The Emperors' New Clothes

There is a moment in the Hans Christian Andersen story where everybody realises the same thing at exactly the same time. The Emperor is naked. The courtiers know it. The crowd knows it. The advisers know it. But nobody quite wants to be the first person to say it out loud because everybody else appears to be nodding along politely at the brilliance of the invisible fabric.

Hans Christian Andersen's emperor was not deceived by malice. He was deceived by a collective unwillingness to state the obvious. Everyone in the crowd could see what was — and wasn't — there. The NHS is, at risk of stretching a metaphor only slightly, currently parading in a rather similar state of undress. The vision is magnificent. The garments, however, remain largely theoretical.

We are now several years into widespread consensus around the NHS “three shifts” agenda. Almost nobody disputes the direction of travel in principle. Moving care from hospital to community. Moving from analogue to digital. Moving from sickness to prevention. Conceptually, it is hard to argue against any of it. In fact, much of it is long overdue.

The problem is not the vision. The problem is that there remains a vast and uncomfortable gap between the vision and the operating reality of the NHS in 2026. Everybody can see it, but not many seem prepared to mention it.

This week, NHS Employers published resources from its OD in the NHS conference. Among them was an especially thought-provoking session from Linda Holbeche on the future of organisational development in the NHS. The accompanying slide deck paints a compelling picture of the workforce capabilities the NHS will need if the three shifts are ever to become reality. Invest in staff properly. Improve wellbeing and mental health support. Develop new roles with structured training and supervision. Redesign work around different workforce patterns. Build system-wide workforce planning capability. Use agentic AI intelligently to support workforce redesign rather than simply automate existing dysfunction. Develop analytical capability that supports prevention and population health management.

None of this is controversial. In fact, much of it is deeply sensible. It is exactly the sort of thinking the NHS should be engaging with if it genuinely wants to create a more preventative, community-oriented and digitally-enabled model of care. But reading through the material, one question kept surfacing.

Who, exactly, is leading this transformation in operational reality?

Not in conference presentations. Not in pilot sites. Not in innovation showcases. Not in strategy documents that speak fluently about “place-based partnerships” and “whole-system redesign”. In day-to-day NHS operations. Which organisations currently have the spare managerial bandwidth, workforce capacity, financial headroom and political stability required to fundamentally redesign care pathways while simultaneously trying to recover elective performance, reduce waiting lists, manage industrial relations, deliver financial balance and respond to rising demand? Because that is the part of the conversation that often feels strangely absent.

The recently published Targets and Trade-offs report from the NHS Alliance perhaps comes closest to acknowledging the uncomfortable reality. The report captures what many NHS leaders are quietly saying behind closed doors: organisations are overwhelmingly focused on survival.

• Keeping the lights on.

• 
  

• Balancing the books.

• 
  

• Reducing deficits.

• 
  

• Protecting urgent care performance.

• 
  

• Managing workforce morale during another round of cost improvement programmes.

The report notes that more than half of trust and GP leaders expect workforce cuts this year, while many organisations believe they may need to reduce services simply to meet financial plans. Staff morale remains a major concern across systems.

This matters because transformation is not cost-free. Real transformation requires leadership capacity, programme infrastructure, analytical capability, workforce investment, training time, organisational stability and, perhaps most importantly of all, protected space to redesign services before the old model collapses under the pressure of maintaining the current one.

The NHS is currently attempting to do both simultaneously. That is not impossible. But it is extraordinarily difficult. Take the shift from hospital to community. Almost every major NHS strategy document over the past decade has supported this ambition in one form or another. Yet acute hospitals remain under relentless operational pressure, community services are often fragmented and under-resourced, social care capacity remains fragile, and integrated working still frequently runs into the brutal reality of organisational finance.

System integration sounds elegant in policy documents. It is considerably harder when every organisation within the “system” is itself under severe financial strain and understandably reluctant to transfer budget, activity or risk elsewhere.

The same contradiction appears in workforce planning. We are still waiting for the publication of the next national workforce plan, following delays that feel eerily familiar. One suspects the challenge is not simply drafting the document. The challenge is reconciling two entirely different versions of the NHS workforce simultaneously.

The workforce we need today to safely run existing services. And the workforce we might need in ten years if the three shifts are genuinely realised at scale.

Those are not the same workforce models. One is labour intensive, hospital-centric and built around managing high levels of immediate demand. The other assumes greater digital maturity, stronger community infrastructure, more integrated neighbourhood working, increased automation, improved prevention and different professional boundaries. The gap between those two positions is enormous.

And what often feels missing is a transparent, funded, operationally-owned transition plan sitting between them. Not the destination. The bridge.

That is perhaps the part nobody quite wants to say aloud. Because once you acknowledge the scale of the transition challenge, the conversation becomes much less comfortable. It forces difficult questions about sequencing, affordability, workforce substitution, training pipelines, double-running costs and whether the NHS genuinely has the spare capacity required to transform while simultaneously trying to recover performance and reduce expenditure.

It also forces us to confront another awkward truth. Many of the most exciting examples of transformation currently cited across the NHS remain pilots, exemplars or localised proof-of-concept programmes. And pilots are important. They matter enormously. Innovation almost always starts at the margins. But pilot success and system transformation are not the same thing. The NHS has historically been very good at generating pockets of innovation. It has been considerably less successful at scaling them consistently across the service.

Which brings us, with some inevitability, to the workforce plan. Expected in Spring 2026, it now appears — on the basis of remarks made publicly at the Clinical Pharmacy Congress earlier this month — to be running to June at the earliest (Pharmaceutical Journal, 2026). This will surprise nobody who followed the delay to its predecessor. The 2023 long-term workforce plan was late for the same structural reason this one risks being late: the tension between the workforce needed to run the service today and the rather different workforce a transformed system would require is not a tension that resolves easily on paper. It requires either the political courage to be honest about the gap and the time needed to bridge it, or the analytical confidence to project past it. The House of Commons Library has noted that the 10 Year Health Plan itself was published without a specific implementation plan, with the workforce plan expected to carry much of that weight (House of Commons Library, 2026). Both the Health Foundation and the BMJ Commission welcomed the broad vision while noting the limited resources available for the transition. That is not ideological criticism. It is an observation about the difference between a destination and a map.

"Nobody has quite worked out how to write, clearly and in public, what bridging from here to there will actually cost — or who will be held accountable for closing the gap".

That is why the forthcoming workforce plan matters so much. Not because it needs to present another utopian vision of a transformed NHS in 2035. We already have plenty of those. What the system arguably needs now is something more grounded.

• What are the first practical steps over the next two to three years?

• Which workforce models should genuinely be prioritised for scaling?

• What should national bodies fund centrally?

• What capabilities should every integrated care system realistically be expected to develop locally?

• Where should investment in analytical capability sit?

• How will organisations be supported through double-running costs during transition?

• And perhaps most importantly of all: what should the NHS stop doing in order to create the bandwidth for transformation to happen properly?

One small child, in Andersen's story, finally says the obvious thing. The crowd hears it and knows it to be true. What the NHS needs now is not more eloquent descriptions of the transformed future — the OD community, to its considerable credit, can do that with genuine sophistication. What it needs is someone, somewhere with the authority and the honesty to say: here is what the first steps cost, here is who owns them, and here is what we will stop pretending is sufficient when it clearly isn't.

The emperor, after all, already knows he's cold.

Bibliography

Andersen, H.C. (1837) The Emperor's New Clothes. Copenhagen: C.A. Reitzel. [Fairy tale referenced as structural metaphor throughout.]

Health Foundation (2026) Cost pressures on the NHS will only grow. Available at: Health Foundation (Accessed: 18 May 2026).

House of Commons Library (2026) The 10 Year Health Plan for England. Research Briefing CBP-10368. London: House of Commons Library. Available at: https://commonslibrary.parliament.uk [Accessed: 18 May 2026].

Institute for Government (2025) Performance Tracker 2025: NHS. London: Institute for Government. Available at: https://www.instituteforgovernment.org.uk [Accessed: 18 May 2026].

King's Fund, The (2025) Securing the NHS Workforce for the Future: Recommendations for Action. London: The King's Fund. Available at: https://www.kingsfund.org.uk [Accessed: 18 May 2026].

Holbeche, L. (2026) The Future of OD. NHS Employers Conference Presentation, 7 May. Available at: NHS Employers PDF (Accessed: 18 May 2026).

NHS Alliance (2026) Targets and Trade-offs: NHS Finance and Performance Ambitions in 2026/27. Available at: NHS Alliance report (Accessed: 18 May 2026).

NHS Employers (2026) OD in the NHS 2026: Confidence in Change. Available at: NHS Employers event page (Accessed: 18 May 2026).

NHS Employers (2022) Catalysts for Change podcast with Mee Yan Cheung Judge and Linda Holbeche. Available at: NHS Employers podcast (Accessed: 18 May 2026).

The King’s Fund (2025) NHS priorities for 2026/27 to 2028/29. Available at: The King’s Fund blog (Accessed: 18 May 2026).