The 2025 Comprehensive Spending Review (CSR) delivered a strong and much-needed signal that health is once again at the centre of the national agenda. With an above-inflation increase of around 3% per year in NHS resource spending and record capital allocations—including billions for digital transformation and estates renewal—the government has recognised both the symbolic and structural importance of the NHS.
But once the applause dies down in Parliament—and the banners about “record investment” are taken down—we face a more sobering question: what now?
That question is made all the more urgent by a stark warning from the British public. The latest British Social Attitudes survey shows that satisfaction with the NHS has fallen to just 24%—a record low in over four decades. Over half of respondents say they are dissatisfied. This isn’t just discontent; it’s a burning platform. Public trust is ebbing away, even as financial commitment surges. That tension cannot be ignored.
The broad contours of the settlement are clearly positive. The £29 billion resource uplift by 2028–29 allows for strategic investments: expanding GP and dental access, embedding mental health support in schools, and enhancing digital pathways through the NHS App. On the capital side, the commitments are even more eye-catching. The government has pledged up to £30 billion for NHS estates over five years, including £5 billion to address critical repair backlogs. Another £10 billion is allocated for digital transformation—vital for improving productivity and enabling patients to manage care more easily.
These are the kinds of commitments the service has long asked for. After years of revenue-heavy but infrastructure-light budgets, the shift toward bricks, bandwidth, and backend systems is overdue.
However, the figures deserve close attention. Capital investment will likely peak in 2025–26 at around £17 billion before falling slightly in real terms by 2028–29. The £10 billion for digital—while welcome—still falls short of independent estimates suggesting full digitisation across health and care could cost more than £21 billion. The risk is that enthusiasm for “shiny new” projects overshadows persistent challenges around maintenance, legacy systems, and workforce readiness to make use of new tools.
More fundamentally, the CSR’s generous headline for health masks growing pressure across the rest of government. The Institute for Fiscal Studies has made it clear: allocating 2.5–3% real growth to the NHS leaves virtually nothing for other departments. And therein lies the rub. Without stronger support for social care, local government, and public health—sectors that remain financially constrained—the NHS risks becoming a better-funded island surrounded by struggling partners.
This has real implications for the NHS’s ability to “shift left”—moving care upstream into prevention, early intervention, and community-based management. It’s not simply a matter of funding community services more. ICBs will need to make tough choices about the relative value of interventions across pathways and population groups. This means prioritising not just based on what is politically visible or quick to deliver, but what will have the most sustained impact over time.
We need to reframe what “spending well” means. Allocative efficiency must sit alongside economic efficiency. More clinics and more staff are only part of the story. The bigger prize is getting the right mix of services, in the right places, to keep people out of hospital—not just moving them through it faster.
For Integrated Care Boards (ICBs), the temptation will be to anchor decision-making around the marginal increases. But the real challenge—and opportunity—is to focus on total spend. This means becoming the strategic commissioner and intelligent payer described in NHS England’s model ICB blueprint.
While £29 billion in additional resource sounds like a windfall, it is modest compared to the overall NHS budget, which will rise from around £193 billion in 2025–26 to £226 billion in 2028–29. This broader fiscal context—not the marginal growth—must frame all commissioning decisions.
ICBs must avoid slipping back into reactive contracting and incremental service expansion. The CSR gives them the tools and the mandate to act differently. That means crafting system-wide investment plans, not allocating marginal growth year by year. It also means using data and evidence to understand the opportunity cost of continuing with low-value services that crowd out prevention and community-based care.
Some ICBs are already stepping up—developing outcomes-based commissioning frameworks and mapping service footprints against health inequalities. But this must go further and become the norm, not the exception.
The 2025 CSR is perhaps the most optimistic financial settlement the NHS has received in a decade. But optimism does not equal impact. Unless capital investment is matched by sufficient workforce growth, unless digital tools are adopted and not just purchased, and unless place-based partnerships work to rebalance care away from acute beds, the “record funding” may yield disappointing results.
Most crucially, unless that funding delivers visible improvements for patients, it will do little to reverse the steep decline in public satisfaction. And if trust continues to fall, the political licence for further investment—no matter how justified—will erode.
This review gives the NHS a chance to move beyond crisis management. But in doing so, it asks more of leaders—not just to spend more, but to spend smarter. The left shift isn’t a line in a strategy document; it’s a different logic of care. With public trust on the line and fiscal headroom narrowing elsewhere, this may be the best chance in a generation to get it right.
