From plan to practice: Reacting to the 10-Year Plan in Greater Manchester

The meeting, held against the backdrop of a period of seismic reform for the NHS and wider care system, revealed both the promise and pain points of system integration. Stakeholders present emphasised leadership, system-wide data use, behaviour change, and trust as critical enablers of transformation. Participants included NHS trust CEOs, ICS leaders, clinicians, and senior public health officials from across Greater Manchester, considered to be one of the most integrated health systems in England.

The dinner also featured a presentation from HealthPathways Advisor, David Meates, who previously led the integrated Canterbury Health System in New Zealand. HealthPathways supports clinicians across New Zealand, Australia, and the UK by providing access to evidence-based best practices at the point of care. Its system-wide approach to care pathway redesign has demonstrated significant benefits for patients, staff, and health systems. Notably, its work with New Zealand’s Canterbury District Health Board resulted in marked improvements in productivity and patient outcomes across the system, highlighting the importance of prioritising cultural change, intelligent incentivisation, and ongoing community and patient engagement.

Despite widespread agreement about the direction set out in the 10-Year Plan, there was a clear sense from the meeting that national policy has so far failed to address the deeper behavioural, cultural and financial architecture that will determine whether the plan succeeds or fails.

A region built for integration, still struggling with fragmentation

Greater Manchester, with its devolved governance model and longstanding commitment to integration, is arguably the most fertile ground in England for delivering on the ambitions of the 10-Year Plan. With nine provider trusts and deep collaboration with the Greater Manchester Combined Authority, the region has made major advances in data sharing, population health management, and broader public service alignment.

However, challenges for the region remain stark. There remain significant post-Covid performance pressures, and Greater Manchester has some of the longest waiting lists in the country, in addition to large-scale financial deficits. “We’ve built some of the most sophisticated integrated data infrastructure in the UK,” said one attendee, “but we still face fundamental problems of access and inequality.”

As one trust leader put it, “We’ve made progress, but we haven’t yet cracked the problem of how to enable the system to truly work as one.”

Vagueness as virtue or risk?

The 10-Year Plan has been welcomed in Greater Manchester for its broad framing and long-term outlook. However, delegates argued that the plan’s perceived vagueness is a liability to tangible service improvement. “The plan leaves the hard questions, such as trade-offs, funding and prioritisation, on the table,” one participant said. “NHS England makes a virtue of this in order to give local leaders space to develop local solutions. However, we need clarity about who is empowered to answer those questions locally.”

David Meates pointed to the opportunity inherent in this ambiguity. “Don’t wait for the centre to tell you what to do,” he said. “Use that space. Make it yours.”

There was widespread agreement that success now depends on local leaders stepping into that gap, with both strategy and delivery. “This isn’t a conversation we can leave in Whitehall,” one attendee reflected. “This is about what we do locally.”

Lessons from New Zealand

Many of the issues faced by David Meates when he took over the Canterbury system have clear parallels to NHS struggles, including a fragmented system and a lack of local cohesion. As Meates articulated, exponential increases in funding from previous New Zealand governments had yielded little to no improvement in service delivery, productivity or patient outcomes.

Meates’ team sought to create a framework for “a connected system, centred around people, that aimed not to waste their time”. This was built upon three core strategic objectives:

• People take greater responsibility for their own health
• People stay well in their own homes and communities
• People receive timely and appropriate care

Crucial to addressing these issues was the creation of the community-based HealthPathways, aimed at improving the interface between secondary and primary care. After reviewing a backlog of referrals, clinicians identified that many common issues could have been prevented through better communication between hospitals and primary care providers. GPs and hospital specialists were then brought together to agree on optimal management and referral pathways for specific conditions. The HealthPathways methodology is currently gaining traction as an approach across the Northern hemisphere, including England and Wales.

The left shift: Still a distant reality?

Participants echoed a now-familiar frustration: that the NHS continues to talk about shifting care into the community while still funnelling most funding and attention toward acute settings. “NHS England isn’t taking the left shift as seriously as the Greater Manchester system is,” one leader argued.

There was deep concern that the national focus on individual provider performance and waiting list targets was actively pulling against the system logic of integration and prevention. “If we keep paying for activity, we’ll keep getting activity,” one speaker noted. “We need to change what we value and how we fund it.”

Instead of continuing to reward throughput, participants called for an urgent shift toward outcomes-based funding. “The current incentives are not aligned with what patients actually need or what the system is trying to achieve,” said another attendee.

From data to delivery

Several leaders highlighted the power of Greater Manchester’s linked datasets, which have begun to reveal critical insights into unmet need, health inequality, and clinical variation across the region. One senior clinical lead described how analysts had used linked data to identify patients receiving suboptimal care, stratify risk, and deploy neighbourhood teams to intervene.

“We’ve used data to change how we deliver care at the local level, but the opportunity is far bigger,” they said. “This is about system-wide intelligence, not just analytics.”

However, others warned that data alone would not deliver change. “We’ve got brilliant information,” one attendee noted, “but unless it’s made usable, and unless we align it with pathways and accountability, it’s just noise.”

One participant summed up the challenge: “Change happens at the speed of trust. If the system doesn’t trust the data, or the people using it, it won’t move.”

The cultural fault lines: Professions, power, and permission

The discussion often turned to the deeper cultural and behavioural dynamics holding the system back. Professional silos, legacy power structures, and the politics of hierarchy were seen as major obstacles.

“We [system partners] have irritated each other for years,” said one participant. “The radicals and the pragmatists, the commissioners and the providers. And we’re still stuck with binary questions such as: who controls the money? Who owns the patient?”

Several attendees emphasised the need to move beyond organisational identities toward collective purpose. One leader said: “There’s no such thing as integrated neighbourhood teams if you don’t have full primary care at the table. We need inclusive leadership, and we need to stop second-guessing what communities want.”

Others argued for a more clinician-led approach to transformation. “You can’t prescribe behaviour change to doctors,” one attendee noted. “Ask them to define the problem and let them solve it. That’s where the buy-in comes from.”

Funding, incentives, and the problem of productivity

A recurring theme was the mismatch between national funding mechanisms and local ambitions. “Strategic commissioning? Wasn’t commissioning always supposed to be strategic?” one participant asked.

Several leaders warned that simply rebranding roles or structures, without real changes to financial flows, will have little to no impact. “The incentives are still fundamentally wrong,” said one. “And if we don’t fix that, the 10-Year Plan is just a dream.”

There was a strong appetite for exploring new financial models, especially those that allowed local areas to reinvest savings, take managed risks, and move money around the system to meet citizen needs. “If you’re funding institutions, you protect institutions. If you’re funding outcomes, you protect people.”

Reimagining public health as everyone’s business

Public health leaders voiced concern that prevention still sits too far outside the core machinery of the NHS. One commented: “We have to stop defining health in such a narrow way. The system still treats public health as someone else’s job.”

David Meates noted that in Canterbury, integrating public health into mainstream service delivery had been one of the toughest challenges, but the most essential. “Public health has to be seen as a system-wide priority,” he said. “It’s about changing the narrative, not just the structure.”

Others called for a broader conceptualisation of prevention beyond the medical model, one which encompasses education, employment, housing, and lifestyle. “Hairdressers are frontline,” one leader said, “and professions such as taxi drivers should be considered part of the health system.”

From rhetoric to results

The dinner concluded with a clear message: the opportunities presented by the 10-Year Health Plan are real, but only if local systems seize them and develop local solutions in collaboration with system partners.

“We have to stop waiting for permission,” said one attendee. “Use alliance agreements. Build partnerships. Change the story from ‘I’ to ‘we’.”

As one final reflection summarised: “This is about codifying change, not just for the boardroom, but for the clinic, the pharmacy, the community centre. The 10-Year Plan won’t work because it’s written down. It’ll work because people make it work together.”