Should, and Should Not, Do
At a recent health policy forum, four senior experts from across the NHS, think tanks, media, and patient advocacy came together to present their manifestos for how government can better support NHS spending.
What followed was revealing. No two manifestos were the same. Each expert brought a distinct lens, shaped by their background, experience, and vantage point within the system. From calls for greater autonomy and digital investment, to urgent action on social care and system-wide coherence, the manifestos reflected the complexity and scale of the challenge facing the NHS. That each speaker offered a different answer is perhaps the most honest reflection of where we are: a system under strain, being pulled in multiple directions, and in need of thoughtful, well-aligned support.
Yet amid the diversity, some clear and consistent themes emerged. These themes reveal not only areas of common concern but also shared priorities that should guide how government acts. Below, we distil the key insights and lessons drawn from the discussion.
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Budgeting: Allocation Over Expansion
One of the clearest themes that emerged was a collective shift in focus from the size of the NHS budget to the way it is allocated and used. Rather than debating how much more money is needed, contributors emphasised that more impactful results could come from predictable funding, smarter allocation, and cross-system flexibility.
There was a call for longer term budget cycles and greater assurance over timelines, enabling organisations to plan effectively and make strategic investments with confidence. Pooled budgets, particularly with local authorities, were identified as a way to support integrated care, but challenges remain. Structural and legal barriers, such as the differences in financial regulation and VAT treatment between NHS providers and local authorities, hinder collaboration.
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Technology: Invest Beyond the Hardware
Technology featured prominently across the manifestos, but the discussion went beyond simple procurement. The consensus was that the real value of technology lies in how well it is deployed, integrated, and used, not just whether it has been bought.
There was a strong case for prioritising “obvious” technologies that address operational pain points, such as ambient note taking, but deploying technology alone is not enough. The effectiveness of digital tools depends on whether staff have the training, time, and support to use them properly.
A related theme was the need to invest in data capabilities; not just systems, but the people who analyse, interpret, and act on that data. How this happens in a changing landscape, with the abolition of NHS England and the headcount reductions in ICBs is another significant challenge. Moreover, given the focus on local planning and leadership, left-shift, and autonomy, how can we ensure that local areas have access to the data required to support decision-making.
There was also recognition of the budgetary complexity around digital investment: technology often spans capital (CDEL) and revenue (RDEL) budgets, creating unnecessary friction. One proposal was the creation of a dedicated ‘Digital DEL’ category to better reflect the cross-cutting nature of digital initiatives.
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Workforce: Manage for Stability and Skills
Workforce strategy was reframed not simply as a matter of headcount, but as a core component of productivity, innovation, and sustainability. Speakers challenged the assumption that more staff automatically means better outcomes, suggesting that in many organisations, a sudden workforce increase would not translate into improved performance without accompanying system and skill development.
The problem of boom-and-bust workforce cycles, periods of intense hiring followed by freezes, was raised as a critical issue undermining long term workforce planning. Instead, the system needs stability, flexibility, and a greater focus on upskilling existing staff to use new tools, technologies, and data effectively.
This view aligns with the broader understanding that digital transformation and workforce strategy are deeply intertwined. Supporting the workforce means not only recruitment, but also retention, training, and empowerment within an evolving care model.
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Left Shift: Still More Rhetoric Than Reality
The “left shift”, the strategy of moving care upstream into prevention, primary, and community settings, was universally acknowledged as the right direction. However, there was also broad agreement that in practice, it remains underdelivered and underfunded.
Despite years of strategic intent, funding, workforce, and performance incentives remain concentrated in acute care. For example, the Government’s recent re-commitment and focus on the 18-week elective care target, above others, may inadvertently reinforce hospital-centric models at odds with the shift towards proactive, community-based care. Whilst this may be expected, given its centrality as a manifesto commitment, the ED four target is now understood to be a better measure at describing a system’s performance given its reliance on flow throughout the full pathway, including discharge into social care.
While the left shift model is well understood in theory, its delivery will require much clearer alignment between policy, budgets, and accountability structures.
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Coherence Over Constant Change
Another consistent message was the need for coherence and stability in system design. Repeated structural reforms often absorb energy and resources while delivering limited benefit. Government was urged to avoid micromanagement and overcentralisation, and instead focus on setting clear strategic goals, allocating budgets fairly, and measuring what truly matters to patients and communities. System leaders called for stability in the rules of the game, rather than constant changes in priorities, structures, or reporting frameworks.
Interestingly, most recent attempts at structural reform relate to the commissioning, performance management, and regulatory landscape, as well as aspects of community and primary care. Comparatively speaking, the acute settings has remained relative consistent within the overarching system. Thinking back to the successful reform of the NHS by new labour in the early 2000s, this successful was supported by effective incentives and targets within the acute setting.
The upcoming ten-year plan must think through the right incentives, structures, and targets to support the Left-Shift and focus on the community setting and organisations, not simply re-working the early 2000s playbook.
Conclusion
Taken together, the manifestos reflect a system that does not need wholesale reform, but rather permission to operate with stability, clarity, and trust. There was little appetite for new restructures or headline grabbing initiatives. Instead, the call was for:
- The right investment in people and data, not just tools and tech
- Incentives that support the right organisational behaviour, rewarding prevention and integration, not just activity
- Strategic coherence, rather than policy churn, and funding security
Ultimately, smarter NHS spending is not just about what government does, but how it does it. The most powerful role government can play is to enable the system, remove the friction, and let local leaders lead.
“Smarter spending does not always mean spending more. Sometimes it means simply getting out of the way.”
