On the day briefing: Medium term planning framework 2026-2029

On 24 October 2025 NHS England (NHSE) and the Department of Health and Social Care (DHSC) jointly published a Medium Term Planning Framework covering the financial years 2026/27 to 2028/29.

This briefing highlights the key points from the framework that providers should be aware of, including submission deadlines. It also sets out the work NHS Providers has done to influence and gives our view on the guidance. The remainder of the briefing contains more detail about the guidance.

Unlike most recent planning guidance covering only one year, this planning framework covers three years, following the three-year revenue and four-year capital spending review settlements published in the summer.

The framework commits to more ambitious targets across cancer, urgent care, waiting times, access to primary and community care, mental health, learning disabilities and autism, and dentistry, with an ambition to achieve constitutional standards by 2028/29 where possible. It also ‘returns to some of the basics that have taken a back seat over the last decade’ incorporating expectations around patient and staff feedback, and aims to support delivery of the ambitions in the 10-year health plan (10YHP). 

Elective care, cancer and diagnostics:

• In 2026/27: deliver a minimum of a 7% improvement in 18-week performance, or deliver care to 65% of patients within 18 weeks, whichever is greater, to meet the national performance target of 70%. 
  
  
• In 2028/29: achieving the standard that at least 92% of patients are waiting 18 weeks or less for treatment. 
  
  
• Maintain performance against the 28-day Faster Diagnosis Standard (FDS) at 80%. Improve against cancer constitutional standards – 31-day performance to 94% and 62-day performance to 85% by March 2027 and maintain performance against the 31-day standard at 96% and 62-day standard at 85% by 2028/29.
  
  
• Improve performance against the DM01 diagnostics 6-week waiting standard in 2026/27 to deliver a minimum 3% improvement or performance of 20% or better, whichever is greater, and by 2028/29 to achieve a rate of 1% for waits over 6 weeks.

Urgent and emergency care:

• 4-hour A&E performance: every trust to maintain or improve to 82% by March 2027, up from 78%. National target of 85% set for 2028/29.
  
  
• 12-hour A&E performance: improve performance on the percentage of patients admitted, discharged and transferred to ED year on year.
  
  
• Improve Category 2 ambulance response times to an average of 25 minutes in 2026/27 and 18 minutes in 2028/29, returning to constitutional standards. 

Community services and primary care:

• New target to deliver same-day appointments for all clinically urgent patients (face to face, phone or online) is 90% for all years covered by the framework. 
  
  
• Addressing long waits for community services: 78% of activity within 18 weeks in 2026/27; 80% within 18 weeks in 2028/29. 
  
  
• ‘Develop a plan’ to eliminate all 52-week waits and ‘actively manage’ long waits for community services.  
  
  
• New target to deliver 700,000 additional urgent dental appointments against July 2023 to June 2024 baseline period. 

Mental health, learning disabilities and autism:

• New targets for those accessing talking therapies - 805,000 courses of NHS talking therapies by the end of 2026/27 (up from 700,000) with a 51% reliable recovery rate (up from 48%) and a 69% reliable improvement rate (up from 67%). 915,000 courses of NHS talking therapies by end of 2028/29 with 53% reliable recovery rate and 71% reliable improvement rate.
  
  
• Expanded coverage of mental health support teams (MSHTs) in schools and colleges, aiming for 77% coverage of operational MSHTs in 2026/27 and 100% coverage in 2029.  
  
  
• Moving towards the elimination of inappropriate out-of-area placements, reducing the number by March 2027 and further reducing or maintaining the number at zero in 2028/29. 
  
  
• Reduce reliance on mental health inpatient care for people with a learning disability and autistic people by 10% in 2028/29. 

Workforce:

• Annual limits on bank and agency spend will be set individually for trusts, based on the national target of 30% reduction in agency use in 2026/27 and 10% year on year reduction in spend on bank staffing, working towards zero spend on agency by August 2029. 
  
  
• Ambition to reduce sickness absence rates to the lowest recorded national average level (approximately 4.1%).

The final section of the guidance sets out a broad timetable for submission. The 10YHP 'foundational' planning began in July with integrated care board (ICB) engagement and publication of the early-stage planning framework in September.

From October to December, providers should develop their first submissions, to be sent to NHSE 'before Christmas': 

• 3-year revenue and 4-year capital plan return.
  
  
• 3-year workforce return.
  
  
• 3-year operational performance and activity return.
  
  
• Integrated planning template showing triangulation and alignment of plans.
  
  
• Board assurance statements confirming oversight of process.

Plans are expected to be finalised in early February. Full plan submissions will include updated versions of those listed above plus the five-year narrative plan. 

System plans are no longer required, however providers' integrated plans should be developed in collaboration with their NHS partners and in discussion with NHSE regional teams.

One of NHS Providers’ key purposes is to positively influence the environment in which trusts and foundation trusts operate.

Since the publication of the 10YHP, we have continued to represent members’ views to NHS England, DHSC and HM Treasury that: 

• The general direction of travel set out is the right one, but the operating context must be reformed appropriately to support delivery. 
  
  
• Many trust leaders have been increasingly frustrated by the annual planning process – single-year planning hampers efforts to tackle systemic longer-term challenges and reinforces focus on short-term savings rather than delivering longer-term productivity benefits. 
  
  
• The NHS needs longer-term planning cycles and financial flows that properly incentivise the three shifts and sustainability. 

We also:

• Engaged constructively with the relevant teams at NHSE in designing their proposed changes to the payment models for urgent and emergency care (UEC) and elective care.
  
  
• Continue to sit on NHSE’s Quality Reference Group working on the new quality strategy, as well as on the Maternity and Neonatal Equity and Equality Steering Group, and to call for appropriate priority for mental health services, including protecting mental health spending, as the 10YHP is implemented. 
  
  
• Continue to work closely with relevant colleagues at NHSE and DHSC to influence operating model reforms, including the forthcoming strategic commissioning framework, new FT framework, model IHO and the model neighbourhood, ensuring there is clarity for providers. 

We shared feedback on a draft of this guidance, highlighting the focus on operational priorities ahead of transformation in line with the 10YHP, and voicing concerns about the risk of mental health in particular being overlooked. 

The shift away from annual planning and financial cycles to a three-year window is significant, welcome, and something we have long been calling for. We greatly welcome the commitment to publish this framework earlier than in previous years. However, an expected turnaround for initial plans before Christmas is hugely challenging for providers, particularly in this first iteration of a new three-year cycle and without financial allocations being published at the same time.

It is clear that the government has twin priorities of both substantial reform and significant improvement on operational and financial performance, and it is good to see the framework recognise that a full return to constitutional standards is contingent on also delivering the significant reform of the fundamentals successfully. The recovery targets in here are ambitious but for the most part realistic in scope, given the current financial envelope (and subject to improving the system at pace), and if delivered will result in a significantly better experience for patients. 

The framework could be understood as a bridge between the 10YHP and future guidance. While providers are already developing their plans to deliver the three shifts, we await further specifics on the shift to neighbourhood care, the future shape of the provider sector, and new contractual models. In advance of the 10 year workforce plan’s publication, the production of accurate workforce plans may continue to prove challenging. We also hope that the forthcoming guidance will provide the clarity and enablers for trusts to make swift progress on neighbourhood ambitions, in particular to help keep elderly people healthy for longer and care for them in their place of residence, avoiding unnecessary hospital admissions.

It is notable that the guidance offers no further development on the 10YHP's pledge to shift resources from hospital to community care. This, together with the focus on well-established constitutional standards, makes it likely that the drift towards an increasing proportion of revenue spend going to the acute sector will continue. 

Likewise, there is a gulf between the aims of this guidance and the 10YHP's emphasis on the need to improve population health. National leaders have committed to building better population health and collaborative working into how providers are overseen and rated. However for now, the concrete areas of focus in the framework remain well-understood operational metrics such as urgent and emergency care (UEC) and referral to treatment (RTT) targets, to deliver the improvements patients seek.  

Equally on the shift to digital and more strategic use of technology, where there is evidence to support it, specific productivity targets associated with, for example, the use of ambient voice technology, might be considered. 

We will be keen to see how these key targets will be reflected in the next NHS Oversight Framework (NOF), alongside relevant metrics to drive the required reform. Substantial progress towards the 10YHP’s population health ambitions will require the key drivers, including the funding flows and operating model, to be aligned successfully and speedily. 

Trust leaders broadly welcome reforms to the NHS financial regime, including a shift to multi-year planning and a fairer funding allocation model. These changes support longer-term improvements in care but must be implemented at a manageable pace to avoid financial instability. While the requirement to deliver break-even positions and 2% annual productivity gains is challenging, trusts have shown readiness to take tough decisions to ensure value for money. There are significant unknowns in relation to costs, not least on drug pricing, which could materially affect trusts’ ability to deliver breakeven next year, if financial support to cover such cost pressures was not provided. It will be essential to see the financial allocations to understand how realistic these targets are. 

We have consistently highlighted the long waits faced by children and young people and we welcome the strong focus on this throughout the framework.  

The absence of any reference to the mental health investment standard is very worrying, as this has helped safeguard spending on these essential services over many years. We have been clear all mental health trusts need to receive the MHIS as a minimum. We hope to see more detail in forthcoming financial technical guidance on how mental health resourcing will be protected. 

Trust leaders will welcome a renewed acknowledgement of the importance of calling out all forms of discrimination in the NHS, but we are concerned that the EDI improvement plan has still not been recommitted to.  

Efforts to improve staff experience at work are welcome: we ask NHSE to commit to working with providers to review implementation and unlock any barriers to progress – some of which will be national rather than local. 

Trust leaders will welcome the increased focus on quality and have called for a national strategy that supports local improvement. They emphasise the need to align quality with finance and operations, empower frontline staff, and ensure new maternity care interventions are well-monitored to avoid unintended consequences. We look forward to supporting our members to work with NHS England on their new approach, and building where necessary on the work we have carried out to date, to develop this.

Finances

The framework outlines significant changes to the NHS financial regime, which aim to deliver: 

• Incentives that are aligned to key delivery priorities;
  
  
• A fairer distribution of funding;
  
  
• Longer-term planning; and 
  
  
• A revised approach to capital funding.

We expect further details on the changes to the financial framework and multi-year revenue and capital allocation to be set out in the accompanying technical guidance. At present, this guidance has yet to be published. 

Financial priorities

All ICBs and trusts will be expected to deliver the following in all years of the planning period: 

• A break-even or surplus financial position without deficit support funding.
  
  
• Meet a 2% annual productivity ambition. 
  
  
• Adherence to other requirements (including guidance on managing provider/commissioner funding changes and a new board risk assessment process). 

Urgent and emergency care payment reform

Work is underway to dismantle block contracts and reform the payment scheme. For 2026/27, a new payment model will be introduced for urgent and emergency care (UEC) comprising a fixed element (based on cost x activity) and a variable element (roughly 20% of total payment). New best practice tariffs on day cases, outpatients and more efficient ways of working will also be proposed as part of the 2026/27 NHS Payment Scheme. The UEC payment model will be further developed to incentivise shifting more care out of hospitals and into community settings, to be trialled with pilot sites in 2026/27.  

Fairer distribution of funding

A review of the wider funding formula is underway which will seek to return system allocations to their corresponding fair share of resources. The pace of implementation will be balanced with ensuring finances are not destabilised in the short term.  

Further information on changes to the financial framework, as well as the multi-year revenue and capital allocations, will be set out in the forthcoming technical guidance.

Productivity

To deliver the 2% year-on-year improvement to productivity, the framework outlines two key areas of focus:

• Getting the basics right – reducing inpatient length of stay, improving theatre productivity and returning to pre-pandemic levels of activity per whole-time equivalent (WTE). 
  
  
• Seize the opportunities offered by technology, service transformation and cost variation – accelerating the shift to digital-by-default and embedding more efficient models of care.  

Systems are expected to make demonstrable progress on two key shifts in care models: 

• UEC: expanded use of digital and telephony-based triage and increased access to same-day or next-day scheduled care. 
  
  
• Outpatients: expanding the use of advice & guidance and digital triage tools and empowering patients with greater choice and control over their follow-up care. 

Digital

All acute, community and mental health providers are expected to be onboarded to the Federated Data Platform (FDP), and by 2028/29 using its core products for elective recovery, cancer, and urgent and emergency care. 

The NHS App should be fully adopted across all care settings by the end of 2028/29. From April 2026, providers are expected to: 

• Adopt and implement all core national products and services specified in the forthcoming national product adoption dashboard by the end of 2027/28 including: Electronic Prescription Service & Electronic Referral Service APIs
  
  
• Achieve full compliance with the Digital Capabilities Framework standards and 100% coverage of electronic patient record systems (EPRs) as soon as possible.  
  
  
• Deploy Ambient Voice Technology (AVT) at pace, as well as digital therapeutics. 

Quality of care

From April 2026, ICBs and providers will be expected to: 

• Use the forthcoming National Quality Board (NQB) quality strategy to improve the quality of care they deliver.  
  
  
• Implement modern service frameworks (MSFs). The first three will be focused on CVD, serious mental illness and sepsis, with further MSFs on dementia and frailty to follow.
  
  
• Implement the New Care Delivery Standards (which are currently under development and due for publication in March 2026).
  
  
• Plan for the introduction of the Single National Formulary in the next two years, prioritising the following efficiency savings in 2026/27 to enable headroom for the uptake of new innovations: use of best value Direct Acting Oral Anticoagulants, SGLT-2 medicines and adoptions of the wet AMD Medical Retinal Treatment Pathway. 
  
  
• Continue to focus on improving all-age continuing care (AACC) services, addressing unwarranted variation while meeting statutory NHS Continuing Healthcare duties. 
  
  
• Review local processes and workflows to make sure digital systems are used and paper-based processes removed. 
  
  
• Implement the Paediatric Early Warning System (PEWS) by April 2027, with a view to complete the transition by April 2028. 

The framework has a specific focus on the quality of maternity services, asking that all ICBs and providers take immediate action to improve maternity care by:  

• Implementing best practice resources as they are launched. 
  
  
• Using the national Maternity and Neonatal Inequalities Data Dashboard to identify variation in practice and put in place interventions for improvement. 
  
  
• Participating in the Perinatal Equity and Anti-Discrimination Programme.

The Maternity Outcomes Signal System (MOSS) will be implemented for all trusts by November 2025, enabling the use of near real-time data to monitor key safety indicators such as stillbirth, neonatal death, and brain injury rates. 

Patient experience

Between now and the end of 2025/26, all NHS trusts will be expected to: 

• Complete at least one full survey cycle to capture the experience of people waiting for care.
  
  
• Capture near real-time experiences, on at least five wards/departments from patients prior to discharge. A resource pack will be published on NHS England’s website before the end of October to support those organisations who don’t already do this.  

Leadership and management

Ahead of the publication of the latest staff survey results, NHSE will work with staff experience leads to revise the approach to national pulse surveys alongside annual staff surveys, to support local boards in measuring and improving staff experience. In the meantime, boards are expected to use recent survey findings to produce detailed analysis of all free text comments, as well as identify at least three areas with the greatest staff dissatisfaction, analyse their impact, and develop plans to resolve in-year where possible. 

The framework calls for ‘redoubled’ efforts to create safe and welcoming environments for staff and patients. Organisations are expected to continue to tackle sexual misconduct, including regularly assessing progress on the Sexual Safety Charter. No date is given for manager disbarring to be introduced. 

There is acknowledgement that high expectations of leaders and managers in the NHS must be accompanied by the right tools and support:

• A Management and Leadership Framework is due this autumn. It must be embedded into all recruitment and appraisals (with leaders self-assessing against it). Supporting digital tools are due in 2026/27. 
  
  
• 2026/27 will see more progress towards a College of Executive and Clinical Leadership, and the publication of a national curriculum and interactive online models for leadership and management development. 
  
  
• National leadership programmes will be updated. ICBs and providers should incorporate these national offers as part of personalised development pathways for leaders and managers.
  
  
• NHSE will develop a talent database of leaders to guide challenged systems and organisations. 

Genomics, life sciences and research

• The framework restates the 10YHP’s 150-day target for clinical trial set-up times. 
  
  
• From April 2026, providers should deliver services in line with the NHS Genomic Medicine Service specification. 

Elective, cancer, diagnostics

NHS performance improvement targets for elective, cancer and diagnostic waiting times propose gradual annual improvements with an ambition to return to delivering constitutional standards in full by 2028/29. This includes a requirement to treat 70% of patients within 18 weeks next year, and 92% by 2028/29. 

The key priorities include the transition to using the e-Referral Service (e-RS) for all advice and guidance requests from primary care from July 2026, and via third-party platforms from October 2026. For patients who require specialist outpatient care, providers are expected to: 

• Reduce the number of clinically low-value follow-ups, supported by forthcoming good practice guides from GIRFT. 
  
  
• Expand ‘straight to test’ pathways and one stop clinics, with the aim of including all clinically appropriate specialties by March 2029.  

Other priorities include:

• Waiting lists to reduce during 2026/27, prioritising patients by clinical need, and validating lists. 
  
  
• Improve long waits for children and young people’s (CYP) planned care, developing ringfenced CYP capacity within ICB footprints. 
  
  
• Cancer care expectations include continued prioritisation of diagnostics and treatment capacity for urgent suspected cancer pathways.  
  
  
• Diagnostic capacity should be expanded in line with targets through the full utilisation of community diagnostic centres, capital-funded capacity increases, improved productivity initiatives and demand optimisation (which will be supported by the ‘Right Test, Right Time’ campaign this autumn).  

Urgent and emergency care (UEC)

NHS urgent and emergency care improvement targets have been set for 2026/27 and 2028/29. Over the coming weeks, NHSE will work with NHS providers and the relevant professional bodies to develop a new approach enabling more patients to be seen in urgent treatment centres (UTCs) and more rapid assessment and treatment for children throughout 2026/27. 

Priorities for improvement include:

• Ensuring the full utilisation of 111 and ‘hear and treat’. A renewed focus on directing to UTC by default where relevant. 
  
  
• Neighbourhood care expansion, delivering more care in the community to frail older people. 
  
  
• Continued collaboration between acute trusts and ambulance services to reduce handover times towards the 15-minute standard.
  
  
• Category 2 ambulance responses – improving from 30 to 18 minutes by 2028/29, returning to constitutional standards. 
  
  
• Alignment with the soon-to-be-published Model Emergency Department and clinical operational standards for the first 72 hours in hospital to improve against four-hour performance target (82% by March 2027, and 85% by March 2029). 
  
  
• Improve emergency department paediatric performance, with the expectation of returning to 95% over the coming months. 
  
  
• Establishment of mental health emergency centres in type 1 emergency departments.  
  
  
• Improve in-hospital discharge processes, making best use of community beds, and increasing home-based intermediate care capacity. 
  
  
• Take early action to improve flu vaccination uptake among staff and the public.

Community health

Key priorities for all ICBs and community health services providers for 2026/27 include: 

• Increase community health service capacity to meet 3% expected annual growth in demand, reducing the proportion of waits over 18 weeks and developing a plan to eliminate all 52-week waits. 
  
  
• Identify and act on productivity opportunities, including ensuring teams have the digital tools and equipment they need, and expanding point-of-care testing in the community. To support this, community health service productivity metrics will be published later this financial year. 
  
  
• Continue to standardise core service provision. 
  
  
• Consider where approved digital therapeutics, such as for MSK treatment, could be deployed at pace. 

A key success measure is to address long waiting times, with at least 78% of community health service activity occurring within 18 weeks in 2026/27. The target increases to 80% in 2028/29.

Mental health

The planning guidance commits to working with NHS mental health providers to develop a new approach for mental health in 2026. No mention is made of the mental health investment standard, unlike previous years.

Key priorities for ICBs and providers in 2026/27 include: 

• Reducing inappropriate out of area placements. 
  
  
• Developing local plans for establishing mental health emergency departments by 2029/30. 
  
  
• Using ring-fenced funding to support the delivery of 63,500 people accessing individual placement and support and 805,000 courses of NHS talking therapies.  
  
  
• Expanding coverage of mental health support teams in schools and colleges to 77% next year. The target is 94% in 2028/29, reaching 100% in 2029.  
  
  
• Identifying and acting on productivity opportunities e.g. in children and young people’s community mental health services and length of stay in adult acute mental health beds.
  
  
• Ensuring all mental health practitioners undertake training and deliver care in line with the Staying safe from suicide guidance.

Learning disability, autism and ADHD

The framework recognises that people with a learning disability and autistic people too often experience avoidable health inequalities and can be inappropriately admitted to mental health hospitals for long periods. Plans for the reform of SEND will be published 'in due course'.

All ICBs and providers must reduce reliance on mental health inpatient care for people with a learning disability and autistic people by 2028/29, delivering a minimum 10% reduction year-on-year.

Workforce

As noted above, providers are asked to submit an initial three-year workforce return to NHSE "before Christmas". In addition to this, providers are asked to: 

• Produce workforce plans (ahead of the 10-year workforce plan) which account for delivering the three shifts, and finance and activity plans. 
  
  
• Implement the 10-Point Plan to improve resident doctors’ working lives and publicly report progress. 
  
  
• Demonstrate progress to reduce sickness absence rates to the 10YHP’s 4.1% target. 
  
  
• Continue to reduce agency staffing reliance.
  
  
• Implement the statutory/mandatory training framework and staff safety management, when published in March 2026. 
  
  
• Implement reforms to consultant job planning and:
  • Ensure that 95% of medical job plans each year are signed off in line with business cycles. 
  • Enact a system monitoring and assuring job planned activity, by the end of 2026/27.
  • Achieve tracking of job planned activity for the full year by the end of 2027/28. 
  • Ensure multi-professional service level activity and job planning are in place by the end of 2028/29. 

The new operating model

New in the planning framework is a definition of integrated health organisations (IHOs) as contract-based delivery methods, not new forms of organisation. Updates to the NHS Oversight Framework, to support the new operating model, are planned for 2026/27. 

A suite of guidance will be published over the coming months to support delivery of 10YHP ambitions. These include: 

• A strategic commissioning framework (due this month).
  
  
• Draft new foundation trust framework for consultation (due in November).
  
  
• A system archetypes blueprint (due in November).
  
  
• A draft Model Neighbourhood framework (due in November).
  
  
• An integrated health organisation (IHO) blueprint (due ‘later this year’). 

NHSE England will also publish:

• a national neighbourhood health planning framework to guide collaborative planning locally; 
  
  
• model neighbourhood health centre archetypes offering options to optimise existing estates and new build solutions.