By Laurence Smith, Greybeard Healthcare Co-Founder
June 2026
James Murray, Labour Member of Parliament for Ealing North, was appointed to the role of Secretary of State for Health and Social Care in May 2026. This followed a limited Cabinet reshuffle triggered by the resignation of Wes Streeting, who previously occupied the health brief. Murray became the 25th person to hold the role since its creation in 1968, and takes on the responsibility at arguably the most challenging time in the history of the National Health Service (‘NHS’).
In this short article, Greybeard discusses the six issues which, we suspect, are near the top of his in-tray:
- Workforce establishment planning
- Modernization of the legacy estate
- Delivery of innovation
- Patient access
- Social care integration
- Tighter funding settlements
Workforce establishment planning
It might seem counterintuitive for ‘workforce’ challenges to be identified as a major concern for an organisation employing over 1.5 million people, especially given the increase of around 260,000 since 2010. However, a lack of long-term coordination has meant many of these roles are created on a reactive basis, and filled through emergency recruitment from overseas and the use of agency staff (approximately one-quarter of NHS staff are recruited internationally).
The NHS’s first ‘Long Term Workforce Plan’, published in 2023, acknowledged that the situation had “limited our ability to best use the skills of NHS staff, the ability to set out forecasts of future need and then act on them, and being able to properly link workforce, service and financial planning” [1]. As a result, notwithstanding the size and scale of the workforce, reported vacancies were already 112,000 – forecast to grow, in the absence of corrective action, to between 260,000 and 360,000 by the mid 2030s.
Building a workforce which is aligned with future needs will require multiple interventions, including:
- Increasing the pipeline of domestic talent through the various professional pathways – medical schools, GP and dentistry training, nurse training, and apprenticeships
- Retention of highly skilled staff through revitalising the NHS’s culture (extensive evidence exists to show how excessive bureaucracy has driven away top talent), flexible working opportunities and support for professional development
- Retraining highly qualified medical professionals to ensure they have the right skills for a rapidly changing healthcare landscape – including emerging areas of specialty and competence such as robotics, personalized medicine and mental health
Modernization of the legacy estate
The legacy NHS estate is vast, comprising around 130,000 buildings (hospitals, clinics, administrative offices, and more), and adding up to a combined floor space of 42 billion square feet [2] – perhaps easily to visualise as more than half a million football pitches.
When considering a property strategy, there are a number of benefits in having a legacy estate, particularly one of this scale. For example, someone else has already completed the heavy lifting around identifying space, overseeing building works, and negotiating property-related contracts. However, there is a counterbalancing disadvantage which in many cases overwhelms these considerations. If the legacy estate is not fit for purpose, it becomes a millstone. Properties are in the wrong places, configured for services that are no longer provided, and built to inefficient specialisations.
Analysis conducted by Wilhem, an Australian firm of healthcare engineers, estimates that the lifetime operating cost of new build healthcare facilities can be up to 28 per cent lower than that of legacy premises. Examples of the financial burden of obsolete hospital real estate include “higher maintenance expenses, greater energy consumption, the need for more frequent repairs or replacements … manual handling injuries, and (poor) infection prevention.” [3]
Modernizing the NHS’s legacy estate cannot happen overnight; however, a strategic approach to property over a 15 to 20-year period will free up considerable resources for frontline care. Priorities include:
- Final delivery of the NHS estates optimisation plan, initially drafted by Lord Carter [4]. This includes a reduction in space allocated for non-clinical activities, and maintaining the non-utilized space ratio below 2%
- Future-proofing new build hospitals through modular designs
- Accelerating the shift away from hospital-based care, except when essential – through use of virtual technologies for consultation, hospital at home capabilities, and the piloting of micro-hospital solutions which are shown to benefit patient experience, operational efficiency, scalability and technology integration [5].
Delivery of innovation
There is an impressive body of literature that explores the systemic failure of large organisations to innovate rapidly and effectively. One influential report attributes this phenomenon to three features: a “lack of top management support and attention”, a “reluctance to experiment”, and a “failure to pivot” [6]. Another cites factors such as the “myth of the lone genius”, a “fear of failure and short-term thinking”, and “bureaucracy and lack of agility” [7].
These struggles have been apparent throughout the history of the NHS, but addressing them is now mission-critical due to the speed of change in the practice and delivery of healthcare globally. Very few of the ground-breaking innovations in the past 15 years have originated in the UK. For example, virtual hospital models have been pioneered in the United States; the Gulf States are at the forefront of genetic medicine and healthcare A.I.; and there have been some remarkable applications of robotics in precision treatments in South Korea and Japan.
To accelerate innovation within the NHS, the following tools could be of value:
- Central horizon scanning to set priorities according to agreed criteria – this will have the side benefit of reducing the inevitable duplication of effort when different silos within the health service are simultaneously pursuing overlapping projects
- A ‘skunkworks’-style framework whereby innovation can be piloted, prior to rollout, without the constraint of policies developed for BAU operations
- A gating system that filters innovation ideas objectively and according to the evidence (perhaps modelled on the disciplines used in private equity to screen out 95 per cent of business cases to drive focus on those meeting investment criteria)
Patient access
For many years, politicians boasted that the NHS’s free-at-the-point-of-use operating principle made it the “envy of the world”. Since the mid-200s, this phrase has fallen from fashion, for one reason above all others: as more British citizens experience alternative healthcare systems while living and working abroad (or, at least, read about those systems through internet blogs and podcasts), they realise there are yawning gaps in the standard of care and service delivered.
The UK now falls short of global benchmarks on multiple outcome measures, for example, around cancer survival rates, but possibly the sharpest differences relate to access, which, in the absence of a price mechanism, has become the default tool used by the NHS for managing demand. At a time when customers of other types of products and services have become accustomed to instant gratification, healthcare in the UK now involves waiting times that would be unimaginable in most other developed countries.
Almost 9 per cent of patients are forced to wait more than 22 days for a GP appointment [8], and the waiting list for elective treatments stands at 7.1 million people, up from 4.6 million before the Covid pandemic (just 65% of patients are now seen within the target 18-week period). The average wait time for diagnostic tests is 17 days, and for elective treatments it typically ranges from 18 to 40 weeks. The situation is equally stark in emergency care; in the past 12 months, more than 1.56 million people have waited more than four hours in A&E before being admitted, transferred or discharged [9]. Some of these numbers are almost incomprehensible to patients in, for example, the Gulf countries, where same-day primary care appointments are the norm.
One of the Greybeard team recently shared his personal experience, giving a sense of the human impact behind the raw numbers: “A while back, I remember going onto the NHS website to look for an appointment for something very simple and it said the first one available would be in 152 weeks – so three years. Another example – the doctor who prescribed blood thinners sets up a periodic check with me – this got moved from February 2026 to May at a time I couldn’t make. I phoned up to change it, and they said: ‘We can’t find your appointment .. oh no wait a minute it has been moved to May 2027!’”
Regrettably, there is no magic formula for fixing access, but international experience suggests that a range of tools can play a part:
- Increasing capacity through flexible opening hours, a range of slot times (reduced for repeat cases), and active management of virtual consultations as a legitimate alternative to in-person encounters
- Combatting the number of highly qualified physicians choosing early retirement, when their retention (for example, on a sessional part-time basis) would provide an immediate capacity boost
- Referral pathways embedded into workflows, using decision trees to determine which patients do (and do not) meet the threshold for specialty referral
- Active management of no-shows and late cancellations (for example, appointment reminders)
- Planned discharge of inpatients before noon to free up bed capacity
Social care integration
It has long been recognised that an unintended consequence of the UK’s particular funding and organizational arrangements has been to create structural barriers between healthcare and social care: “the NHS is largely free at the point of use and funded by general taxation, whereas social care is means-tested, administered by local authorities, and requires contributions from service users” [10]. Making matters worse is that the two sectors operate under separate regulatory regimes, and employment conditions and pay scales can vary widely. Even issues as basic as the different geographical boundaries of health and social care authorities can impede collaboration.
Inefficiency is an easily measured result of the absence of coordination. For example, in 2021 an estimated 10,000 patients were occupying hospital beds not because they required inpatient care, but because of delays in the next stage of care, including “a residential home, or rehabilitation unit, or a smaller community hospital, or a lack of a supportive care package for their return home” [11].
Even more worryingly is the impact of integration failures on care quality, especially for people suffering from multiple health issues, requiring complex and continuous care. In 2023, a House of Lords report expressed this risk in dramatic terms, stating that patients were “endangered … because they are not receiving joined-up care, in the right place, at the right time” with “profound consequences for their long-term health”. It provided examples of patients who have suffered vision loss because of the mishandling or loss of records between services, and other instances of patients who, in despair, head to their local A&E when they feel there is “nowhere else to turn” [12].
The incoming Secretary of State will need the precious skill of “knocking heads together” (figuratively, of course!) if he is to accelerate many of the solutions which have been advocated by subject experts in both fields over many years, including:
- Integrated care systems underpinned by the sharing of electronic records between approved organisations
- Multidisciplinary teamwork to overcome barriers; for example, NHS staff, community nurses, social workers and allied health professionals working together on shared projects with pooled budgets, attending common training programmes, and located in the same premises
- Population health initiatives that reflect the priorities at a local level, and in which all relevant health and social care providers participate
- Celebration of success to build confidence and momentum
Tighter funding settlements
Exacerbating each of the previous five challenges is the unavoidable fact that the NHS is unlikely to continue enjoying the 3.7 per cent average real-term growth in funding from which it has benefitted for much of the past three decades (and which has resulted in a doubling of the absolute real-term budget since the mid 1990s) [13].
The constraints that will affect future funding settlements include the UK’s anaemic growth rate, the fiscal rules imposed by HM Treasury to control the size of the national debt, and commitments to turbocharge spending in other priority sectors such as defence. Despite the challenges of an ageing population, it is foreseeable that future NHS budget increases may simply track the 1.0% to 1.5% underlying growth rate of the wider economy.
As the incoming Secretary of State considers his options, the following strategies are likely to emerge as pragmatic routes for mitigating the consequences of tighter funding settlements:
- Productivity improvements: NHS England has estimated that productivity needs to improve by a minimum of two per cent per annum (compared with a historic increase of 0.5% per annum); if achieved, this would free up the equivalent of £17 billion per annum [14]. Jeremy Hunt, the UK’s longest serving Health Secretary, has written: “From my battle with the doctors, I learnt the hard way just how difficult it is to improve public sector productivity – even if the need to do so is blindingly obvious. The physical and mental exhaustion involved is one reason why the reform we so desperately need often ends up being ducked or dodged by ministers.” [15].
- Greater use of the private sector, either for routine clinical services such as cataracts or to provide overflow beds
- Digital transformation and system consolidation and integration: This will have the dual benefit of managing the IT costs across the many organisations comprising the service, as well as promoting consistency of data definitions and comparisons (please refer to numerous other Greybeard articles for examples of use cases and expected benefits)
- Closing gaps in operational performance by learning from best practice between different NHS providers, including length of stay benchmarks and appropriate levels of spend on agency and bank staff (a National Cost Collection exercise has been underway since 2024, so that all NHS Trusts understand where the 50 percentile and 75 percentile points lie)
- Capital spend: applying a consistent mechanism with a blend of measures (financial, patient, workforce, quality, operational) to ensure projects receive funding based on merit rather than political or other pressures.
In closing
A fortnight after his appointment, James Murray stated in the House of Commons that “our priority is to boost investment and to modernise the NHS for the future; it is exactly that combination of investment and reform that will deliver the health service that constituents need and deserve. [16].
Greybeard hopes the ideas explored in this article are a constructive contribution to an assessment of which interventions are most likely to deliver this outcome.
Notes
[1]. NHS Long Term Workforce Plan, June 2023
[2]. Health Business, https://healthbusinessuk.net/features/making-savings-nhs-property#:~:text=The%20NHS%20alone%20has%20around,Government%20Property%20Strategy%20has%20an
[4]. Lord Carter, ‘Productivity in NHS hospitals’, February 2016
[5]. Modern Clinical Planning, ‘Micro-Hospitals vs. Traditional Hospitals: A Cost-Effective, Repeatable Model for Modern Healthcare Expansion’. May 2025
[6]. Serguei Netessine (Professor of Operations, Information and Decisions at the Wharton School, University of Pennsylvania). ‘Why Large Companies Struggle With Business Model Innovation’, INSEAD Knowledge, Sept 2013
[7]. Tom Ferris, ‘Why Most Companies Fail at Innovation (And How to Fix It)’, New Icon, March 2025
[8] Joe Gerrard, ‘One in 10 faces three-week wait for GP appointment’, BBC, April 2024
[9] British Medical Association, ‘NHS backlog data analysis’, May 2026: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis
[10]. Richard Humphries, ‘Integrated health and social care in England – Progress and prospects’, Science Direct, July 2025
[11]. Cook BA. Why is the Government not taking more action to alleviate the blocking of hospital beds? 2021. https://www.bettal.co.uk/why-is-the-government-not-taking-more-action-to-alleviate-the-blocking-of-hospital-beds/#:∼:text=Bedblockingisamajor. Accessed June 2022
[12]. House of Lords, ‘Patients at the centre: integrating primary and community care’, Report of Session 2023–24, December 2023
[13]. George Stoye et al, ‘The past and future of UK health spending’, Institute of Fiscal Studies, May 2024
[14] Elizabeth O’Mahony, Chief Financial Officer, NHS England, ‘NHS Financial performance update’, July 2025
[15]. Jeremy Hunt, ‘Can We Be Rich Again?’, published by Swift Press, June 2026
[16]. As reported in ‘Health Bill in House of Commons draws questions on data privacy, inequalities, and Single Patient Record’, Health Tech Newspaper, 2 June 2026: https://htn.co.uk/2026/06/02/health-bill-in-house-of-commons-draws-questions-on-data-privacy-inequalities-and-single-patient-record/
