NHS priorities for 2026/27 to 2028/29: what does it mean for the system, staff and patients?

The government has published its national NHS planning guidance – rebadged this year as the Medium Term Planning Framework. This is a suite of documents that set out the national priorities and targets for local systems for the next three years.

This is the first major document setting out performance priorities and expectations for local areas following the 10 Year Health Plan. That plan, published in July, was extremely light on implementation detail, so the publication of this guidance – shedding light on expectations for what leaders should be doing – will be met with some relief. It is also welcome that the guidance covers a three-year horizon, giving more clarity for longer, and comes much earlier in the year than planning guidance in recent memory, giving more advance notice of expectations.

The document is strongly aligned with the 10 Year Health Plan, covering the three shifts plus focuses on system reorganisation; financial rewiring; patient experience and care quality; workforce – all the major areas as set out in the plan. On top of this, there are a range of targets relating to operational performance and transformation, sticking with elective recovery waiting list targets while ratcheting up ambition in a range of areas including urgent and emergency care and cancer.

Politicians are trying to balance both what matters most to patients (whether they can get the care they need when they need it) and necessary longer term system transformation. But this leaves local leaders with a huge range of priorities and areas to juggle all at once, against a tight financial settlement.

Below some of our experts give their analysis on some of the key areas of the framework. Which areas have got the most attention, where is further detail needed, and if the guidance is followed, what change will we see?

NHS performance recovery

'Growing expectations against a shrinking share of spending' Katie Purbrick-Thompson

Katie Purbrick-Thompson

Policy adviser

The guidance again reaffirms the government's aim to reinstate the constitutional standard of 92% of patients waiting no longer than 18 weeks for elective care by 2028/29, with an interim target of 70% by 2026/27. Currently more patients join the waiting list each month than receive treatment – so this will be extremely tough to achieve. The longer waiting times faced by children and young people for elective care are highlighted in the guidance, with an instruction to systems and providers to improve this – a welcome, although vague, ambition.

The guidance sets out some stretching ambitions for urgent and emergency care, with significant ramping up of the targets for 4-hour A&E performance and ambulance category 2 response times. These targets feel challenging when the system is currently a long way off meeting them even in summer when demand is much lower than in winter. A forthcoming Model Emergency Department document will shed some light on how trusts will be expected to achieve this.

Community health services are a new addition to the 18-week-wait target. The guidance states that 78% of community health service activity should be carried out within 18 weeks by 2026/27 and 80% by 2028/29.

It is striking that mental health targets are not currently backed by a recommitment to the Mental Health Investment Standard (MHIS). Previous guidance stated that investing in line with the MHIS was an expectation for integrated care boards (ICBs). Mental health ambitions include a target to eliminate out of area placements – a target first announced in 2016, but limited progress has been made on this to date.

The government’s election manifesto pledged to restore all waiting times back to constitutional standards, and this framework echoes that ambition. But many of these targets are hospital-based and another ambition set out in the 10 Year Health Plan is to reduce the share of frontline spending on hospitals – so there are growing expectations against a shrinking share of spending.

Primary care and neighbourhood health

'The current focus is on keeping high priority cohorts out of hospital' Beccy Baird

Beccy Baird

Senior Fellow

In many ways the planning guidance for neighbourhood health isn't radically different from the neighbourhood health guidelines NHS England published in January 2025. There’s a focus on integrated care teams serving ‘high priority cohorts’ (people who have moderate to severe frailty, are living in a care home, are housebound or are at the end of life) in order to keep them out of hospital. While a New Model Neighbourhood Framework is expected in November, setting out definitions, goals and the scope of neighbourhood health, it remains to be seen if the focus will move beyond a very narrow definition of neighbourhood health.

The guidance does recognise that more investment is needed, with ICBs required to assess total resources spent on those living with frailty and shift a proportion of those resources to better community provision. ICBs are also required increase to increase community health service capacity to meet growth in demand.

In wider primary care, the focus on GP access continues, with a proposed new target of 90% of 'clinically urgent' cases seen on the same day. The government says it will 'consult with the profession' on this, but given the pressures already on triage, this might be quite a tense consultation. The role of community pharmacies continues to be expanded to include delivery of HPV vaccination, and the government’s commitment to deliver an additional 700,000 urgent dental appointments continues but without the commitment to significant overhaul of the dental contract that many have called for.

Finance and productivity

'Long-term planning while parts of the financial system are being dismantled will be tough’ Danielle Jefferies

Danielle Jefferies

Senior Analyst

The system is no longer just delivering the three shifts: this guidance has added ‘and improve productivity’ to the list. This guidance challenges the NHS to do more with average-at-best increases to funding, while also being a vital part of the government's ambition to improve the productivity of whole economy.

This guidance confirms that the financial rigour ICBs and providers have experienced over the past few years is not going away: deficits and last-minute deficit support will also no longer be allowed. Financial management expectations have perhaps been slightly softened, acknowledging the tight financial landscape: ICBs and providers are expected to break even without deficit funding by the end of the planning horizon rather than immediately. But ICBs and providers are not getting any more money to deliver the shifts, they must ‘reprioritise their existing budgets’. They must also improve productivity by at least 2%, and while there has been an improvement in productivity recently, there are already doubts about whether it is possible to sustain.

Positively, this guidance shows the government is serious about doing more long-term financial planning. ICBs and providers now need to submit 3-year revenue and 4-year capital plans by Christmas this year.

However, it is going to be tough to plan long-term while parts of the financial system are being dismantled, for example block contracts in urgent and emergency care. New models will take their place (eg, urgent and emergency care payment models and best practice tariffs) but it will be some time before we have the full details of how these models will work. Furthermore, a refresh of the fair share ICB allocations and the Carr-Hill formula will create another layer of uncertain for ICBs and providers.

System organisation

‘Significant structural reform’ Anna Charles

Anna Charles

Senior Fellow

It’s no surprise that ongoing changes to the NHS operating model feature in this year’s planning guidance given the significant structural changes underway in the NHS and the ambitious reform agenda set out in the 10 Year Health Plan. The document promises that these reforms will ‘completely rewire how the NHS works’ and ‘return freedom and innovation to the frontline’.

In the main, the document restates elements already trailed in the 10 Year Health Plan and elsewhere, including a new foundation trust framework, the establishment of integrated health organisations and a new approach to oversight of trusts and ICBs. It offers little in the way of further clarity on what these plans will entail (the details are largely left for future documents expected in the coming weeks and months), but it’s a reminder of just how complex and crowded the current reform agenda is. Taken together, these changes add up to significant structural reform. It’s hard to see where NHS leaders will find the bandwidth to manage these changes alongside the long list of pressing operational and financial issues they are facing.

The guidance confirms that integrated health organisations (providers responsible for managing the whole health budget for a local population) will be established through contractual mechanisms rather than a new organisational form. While integrated health organisations could create stronger incentives to invest in prevention and community-based care, their development needs to be informed by previous attempts to use novel contractual levers to drive integration, many of which ran into complex practical challenges and were abandoned (such as 2018 proposals for commissioners across a local area to bring together funding in a simplified capitated budget).

ICBs and providers are expected to set out detailed plans describing how they will meet targets in this framework, as well as how they will deliver the three shifts, and improve productivity. This is a marked contrast to last year’s planning guidance when system plans were still the order of the day). It is essential that the NHS doesn’t retrench into organisational siloes. Problems such as disjointed care, long A&E waits, delayed discharges and health inequalities can’t be solved by organisations acting alone.

Care quality

'How much better would it be if national actions on quality were really joined up with independent diagnosis?’ Alex Baylis

Alex Baylis

Assistant Director, Policy

Lord Darzi’s 2024 investigation into the NHS highlighted how the degree of national priority given to care quality reduced since 2010. It is very welcome that the planning framework emphasises improving care quality and safety, including patients’ experiences.

To some extent, what it says reasserts the importance of existing expectations – from responding to and learning from safety incidents to ensuring fair access to continuing health care, for example. It also signals expanding early-stage initiatives – such as modern service frameworks and further focus on maternity care – but relatively little in the way of brand new ones. A new quality strategy will bring all these strands together. That is all good… so long as the quality strategy really does ensure a shift to a higher gear for the prominence and expectations of care quality.

And the way in which, once agreed, the quality strategy is implemented must not only support the system to go further, but also ensure there are no steps backwards. Valuable work that the Health Services Safety Investigation Body has done to grow local capability to rigorously investigate incidents and to create safe spaces for disclosure, come to mind as examples that may feel challenging to the NHS but are so valuable that progress must be protected, amid the structural changes that include the abolition of Health Services Safety Investigation Body.

The planning framework presented ways forward on improving care quality and safety at a national level, on the same day that the Care Quality Commission (CQC) published its State of care report setting out the challenges. Both documents have their merits. But how much better would it be if national actions on quality were really joined up with CQC’s independent diagnosis? Another ‘must do’ for the national quality strategy and National Quality Board.

Leadership, management and workforce

'Making the NHS a really good place to work must have much greater prominence’ Alex Baylis

Alex Baylis

Assistant Director, Policy

The planning framework places welcome emphasis right from the outset on the leadership implications of its changes to services, ways of working and autonomy. In addition to process changes, these will require staff engagement and, in many cases, changes in mindsets. Its encouragement for innovation, seizing opportunities and creating space for leaders to lead gives exactly the right messages.

However, for many years, fine intentions and pockets of great national support for leaders have been overshadowed by fragmented approaches, initiatives that were too gappy or fuzzy, recourse to summoning and directing (or even naming and shaming) leaders, and shelf-loads of recommendations that were never fully implemented. The planning framework repeats 10 Year Health Plan aims for a comprehensive suite of policies including a national management and leadership framework, the precision and clarity (with accountability) of regulatory expectations, plus programmes and a college to support leadership development. If it is to be better than previous attempts, it is essential that this comprehensive approach is followed through with sustained investment and an unwavering focus on supporting, not just blaming or bullying, leaders.

The key leadership issue that is invisible in this document, is acknowledgement of how the behaviour at the centre sets a tone that ripples right down to organisational culture at the NHS frontline. We support the proposed first principle of system oversight – that its purpose is to drive improvement. That will involve supporting and stretching, not bullying, local leaders. There will be a need to demonstrate that support for leaders and to sustain it, in order to win them over and convince them that it will be different this time.

The planning framework includes a welcome emphasis on leaders engaging and listening to staff, and boards focusing on assuring and improving staff experience. It is important to acknowledge that this is part of re-setting what the overall national expectation is for good leadership in the NHS. The new management and leadership framework, and more generally the ways in which good leaders are recognised, must assert that what is valued in good leadership is much more than hitting targets and balancing budgets: the focus on care quality and making the NHS a really good place to work must have much greater prominence.

Digital

'How are staff and patients going to be supported to use the technology?’ Pritesh Mistry

Pritesh Mistry

Fellow, Digital Technologies

Accelerating implementation, scaling and national roll out of digital technologies are underpinning requirements of the framework across a range of delivery areas. Improved patient communications is being made possible through the requirement for providers use the NHS App notification function by March 2026/27, across hospitals, general practice and pharmacy. It’s unclear what this means for those that are digitally excluded or choose not to use technology who could suffer from worse communication. However, it’s not just the means of communication but what’s in the messages too – information needs to be timely, clear, understandable and with means to respond. Providers will need to use the shift in messaging to transform how and why they communicate as well as how patients can respond.

AI deployment is focused in two areas. Firstly, AI scribe deployment across hospitals and general practice. These tools show promise to reduce admin work and cognitive load while improving patient experience. However, they are positioned as a significant productivity boost with the expectation of staff seeing more patients, which risks staff being overburdened and burnt out. There’s a need to monitor and adjust implementation appropriately. Secondly, the use of AI triage within the NHS App, which the guidance suggests should begin to be rolled out from April 2026. However, there’s unclear evidence that these tools are ready for the large number of patients and their diverse needs. If tools are more risk adverse compared to existing staff enabled processes it will increase workload for the system. The framework accelerates the use of AI but arguably does not do enough to create the momentum to realise the vision of ‘make the NHS the most AI-enabled health system in the world’ by the end of the 10 Year Health Plan.

The technology is being put in place to empower patients and transform care but the key question remains: how are staff and patients going to be informed and supported to be able to use the technology? The guidance highlights the importance of patient empowerment, but there is little on how to do it, and staff needs regarding technology are not mentioned. Without staff engagement and support, technology will remain underutilised and not deliver the changes sorely needed. AI and digital therapeutics will need fundamental changes to workforce roles, responsibilities and mix. Choice, empowerment and self-care all require public awareness, knowledge and capability. Without sufficient public engagement the technology will be deployed but is unlikely to have the transformational impact that is envisioned.

Prevention

'The way the wider system works is more important’ David Buck

David Buck

Senior Fellow, Public Health and Inequalities

The guidance contains commitments to prevention including in tackling obesity, reducing CVD mortality over time and tobacco control, but much is left unsaid and national standards and legislation related to prevention ‘are to come’.  While specific commitments are welcome, if we are to see a meaningful prevention shift, the wider way the system works is more important – 1 page in 36 is dedicated to prevention and none of the performance metrics that the system is being asked to meet is explicitly about prevention. 

It is disappointing to see no mention of how the NHS is expected to contribute meaningfully to the government’s stated goal of halving the healthy life expectancy gap between regions. As we have consistently stated, if the 10 Year Health Plan is really for health, and not just for the NHS, then the NHS needs to work far more coherently with others. The government’s work on English devolution, including a health duty on mayors and their role on ICBs is part of this shift, it is surprising therefore it doesn’t merit attention in the planning framework for the NHS.

We needed to see more evidence of re-wiring the financial framework for prevention, not only more effective and appropriate NHS treatment if the NHS is really to deliver the prevention shift. Therefore, the mention that ‘we are designing a different approach’ that includes delivering the prevention shift is welcome. Given the imperatives to reduce waiting times, this needs to be implemented quickly, fully and with parity with wider priorities if the prevention shift is going to delivered.

Conclusion: where are the trade-offs?

Plans don’t deliver change, people do. But, plans can provide clarity of vision, purpose and goals, allowing people to be confident that they are working together to deliver coherent and strategic change. Therefore, this publication, and the new multi-year focus is extremely welcome.

But this planning framework is wide-ranging – there are a huge number of areas and priorities set out in this framework. Where are the trade-offs? What are local leaders going to be able to stop doing, in order to deliver this step change in performance alongside transformation of service delivery? It remains to be seen whether it this is realistic and deliverable, and therefore ultimately – whether patients will see significant improvement.