Chapter 1: A new service model for the 21st century

1.1. Compared with many other countries, our health service is already well designed. We have high levels of patient satisfaction, generally improving outcomes, strong overall efficiency, and relatively high levels of care coordination [1]. You’re far less likely to be unnecessarily hospitalised for a chronic health condition here than in most other European countries [2]. Indeed, you’re more than twice as likely to have your leg amputated in Germany because your diabetes hasn’t been well managed than you are on the NHS [3]. An NHS where funding is apportioned to population need; where most care is provided through list-based general practice; where we take a planned approach to local and specialist hospital provision; and with a strong scientific tradition of evidence-based decisions about care – these are all organising principles which have stood the test of time.

1.2. But if we were starting from scratch, there are other aspects of the way the NHS works that we’d now design quite differently. This Plan shows how the NHS is going to be using its new funding to improve staffing and expand needed services. But – critical as they are – they’re not the only reason for current pressures in the system. The longstanding aim has been to prevent as much illness as possible. Then illness which cannot be prevented should where possible be treated in community and primary care. If care is required at hospital, its goal is treatment without having to stay in as an inpatient wherever possible. And, when people no longer need to be in a hospital bed, they should then receive good health and social care support to go home. Yet, despite improvements, too often when, where and how care is being delivered is a source of frustration, waste and missed opportunity for patients and the teams looking after them.

1.3. It’s frustrating for the ambulance paramedic unable to answer the next 999 call, because she’s stuck on a hospital ramp waiting to hand over a patient to the accident and emergency (A&E) team. For the emergency patient in A&E waiting for a bed still occupied by someone stuck in hospital waiting for a social care package at home. For the GP whose time is wasted writing prescriptions that could have been given when their patient was discharged from hospital. For the physiotherapist who – with the right continuing professional development (CPD) – could also have helped her patients with their anxiety and depression. For the child rushed to hospital with an asthma attack because she wasn’t helped to use her nebuliser correctly. For the patient with a long-term condition called back for a pointless outpatient appointment every six months. Or for the young man in mental health crisis who ends up at A&E because there isn’t a local community crisis team. And, while most people don’t experience these problems most of the time, every single one of them occurs every single day across our NHS.

1.4. To respond to these challenges, improve care for patients and reduce pressure on staff, this plan means that the NHS will increasingly be:

  • more joined-up and coordinated in its care. Breaking down traditional barriers between care institutions, teams and funding streams so as to support the increasing number of people with long-term health conditions, rather than viewing each encounter with the health service as a single, unconnected ‘episode’ of care;
  • more proactive in the services it provides. The majority of initial medical contacts with the NHS occur when a patient calls NHS 111 or 999, or visits their pharmacist, GP practice, A&E or Urgent Treatment Centre (UTC). At that point the NHS response kicks into action. But increasingly we are supplementing that with the move to ‘population health management’, using predictive prevention (linked to new opportunities for tailored screening, case finding and early diagnosis) to better support people to stay healthy and avoid illness complications;
  • more differentiated in its support offer to individuals. This is necessary if the NHS is to make further progress on prevention, on inequalities reduction, and on responsiveness to the diverse people who use and fund our health service. Individual preferences on type and location of care differ quite widely – as for example with end of life choices, or on use of ‘multichannel’ digital services. More fundamentally, with the right support, people of all ages can and want to take more control of how they manage their physical and mental wellbeing [4]. There is no contradiction between wider collective action on health determinants, and a recognition that different individuals will benefit differently from tailored prevention. Indeed one-size-fits-all statutory services have often failed to engage with the people most in need, leading to inequalities in access and outcome.

This chapter therefore sets out five major, practical, changes to the NHS service model to bring this about over the next five years:

  1. We will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health services.
  2. The NHS will redesign and reduce pressure on emergency hospital services.
  3. People will get more control over their own health, and more personalised care when they need it.
  4. Digitally-enabled primary and outpatient care will go mainstream across the NHS.
  5. Local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through new Integrated Care Systems (ICSs) everywhere.


  1. Dayan, M., Gardner, T., Kelly, E. & Ward, D. (2018) How good is the NHS? The Nuffield Trust. Available from:
  2. OECD/EU (2018) Health at a Glance: Europe 2018: State of Health in the EU Cycle. p.48. Available from:
  3. OECD (2017) Health at a Glance 2017: OECD Indicators. p.107. Available from:
  4. Ham, C., Charles, A. & Wellings, D. (2018) Shared responsibility for health: the cultural change we need. The King’s Fund. Available from: