Health ministers in England face hard choices in 2025

Two narratives emerged from Wes Streeting’s first appearance before the House of Commons Health and Social Care Committee on 18 December 2024.1 The first focused on the pressures faced by the NHS, notwithstanding funding increases announced in October’s budget. In discussion with members of the committee, Streeting showed that he has moved on from campaigning to governing in acknowledging the hard choices that must be made.

Intense discussions are underway between the Secretary of State for Health and Social Care, the Department of Health and Social Care, and NHS England, working in the looming shadow of the Treasury on how this funding should be used. The outcome of these negotiations will be revealed in annual planning guidance for the NHS, now expected later in January 2025.

Despite the additional funding announced in October’s budget, 2025/26 promises to be a very tight year for the NHS in the face of rising demand for care in different sectors. Reducing waiting times for elective care will require funding increases in view of Keir Starmer’s commitment to deliver a maximum 18 weeks’ wait for 92 per cent of patients by the end of this Parliament. The government’s plans in this area, announced by the prime minister on 6 January 2025, include giving patients more choices and offering incentives to hospitals and GPs to reduce waiting times.

Wes Streeting has also announced additional funding for general practice to reverse the recent trend of it receiving a declining share of NHS resources. Darren Jones, chief secretary to the Treasury tweeted his support for this announcement and his role in making it happen—a reminder of the Treasury’s key role in decision making.2 Add the government’s promise to maintain the mental health investment standard, under which funding for mental health services increases in line with overall financial allocations, and provide extra support for hospices, then opportunities to develop other areas of care are already constrained.

Streeting conceded as much in his evidence to the committee. In discussing prospects for the coming year, he spoke of the necessity of making choices and trade-offs, adding that he was “up for a debate throughout the NHS about which targets are useful and which are not.” He added that the NHS is over centralized and that hard choices are required because “if we try to do everything for everyone, everywhere, all at once, we will fail.”

Streeting also acknowledged the limits of his power to bring about change, explaining “I have to mobilise all the people who work in (health and social care) and use those services to help me drive the performance we need.” If this commitment survives first contact with performance failures in the NHS, its impact could be genuinely liberating for local leaders and staff. Streeting’s resolve will be tested by the expectation of parliamentarians that the Secretary of State should be personally accountable for everything that happens in the NHS and intense media scrutiny when things go wrong.

What happens to services not identified as high priorities is the big unknown. Urgent and emergency care is already experiencing huge pressures with patients dying and being harmed by long waits in hospital emergency departments. Another example is maternity services which in some hospitals have recently struggled to deliver good care as assessed by the Care Quality Commission.3 There have also been reports of mothers being transferred when their hospital of choice is unable to provide care.4

The pressures on NHS funding in 2025/26 will likely require stretching productivity improvements of between four and five per cent.4 At a time when current budgets are in deficit, this is a reminder that the increases announced in October are not a panacea. It is also important to recognise that spending on other public services that have an impact on the need and demand for care has not benefited in the same way as spending in the NHS.

This links to the second narrative in Streeting’s evidence in which he emphasised the urgency of reducing demand for care by tackling the wider determinants of health and wellbeing, now and in the future. These are issues to be addressed in this year’s spending review. The government will then have to decide whether improving the health of the population is a higher priority than improving health care and what this means for public spending for the next three years.

If the NHS continues to be favoured, this will constrain the government’s ability to moderate the drivers of ever rising healthcare spending. On the other hand, if improving health is a priority, as Labour’s election manifesto suggested,5 then resources will need to be redirected to the early years, tackling poverty, air pollution, and housing. Failure to do so could result in the growing burden of disease overwhelming the NHS.

The 10-year NHS plan, to be published in May 2025, must confront these choices and be clear about the consequences. The public’s attachment to the NHS will weigh heavily in the government’s decisions as will the need to find a sustainable solution for social care, although hard choices on social care have been postponed until the final report of the Casey Commission not expected until 2028.6 The coming year is a watershed which will define the future of the NHS and the government that acts as its steward. That is when the serious business of governing really begins.