NHS reforms: how did we get here?

The 10-year plan was born out of a need to rescue the NHS; in 2024, the Darzi report described an NHS in ‘critical condition’, characterised by rising demand, increasingly inaccessible and untimely services, a demoralised workforce, falling productivity, deteriorating estates and buildings and unacceptable variation in quality of care. Together, these factors are seen to contribute to increasing morbidity, mortality and inequity in England. ^{Reference Darzi1}

Darzi reiterated the central role of the social determinants of health, including poor-quality housing, low income and insecure employment, as core drivers of the declining health of the nation and thus of increased demand on services. Moreover, Darzi pointed to a myriad of other systemic factors including austerity, starved capital investment, ripple effects of the pandemic, underinvestment in prevention and public health, inadequate patient and staff engagement, overregulation and frequent, costly and distracting system reorganisations.

Among the threats facing the NHS, Darzi highlighted chronic underinvestment in primary care, community services and mental health. Indeed, this very point was instrumental in informing one of the three core shifts of the 10-year plan – ‘hospital to community’. Darzi also painted a bleak picture of the nation’s mental health, characterised by an apparent rise in the prevalence of some mental health problems, increasing rates of referrals and lengthening wait times to access specialist mental health services, particularly for children and young people.

Rising demand

Demand for specialist mental health services in England has risen substantially in recent years. Between 2016 and 2024, the number of people in contact with services increased from ∼2.6 million to ∼3.6 million. ^{Reference Darzi1} Waiting lists have also grown considerably; by 2024, nearly 1 million people were waiting for first contact with mental health, learning disability or autism services. ^{Reference Darzi1} Of these, ∼345 000 had been waiting for over a year and, concerningly, around a third of these were young people (∼109 000 aged under 18). Referrals to NHS Talking Therapies are also consistently high, with over 1.8 million referrals and 1.2 million patients accessing support in 2024–25 alone. ² Demand for inpatient services also persistently outstrips capacity, contributing to long waiting lists for mental health beds and widespread inappropriate use of emergency departments for those in crisis.

Consequently, the UK government launched an independent review into mental health, ADHD and autism, with an interim report published in March 2026. ³ The report describes a gradual increase over recent decades in the underlying population prevalence of psychological distress and common mental disorders, particularly in young adults. In contrast, the prevalence of severe mental illness, ADHD and autism has remained broadly stable, despite an increase in diagnoses and self-identification of the latter two conditions. ³ The full report, when published, will hopefully inform implementation of the 10-year plan.

What does the 10-year plan say about mental health?

The plan is ambitious, calling for transformational changes to the NHS, encompassing three fundamental ‘shifts’ in focus, design and delivery of services: hospital to community, analogue to digital and sickness to prevention. Mental health features in several areas; among its 143 core pages, ‘mental health’ and ‘mental illness’ are cited a combined total of 58 times. ⁴ Many of these references to mental health simply nod to its general importance, while other mentions draw attention to specific patient groups (primarily those with severe mental illness) and gaps in service provision for those in crisis and for children and young people.

But beyond the rhetoric, what specific policy recommendations and meaningful commitments does the plan make to address rising demands on mental health services? The following sections reflect on specific mental health-related commitments made in the plan, linked to each of the three ‘shifts’, and discuss their relevance to mental health service provision in England.

Shift 1: hospital to community

The plan repeatedly argues for greater integration of primary, community and mental health services to achieve a multidisciplinary ‘neighbourhood health service’ that delivers care closer to home, including via neighbourhood health centres. However, there is a lack of clarity on what this looks like for mental health services.

The plan highlights challenges facing people with severe mental illness, including a lack of continuity of community-based care, often resulting in repeat emergency department attendances during mental health crises (characterised by unacceptably long waits in inappropriate clinical environments). In response, the following commitments are made: ‘We will transform mental health services into 24/7 neighbourhood care models. We will improve assertive outreach care and treatment to ensure 100% national coverage in the next decade, with a focus on narrowing mental health inequalities.’ Indeed, NHS England is currently piloting six neighbourhood adult mental health centres integrating community and crisis care, with 24/7 walk-in access and, in some cases, short-stay ‘bed’ availability. Such models may plausibly increase access to support, especially for those who fall through the gaps between existing community-based provision and secondary mental health services, or those facing other barriers to accessing existing services.

However, while these are laudable aims, it is unclear precisely what is meant by ‘24/7 neighbourhood care models’, how they will integrate with existing services and, crucially, how such systems will be staffed to deliver high-quality and safe care. While last year the government appeared to be on track to achieve its target of recruiting ‘8500 extra mental health workers’, the latest RCPsych workforce census highlights unsustainable staff shortages, with 1-in-7 consultant posts vacant and only one consultant psychiatrist for every 12 700 people in England (one for every 2540 people expected to experience a mental illness each year). ⁵ As a result, consultant psychiatrists are reportedly ‘being pushed to their “breaking point” by unmanageable workloads’. ⁵

The recruitment and retention crisis in psychiatry needs to be urgently addressed to resolve these workforce shortages. Otherwise, new and expanded service models will only stretch the workforce further, especially as reorganisation itself amplifies delivery challenges. It will also be important to carefully consider how ‘neighbourhood’ centres complement and interact with existing community-based models and GP practice-led mental health provision. Primary care is facing its own ongoing workforce pressures, yet the ‘shift to community’ may increase demand on GPs as they absorb work from secondary care and undergo workforce redistribution, further reducing their capacity to support those with severe mental illness. Resources and workforce investment must therefore also ‘shift to the community’, to offset pressures and mitigate this risk.

The plan recognises that while the ‘hospital to community’ shift is needed to strengthen early intervention and reduce escalation of needs, urgent care systems will remain vital for those in crisis. Consequently, the government commits to investing £120 million to ‘increase capacity for urgent mental health care by developing dedicated mental health emergency departments (MHEDs), ensuring patients get fast, same-day access to specialist support in an appropriate setting’. The ambition is for 85 MHEDs nationwide, ideally co-located with existing major A&E departments.

This commitment is welcome; however, concerns exist around the separation and polarisation of mental and physical healthcare, especially if MHEDs are not co-located. ^{Reference Mason, Marincowitz and Guthrie6} Careful consideration is needed to design integrated care pathways that safely and effectively connect patients with both mental and physical health specialist care as needed. If not, patients with concurrent physical health needs may receive less timely and comprehensive care, leading to worse outcomes. To the best of our knowledge, there are currently no publicly available data on progress made or preliminary impact of either the pilot mental health centres or MHEDs, nor has the government published a clear framework for their evaluation.

Finally, it is important to note that the community shift is not a new policy aim; it exists against a backdrop of numerous national plans and strategies over many decades. Twenty years ago, the Labour Government published ‘Our health, our care, our say: a new direction for community services’, which explicitly centred on prevention, early intervention and moving care closer to home. ^{Reference Reed and Stein7} Similarly, dedicated psychiatric emergency services are not a new concept, evolving from early iterations such as the Maudsley Hospital Emergency Clinic. We must learn from and build upon previous system reforms and service models to avoid repeating past failures. We also need greater clarity around precisely who the ‘shift to community’ stands to benefit most, how this will be achieved and how new service models will be evaluated.

Shift 2: analogue to digital

The plan relies heavily on the role of the NHS app in transforming access to services as a ‘digital front door’. In relation to mental health, it states how patients will be able to make self-referrals to specialist care, including mental health talking therapies, via the ‘My Specialist’ tool. This aligns with the government’s plans to expand NHS Talking Therapies to enable 915 000 people to access support by March 2029 (compared to 670 000 in 2024). The plan also describes how the ‘My NHS GP’ tool will offer access to ‘instant advice for patients who need non-urgent care, available 24/7’ and how AI algorithms will process patient enquiries and play a key role in providing personalised guidance.

Linked to this, the plan states ‘In the case of mental health, that could mean virtual therapists providing 24/7 support for mild or moderate need. For people with more severe illness, remote monitoring will help support a proactive response in crisis’. Clearly, the government is steering heavily towards telemedicine and AI-enabled ‘chatbot’ support. Yet the acceptability, efficacy and safety of ‘virtual therapists’ remains largely untested. We urgently need further research on the utility of digital mental health support, including chatbots, as part of frontline services. Moreover, given that access to services is increasingly ‘digital by default’, it is vital that health systems implement digital inclusion and facilitation strategies to address structural barriers, especially for socioeconomically disadvantaged communities. Otherwise, the rush to digital risks widening mental health inequities, particularly for those most in need including vulnerable and more severely unwell patients.

Darzi highlighted the chronic underinvestment in digital health technologies for community mental health services. For many practitioners, the plan’s digital vision will feel like a dim and distant prospect. Many healthcare professionals struggle with basic NHS IT functionality and electronic patient records, including having to manage multiple, often outdated and fragmented systems simultaneously without adequate training or support. Instead of rectifying more fundamental issues, overenthusiastic investment in novel digital technologies could be akin to ‘shaving a cyclist’s legs when the bike has no wheels’. ^{Reference Morgan8} To realise the plan’s digital aspirations, the government must provide the resources needed to support both staff and patients to access and use digital mental health technologies.

Shift 3: sickness to prevention

The plan recognises the critical role of primary and secondary prevention and early intervention during childhood and adolescence. Accordingly, the plan commits to ‘expand mental health support teams [MHSTs] in schools and colleges – and provide additional support for children and young people’s mental health through Young Futures Hubs’. Moreover, alongside these service offers will sit new primary care-led ‘neighbourhood multidisciplinary teams’, providing assessment and treatment for children and young people.

Although not extensively discussed, the commitment to develop local authority-led Young Futures Hubs is commendable. The Hubs’ three overarching aims appear rooted in prevention: increasing opportunities, improving mental health and well-being and reducing crime. However, Hub development is in the early stages; it remains to be seen to what extent these models build upon, or indeed replenish, existing youth service provision and how they interface with other parts of the system.

Notably, MHSTs are a pillar of the government’s approach to prevention of mental health problems during childhood and adolescence, with a vision of complete national coverage by 2030. Yet, there appears to be wide variability in implementation, coverage and systematic evaluation of impact on local systems. In light of this, in February 2026, the government launched an inquiry into how mental health support is provided in education and community settings and how this is integrated with specialist mental health services.

Furthermore, these models are all being introduced into a turbulent and rapidly evolving wider service landscape for children and young people, including the nationwide development of ‘Best Start Family Hubs’, which offer important routes to perinatal mental health support, and major special educational needs and disabilities (SEND) system reforms. Moreover, integrated care board (ICB) and local authority boundaries are themselves changing, which will affect how new service models are designed, delivered and funded. It is essential that this mosaic of organisations and services fits together in a coherent way. It is also important to recognise the immense pressures facing local authority social care and public health services, both of which have been chronically underfunded relative to need, despite them playing key roles in prevention. Failure to address these wider system issues will hamper the shift to prevention.

Finally, although not explicitly framed around prevention, the plan highlights an aim to support patients into employment: ‘We will continue to expand provision of Individual Placement and Support schemes to help people with severe mental illness or drug and alcohol addiction find good work, provide employment support through primary care and offer employment advice to those accessing talking therapies.’ It is positive to see a health plan make these commitments, given the strong bidirectional relationships between good employment, socioeconomic circumstances and mental health. ^{Reference Kirkbride, Anglin, Colman, Dykxhoorn, Jones and Patalay9}

What else is missing?

Absent from the plan is recognition of the physical health inequity and premature mortality faced by those with severe mental illness, and the mutually preventative role of addressing both physical and mental health needs simultaneously. Service models evolving from the plan must consider how patients with mental health problems can better access physical health support, and vice versa. Greater integration with GP services via neighbourhood health centres offers a tangible way to achieve this. More broadly, to reduce health inequities, new service models must systematically embed equity and public mental health principles throughout their design, delivery and evaluation. Otherwise, the plan’s overall ambition to halve the gap in healthy life expectancy between the richest and poorest regions in England will fail.

It is also important to note the wider context into which the plan has emerged, including the abolishment and absorption of NHS England into the Department of Health and Social Care, with ICBs expected to lead the commissioning and delivery of neighbourhood health while simultaneously cutting their running costs and staff numbers by ∼50%. While the plan does highlight workforce issues, it presumably leaves much of the detail to be addressed by the upcoming ‘10 Year Workforce Plan’. It is essential that system reconfigurations are evidence-based and that service development is informed by ongoing research and evaluation, which itself requires sustained, systemwide investment. Moreover, the plan does draw attention to the need to improve ‘staff experience’ and well-being but should have been more ambitious in its commitments and relies too heavily on technological solutions. Staff health and well-being must be at the heart of all service models, especially given the pressures. Not giving this due attention will be a critical omission and will lead to further burnout.