The Centre’s role in the 10 Year Health Plan
A more meaningful role for a new Centre
Fewer approval layers give real agency – and the centre now must get better at collaborating, not just critiquing.
FT freedoms matter – but we need DHSC and HMT to resist pulling budgets back when demand spikes.
The failure regime can only work if acquirer Trusts can write down productivity-sapping infrastructure – and sometimes renew it with fresh capital.
A rescue plan is crucial for trusts farthest from FT status – without it, estate poverty = financial poverty, stuck in a vicious circle.
Delivering on the Plan means not just a restructured centre, but a redirected one
Cutting layers is good, supporting Trusts would be excellent
The plan to limit capital approvals to three layers is a welcome reset. We sincerely hope this means Trust Boards, DHSC and HMT. Moving to this clears roadblocks and roundabouts that didn’t just add months to every scheme, but years.
The real shift now required at DHSC and Treasury is moving from approvers to enablers:
Delivery Drive – A basic layer of approval is OK. But approvers are human beings. If you are asked to review a business case, you’ll pick holes in it. That’s your job – unless it isn’t. Unless your job is to drive delivery. Repairing deal-breakers? Yes. Rejecting silly ideas? Yes. Perfecting cases? No. A delivery-focused centre would be redirected away from perfecting business cases to helping drive valid cases through.
Library of Innovation – Set up a central repository of good ideas and actively promote them. The last wave of capital investment (PFI) wasn’t very good at this. Ideas tended to be held by bidders. This time, we need the centre to socialise them and promote them. That doesn’t mean centrally designed and delivered schemes. It means tracking down good practice and good ideas and promoting them to other Trusts.
Standard Contracts – Something PFI was very good at. Each draft of PFI contracts (SOPC, for those who remember it) were better than the last. (Management of contracts was another matter). But we already have central frameworks and industry-standard contracts. The centre should continue that journey.
Co-working Role – Trusts don’t need bosses. They need experts to co-develop and test business cases, chase approvals together, and model risk-sharing meaningfully. While the Centre will always have an approval role, it can also act as a service to Trusts leading on radical change. Other Departments own and draft the business cases, often working with Treasury. We need a Trust leadership role which also encourages DHSC and Treasury to feel some engagement and ownership – rather than always keep them at a distance.
That kind of support doesn’t duplicate Trust expertise. It amplifies it. And it helps ensure that fewer approval layers doesn’t weaken collaboration.
FT Freedoms Versus Budget Panic
The reintroduction of borrowing and reinvestment autonomy is a real win. But past experience suggests that success could overwhelm central capital budgets – and re-trigger the clampdowns. The New Hospital Programme asked the NHS to bid to be one of eight additional projects. It generated 148 bids. There is an enormous pent-up demand for capital investment.
The new freedoms are superb. And we will need DHSC and Treasury to match ambition with backbone. If schemes get good early traction, central pressure to reprioritise is almost inevitable. But that’s the point: the demand is there because the country needs to catch up. We must not treat enthusiasm as evidence of folly.
Back-to-the-Future Failure Regime – But with Funding
A revived provider failure regime is back. Poor performance is going to trigger intervention – and possibly takeover by a stronger Trust. But takeovers only succeed if the acquirer is supported fairly. Think of private sector corollaries: Huge businesses are acquired for a pound – because they need a lot of investment to get them back on track. In some cases, even a pound is too much. And that might well be the case for the NHS estate and tech landscape.
What will help administrators and acquirers recover Trusts with poor quality capital assets?
Write-down flexibility is essential. The acquiring organisation should be able to write down/off underperforming assets without penalty.
Targeted capital support must be available for the worst estates – money isn’t optional when an entire hospital’s condition drags down a system.
Without this, the regime becomes symbolic. Trusts won’t step forward if they see no path to fix the underlying shortfall – especially after years of underfunded estate investment.
Rescue Plan for the Poorest Trusts
As we evidenced in our joint paper with CF, some Trusts are trapped in an estate-finance spiral:
Poor estate quality drives poor operational results
Poor results limit borrowing and investing capacity
Result: estate continues to deteriorate
That cycle must be broken. There must be a route for a strategic estate reset – capital investment ringfenced for hospitals far from FT status and acutely underfunded.
This isn’t charity. It’s investment in stability. It levels the playing field, meaningfully, not just rhetorically. Without it, we entrench a two-tier NHS where geography determines quality.
Conclusion: A new type of NHS needs a new type of Centre
Reduced approvals and restored freedoms are good. The renewed failure regime and appetite from Trusts are promising. But that only works if the centre clarifies its enabling role – and sticks to it when delivery pressures bite.
This is a test moment. Will DHSC and Treasury hold the line on the freedoms they’ve promised? Or will they yield to the same financial caution that stopped FT freedoms in the first place?
The success of this Plan will depend not just on Trusts grasping the opportunity, but on the centre playing a different role in a different way. Then, the NHS can start catching up on overdue capital renewal.