What Is the NHS Medium Term Planning Framework?

The Medium Term Planning Framework is the operational planning guidance for the NHS from April 2026 onwards. It tells every NHS organisation what they must do over the next three to five years.

Before this, NHS planning happened one year at a time. That made it hard for local leaders to think ahead. Now, ICBs and providers must submit:

• 3-year revenue plans
• 4-year capital plans
• 5-year strategic narratives

This gives everyone more time to plan properly. The framework came out five months before the 2026/27 financial year starts. That is earlier than planning guidance has come in recent years.

The framework has three main parts:

1. Financial context and requirements – How the money works
2. Operating model reforms – How the NHS structure is changing
3. Performance requirements – What targets must be hit

It applies to all Integrated Care Boards, NHS trusts, foundation trusts, and providers across England. Everything in the framework links back to the 10 Year Health Plan published in July 2025.

Key Changes from NHS Planning Guidance 2025/26

The 2026/27 framework is different from last year in several important ways.

What’s New in the 2026/27 Framework

The shift to multi-year planning is the biggest change. ICBs and providers can now see what is expected over three years, not just one. This helps with workforce planning, capital investment, and transformation programmes.

Fact: The Spending Review confirmed a 3% real-terms increase in revenue funding and 3.2% increase in capital funding over the three-year period.

New models are being introduced. Integrated Health Organisations (IHOs) will allow providers to manage whole health budgets for local populations. Neighbourhood Health Teams will bring care closer to home for people who need it most.

A new target for GP access has been proposed. The aim is for 90% of clinically urgent patients to be seen on the same day. This is subject to consultation with the profession.

The Mental Health Investment Standard is notably missing. Previous guidance required ICBs to invest in line with this standard. Its removal has raised concerns across the mental health sector.

The Three Strategic Shifts

The framework is built around three big changes. These come from the 10 Year Health Plan. Every NHS organisation must work towards them.

Hospital to Community (Left Shift)

The NHS wants to move care out of hospitals and into communities. This is sometimes called the “left shift.”

Neighbourhood Health Teams are at the heart of this change. These are integrated teams that serve local populations. They focus on people who need the most support:

• People living with moderate to severe frailty
• Care home residents
• Housebound patients
• People at end of life

ICBs must map how much they spend on frail patients. They must then shift some of that money to better community care. The goal is to reduce unnecessary hospital admissions and bed days.

Community health services now have a waiting time target for the first time. At least 78% of community health activity must happen within 18 weeks by 2026/27. This rises to 80% by 2028/29.

The seven-day urgent community response must be expanded. This gives people access to community care at weekends, keeping them out of hospital.

Analogue to Digital

The NHS is moving from paper and phone to digital and online. This shift touches every part of the service.

Key digital targets include:

• 95% of appointments bookable or triageable via the NHS App by 2028/29
• All acute, community and mental health providers on the Federated Data Platform (FDP) by 2028/29
• All direct-to-patient communication moved to NHS Notify by end of 2029
• 100% coverage of Electronic Patient Record (EPR) systems

NHS Online will launch in 2027. This is a new “online hospital” that connects patients to expert clinicians without them needing to travel.

AI-assisted triage will start rolling out through the NHS App from April 2026. Providers should also deploy ambient voice technology. This uses AI to write clinical notes, saving staff time.

Fact: By 2028/29, 95% of NHS appointments must be available through the NHS App after triage, with digital Patient Initiated Follow-Up (PIFU) fully implemented by 2029.

Treatment to Prevention

The NHS wants to stop people getting ill in the first place, not just treat them when they do.

ICB five-year plans must include:

• Obesity services with access to NICE-approved weight loss treatment for 220,000 eligible adults by June 2028
• 250,000 annual referrals to the NHS Digital Weight Management Programme by 2029
• 25% reduction in premature CVD mortality by 2035
• Universal opt-out tobacco dependence model

An online NHS Health Check will be launched. This makes it easier for people to check their health and catch problems early.

All 15 Success Measures: Complete Targets Table

The framework has 15 headline success measures. These are the main things every NHS organisation will be judged on.

Elective Care, Cancer and Diagnostics

Urgent and Emergency Care

Primary Care and Community

Mental Health

Learning Disabilities and Autism

Workforce

Fact: The 18-week RTT target of 92% by 2028/29 reinstates the original NHS constitutional standard. Currently, more patients join the waiting list each month than receive treatment.

Elective Care, Cancer and Diagnostics Requirements

Getting waiting lists down is a top priority. The framework sets out clear expectations for every trust.

18-Week Referral to Treatment Targets

Every trust must either:

• Improve 18-week performance by 7%, OR
• Reach at least 65% performance

Whichever is greater applies. This should bring national performance to 70% by March 2027. The ultimate goal is 92% by the end of 2028/29.

Children and young people are highlighted specifically. Systems must increase activity and improve performance for this group. Surgical hubs should have ringfenced capacity for paediatric patients. Dedicated paediatric surgery days should be run.

Cancer Waiting Times Standards

Cancer performance must improve significantly:

• 28-day Faster Diagnosis Standard: 80%
• 31-day standard (start treatment within 31 days of decision to treat): 94% by March 2027, rising to 96% by 2028/29
• 62-day standard (start treatment within 62 days of urgent referral): 80% by March 2027, rising to 85% by 2028/29

Primary care should stratify urgent suspected cancer (USC) referrals. Lower risk patients should be directed to more appropriate pathways. This keeps the urgent pathway clear for those who need it most.

Diagnostics and Community Diagnostic Centres

The target for the DM01 diagnostics standard is ambitious:

• No more than 14% waiting over 6 weeks by March 2027
• No more than 1% waiting over 6 weeks by 2028/29

Community Diagnostic Centres (CDCs) should extend opening hours where needed. Each system has bespoke diagnostic activity targets to achieve by March 2029.

Outpatient Transformation

The NHS wants fewer outpatient appointments, especially follow-ups. Key actions include:

• Advice and Guidance (A&G) via e-Referral Service (e-RS) for all referrals by July 2026
• Expand Patient Initiated Follow-Up (PIFU)
• Standardise clinic templates using Getting It Right First Time (GIRFT) guidance
• Expand straight-to-test pathways and one-stop clinics

Rather than a single national target, each ICB must model its required outpatient follow-up reduction and submit bespoke plans.

Urgent and Emergency Care Targets

Emergency care must improve significantly. The framework sets stretching targets for A&E and ambulance services.

A&E Performance Standards

The 4-hour target is back:

• 82% of patients seen within 4 hours by March 2027
• 85% as the average for 2028/29

12-hour waits must reduce year on year. More patients should be admitted, discharged or transferred within 12 hours.

For children, the target is higher. 95% of paediatric patients should be seen within 4 hours. Paediatric assessment units should be used to achieve this.

A Model Emergency Department document will be published. This will set out how trusts should work to meet these targets.

Ambulance Response Times

Category 2 ambulance response times must improve:

• 25 minutes average by 2026/27
• 18 minutes average by 2028/29
• 90% of calls responded to within 40 minutes by 2028/29

Ambulance handover times at hospitals must also reach an average of 25 minutes.

Fact: Ambulance Category 2 response times must improve from current levels to an average of 25 minutes by 2026/27 and 18 minutes by 2028/29, with 90% of calls responded to within 40 minutes.

Reducing Hospital Admissions

The framework wants to reduce unnecessary trips to A&E and hospital admissions. Key approaches include:

• Urgent Treatment Centres as the first option for patients unlikely to need admission
• Better use of NHS 111 and increasing “hear and treat” rates
• Expanding seven-day urgent community response
• Improving in-hospital discharge processes
• Increasing home-based intermediate care capacity

ICBs should assess total resources spent on frailty and shift money to better community provision.

Primary Care and Neighbourhood Health

General practice and community services are central to the framework. Better access to local care is essential.

GP Access and the 90% Same-Day Target

A new target has been proposed: 90% of clinically urgent patients seen on the same day. This can be face-to-face, by phone, or online. The target is subject to consultation with the profession.

Patient experience of GP access must also improve year on year. This will be measured through the ONS Health Insights Survey.

ICBs must identify GP practices where demand exceeds capacity. They must develop plans to relieve pressure and improve access.

ICBs should support primary care providers to use ambient voice technology. This AI tool helps with clinical notes, freeing up time for patient care.

Neighbourhood Health Model Explained

Neighbourhood Health is a new model of care. It brings together different services to support local populations.

The immediate focus is on high-priority cohorts:

• People with moderate to severe frailty
• Care home residents
• Housebound patients
• People at end of life

Neighbourhood Health Teams will include GPs, community nurses, therapists, social care staff, and others. They will provide:

• Proactive support for people with frailty and long-term conditions
• Urgent and acute community services
• Rehabilitation and prevention
• Improved access to general practice

NHS England has published guidance including:

• Model Neighbourhood Framework with definitions, goals and scope
• National Neighbourhood Health Planning Framework co-produced with the Local Government Association (LGA)
• System archetypes for commissioning neighbourhood health, including Single Neighbourhood Provider (SNP) and Multi-Neighbourhood Provider (MNP) contracts

High-functioning systems can expand integrated teams to cover other groups including children and young people, mental health, and learning disabilities.

Community Pharmacy and Dental Services

Community pharmacy continues to expand through Pharmacy First. Prescribing-based services will be introduced in community pharmacies through 2026/27.

For dentistry, ICBs must deliver their share of 700,000 additional urgent dental appointments each year. Dental contract reforms will come from April 2026.

Mental Health Requirements

Mental health is covered across the framework, though the sector has concerns about the removal of the Mental Health Investment Standard.

Mental Health Support Teams in Schools

Coverage of MHSTs must expand:

• 77% of schools and colleges by 2026/27
• 94% by 2028/29
• 100% by 2029

This includes operational teams and teams in training. Ring-fenced funding supports this expansion.

NHS Talking Therapies and Individual Placement Support

NHS Talking Therapies must expand significantly:

• 805,000 courses by end of 2026/27 (51% reliable recovery rate, 69% reliable improvement rate)
• 915,000 courses by end of 2028/29 (53% reliable recovery rate, 71% reliable improvement rate)

Individual Placement and Support (IPS) helps people with severe mental illness get into work. Access must increase:

• 63,500 by end of 2026/27
• 73,500 by end of 2028/29

This aims to reduce mental-health-related economic inactivity.

Eliminating Out-of-Area Placements

Inappropriate out-of-area placements must be reduced and then reach zero. This target was first set in 2016, but limited progress has been made. The framework renews the commitment with a 2028/29 deadline.

Fact: The target to eliminate inappropriate out-of-area mental health placements was first announced in 2016, but limited progress has been made. This framework sets a firm deadline of 2028/29 to achieve zero.

Mental Health Emergency Departments

Mental health emergency departments should be set up. These must be co-located with or close to at least half of Type 1 emergency departments by 2029/30.

A new national lead for mental health will be appointed. A Modern Service Framework for severe mental illness will be published.

Learning Disabilities, Autism and ADHD

The framework sets requirements for services supporting people with learning disabilities, autism and ADHD.

Reducing Inpatient Admissions

Reliance on mental health inpatient care must reduce. The target is a minimum 10% year-on-year reduction in admissions for people with a learning disability and autistic people.

The focus is on the longest stays. From 2027/28, ICBs should only commission mental health inpatient services that align with the NHS commissioning framework.

Autism and ADHD Assessment Waits

Long waits for autism and ADHD assessments must reduce. ICBs should optimise existing resources and implement existing and new guidance.

The government will publish plans for SEND reform in due course, in consultation with ICBs and providers.

Community Health Services

Community health services are essential for the left shift from hospital to community. For the first time, these services have waiting time targets.

Community Health 18-Week Wait Target

A new standard applies:

• At least 78% of community health service activity within 18 weeks by 2026/27
• At least 80% by 2028/29
• 52-week waits must be eliminated

This is a significant change. Community services have never had a formal waiting time target before.

Capacity and Productivity

Community service capacity must increase by 3% each year to match expected demand growth.

Productivity must improve through:

• Digital tools
• Point-of-care testing
• Standardised core service provision
• Digital therapeutics (such as for musculoskeletal treatment)

NHS England will publish community health service productivity measures by March 2028. This addresses previous gaps in measuring variation across community services.

Financial Framework and Productivity Requirements

Money is tight. The framework sets strict financial discipline requirements alongside ambitious productivity targets.

Financial Balance Requirements

All ICBs and providers must:

• Deliver a financial balance or surplus each year
• Exit Deficit Support Funding (DSF) within the planning horizon (by 2029)
• Accept that no last-minute deficit support will be available

This is a significant change. Previously, some organisations received late financial support to balance their books. That option is being removed.

Fact: ICBs and providers must achieve at least 2% annual productivity improvement. This is more than double the historical average of 0.9% per year.

The 2% Productivity Target

Every NHS organisation must improve productivity by at least 2% each year. This is challenging. The historical average is just 0.9% per year.

Productivity means doing more with the same resources. It includes:

• Reducing inpatient length of stay
• Improving theatre productivity
• Returning to pre-COVID levels of activity per whole-time equivalent (WTE)

NHS England will publish trust-level productivity measures monthly. These will be incorporated into the NHS Oversight Framework.

Payment Scheme Reform

How money flows through the NHS is changing:

• Block contracts are ending from 2026/27
• A new UEC payment model will have a fixed element plus a 20% variable incentive
• Best practice tariffs will incentivise day cases, outpatients, and digital-first models
• A left-shift incentive is built into UEC payments

Allocations and Fair Share Formula

ICB funding allocations will move to a “fair share of resources” model. The Carr-Hill formula used to calculate allocations is being reviewed.

NHS England will combine PLICS, Model Health System and Health Expenditure Benchmarking to create better data for providers.

The New NHS Operating Model

The way the NHS is organised is changing. A new operating model defines who does what at each level.

How the Operating Model Works

Integrated Health Organisations (IHOs)

Integrated Health Organisations are a new way of delivering care. They are not a new type of organisation. Instead, they are a capitated contract-based delivery method.

An IHO holds a contract to manage the whole health budget for a local population. The body hosting the contract works with other providers through sub-contracting and delegation.

IHOs can redesign pathways from end to end. Any efficiencies are reinvested into better care. A Model IHO Blueprint has been published.

New Foundation Trust Framework

The government is re-empowering trust boards. A new Foundation Trust Framework was consulted on in November 2025.

New foundation trusts must demonstrate:

• Excellent governance
• Organisational self-awareness
• Transparency
• Ability to lead their organisation while working in partnership

High performers get earned autonomy and freedoms. Those struggling get proportionate intervention and support.

NHS Oversight Framework Changes

The approach to oversight is changing. The new approach is driven by:

• Improvement, not bureaucracy
• Greater emphasis on peer support
• Tailored intervention
• Metrics that reflect system-minded behaviours and the left shift

The Care Quality Commission’s definition of provider capability and governance will be incorporated.

Digital Transformation Requirements

Digital is woven throughout the framework. Every part of the NHS must become more digital.

NHS App and Digital Access

The NHS App will become the front door for NHS services. The roadmap includes:

• My NHS GP: AI-assisted triage and data-driven pathways to guide patients to bookings
• Planned care: One place to manage all appointments, referrals and interactions
• Health management: Access to targeted prevention services

By 2028/29, 95% of appointments must be available through the NHS App after triage. Digital PIFU must be implemented by 2029.

Data and Infrastructure

All providers must meet digital standards:

• 100% Electronic Patient Record (EPR) coverage
• All acute, community and mental health providers on the Federated Data Platform (FDP) by 2028/29
• All direct-to-patient communication on NHS Notify by end of 2029
• Comply with the Digital Capability Framework as soon as possible
• Implement services in the national productivity adoption dashboard by March 2028

AI in Healthcare

AI is being deployed across the NHS:

• AI scribe deployment in hospitals and general practice (ambient voice technology)
• AI-assisted triage via the NHS App from April 2026
• Digital therapeutics for treatment

Providers should deploy ambient voice technology to reduce administrative burden on staff.

Quality, Safety and Patient Experience

Care quality and safety must improve alongside performance. The framework sets out clear requirements.

National Quality Board Strategy

A new quality strategy will be published by March 2026. It will bring together all quality initiatives.

National Care Delivery Standards will be published by March 2026. The scope was confirmed in November 2025.

A Single National Formulary for medicines will be introduced by the end of 2027. This will prioritise efficiency savings from drugs like Direct-Acting Oral Anticoagulants and SGLT-2 medicines.

Modern Service Frameworks

Modern Service Frameworks (MSFs) set out high-quality, evidence-based, digital-by-default care for specific conditions.

The first three cover:

• Cardiovascular disease (CVD)
• Serious mental illness
• Sepsis

Further frameworks for dementia and frailty will follow. They are co-designed with clinicians and people with lived experience.

Patient Safety Requirements

All ICBs must continue implementing the NHS Patient Safety Strategy. This includes:

• Embedding the Patient Safety Incident Response Framework (PSIRF)
• Appointing and training patient safety specialists
• Involving patient safety partners in governance

Martha’s Rule must be fully implemented in all acute inpatient settings. This gives patients and families the right to request a second opinion.

Emergency Department Paediatric Early Warning Systems (ED PEWS) will launch in 2026. All hospitals must use it by April 2028.

Maternity Services

Maternity care has specific requirements:

• Implement maternity care bundles
• Use new methods to prevent brain injury in childbirth
• Implement the SANDS bereavement care pathway for stillbirth and neonatal death
• Use the Maternity and Neonatal Inequality Dashboard to identify and reduce variation
• Implement the Maternity Outcomes Signal System (MOSS) across all trusts

Patient Experience Measurement

All providers must:

• Complete at least one full survey cycle for patients waiting for care
• Capture near real-time experience on at least five wards or departments before discharge

Workforce and Leadership Requirements

The workforce is critical to everything in the framework. NHS staff must be supported while costs are controlled.

Agency and Bank Staffing Targets

Agency and bank spending must reduce dramatically:

• 30% reduction in agency use in 2026/27
• 10% year-on-year reduction in bank staffing spend
• Zero agency spend by 2029/30

Annual limits will be set individually for trusts based on these national targets.

Fact: Trusts must work toward zero spend on agency staffing by 2029/30, with a 30% reduction required in 2026/27 alone.

Staff Wellbeing and Sickness

Staff sickness absence must reduce from 5.1% to 4.1%. If you are affected by sickness, you can check your entitlements using an NHS sick pay calculator.

Every NHS board must use the 2025/26 staff survey findings to:

• Analyse free text comments
• Identify at least three areas with the greatest staff dissatisfaction
• Plan actions to address them

Work continues on tackling discrimination, racism and sexual misconduct. Progress against the Sexual Safety Charter must be regularly assessed.

Management and Leadership Framework

A new Management and Leadership Framework was published in autumn 2025. It sets:

• A code of practice
• Standards and competencies for clinical and non-clinical leaders
• Five levels from entry to board

A national curriculum and interactive online modules will be available in 2026/27. The College of Executive and Clinical Leadership will be established.

Job Planning

Consultant job planning must improve:

• 95% of medical job plans must be signed off
• Full tracking of job-planned activity must be achieved

Reforms to statutory and mandatory training will be published in March 2026.

Planning Submission Timeline and Deadlines

ICBs and providers must submit plans in two stages.

First Submission (Before Christmas 2025)

The first submission must include:

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

Final Plan Submission (March 2026)

The final submission must include:

• Updated numerical returns
• 5-year narrative plan
• Board assurance statements confirming endorsement of all plans

Key Dates Summary

Forthcoming Guidance Documents

NHS England promised at least 20 additional guidance documents. Many have now been published.

Already Published

• Medium Term Planning Framework (October 2025)
• Strategic Commissioning Framework (October 2025)
• Model Neighbourhood Framework (November 2025)
• Draft Foundation Trust Framework (November 2025)
• System Archetypes Blueprint (Autumn 2025)
• Management and Leadership Framework (Autumn 2025)
• Model IHO Blueprint (Late 2025)
• Revenue Finance and Contracting Guidance (November 2025)

Expected in 2026

• National Care Delivery Standards (March 2026)
• NQB Quality Strategy (March 2026)
• Statutory/Mandatory Training Reforms (March 2026)
• 2026/27 Payment Scheme
• Modern Service Frameworks (CVD, serious mental illness, sepsis)
• ED PEWS (Launch 2026)

Expected 2027–2028

• Single National Formulary (by end 2027)
• Community Health Service Productivity Metrics (March 2028)
• National Product Adoption Dashboard (March 2028)

Challenges and Risks

The framework is ambitious. Delivery will be challenging. Several risks stand out.

Financial Sustainability Concerns

The 2% productivity target is tough. Historical productivity growth averages just 0.9% per year. Achieving more than double that consistently will be hard.

ICBs are cutting running costs by 50%. Redundancy costs are unfunded. Staff facing this situation can estimate their entitlements with an NHS redundancy calculator. This consumes time and attention of local leaders.

Capital investment of £13.6 billion in 2026/27, rising to £14.6 billion by end of parliament, may still be below what is needed. The NHS estate backlog has worsened significantly.

Workforce Capacity

Reaching zero agency spend while expanding services is a major challenge. The 3% annual increase in community capacity requires staff. Leadership bandwidth is stretched between structural change and operational delivery.

Prevention vs Performance Tension

Prevention receives just one page in a 36-page document. No performance metrics explicitly measure prevention progress. Core20PLUS5 is not mentioned in the framework.

The pressure to hit acute targets may divert attention and resources from the prevention shift.

Mental Health Investment

The Mental Health Investment Standard has not been recommitted. Only some services have ring-fenced funding. There is a real risk that mental health funding is cut to support acute recovery.

What This Means for ICBs

Integrated Care Boards have significant responsibilities under the framework.

Key requirements for ICBs:

• Develop robust 3-year and 5-year plans
• Implement the Strategic Commissioning Framework
• Map frailty care utilisation and shift resources to community
• Assess total resources spent on priority cohorts
• Commission sufficient diagnostic activity
• Plan for neighbourhood health delivery
• Identify GP practices where demand exceeds capacity
• Prepare for vaccination and screening commissioning delegation (likely April 2027)
• Commission additional out-of-hours and surge capacity

What This Means for Providers

NHS trusts and foundation trusts have their own set of requirements.

Key requirements for providers:

• Deliver individual trust performance targets
• Achieve balanced financial position without deficit support
• Meet 2% productivity improvement each year
• Deploy digital technologies (FDP, NHS App, ambient voice)
• Reduce agency and bank usage to individual trust limits
• Implement quality and safety requirements
• Complete patient experience surveys
• Achieve 95% medical job plan sign-off

Frequently Asked Questions

What is the new planning guidance for the NHS?

The NHS planning guidance for 2026/27 onwards is called the Medium Term Planning Framework. NHS England published it on 24 October 2025. It covers three years from 2026/27 to 2028/29, replacing the previous annual planning approach. It sets out 15 headline success measures and requirements across elective care, emergency care, primary care, mental health, and more.

What are the NHS A&E targets for 2026/27?

For 2026/27, the A&E 4-hour target is 82%. This means 82% of patients must be seen within 4 hours. This rises to 85% as the average for 2028/29. 12-hour waits must reduce year on year. Category 2 ambulance response times must reach an average of 25 minutes by 2026/27 and 18 minutes by 2028/29.

What is the NHS 10 Year Health Plan 2026?

The 10 Year Health Plan for England was published in July 2025. It sets out the long-term strategy for NHS transformation. The Medium Term Planning Framework implements this plan over the next three years. The plan focuses on three shifts: hospital to community, analogue to digital, and treatment to prevention.

What are Integrated Health Organisations (IHOs)?

Integrated Health Organisations are a new contract-based delivery model. They allow a provider to manage the whole health budget for a local population. IHOs are not a new organisational type. The host body works with other providers through subcontracting. IHOs enable end-to-end pathway redesign with efficiencies reinvested into better care.

What is neighbourhood health in the NHS?

Neighbourhood health is a model of care that brings services together at local level. Neighbourhood Health Teams serve defined populations, focusing on people with frailty, care home residents, housebound patients, and those at end of life. They provide proactive support, urgent community services, rehabilitation, and improved access to general practice.

When must trusts achieve zero agency spend?

Trusts must work toward zero spend on agency staffing by 2029/30. In 2026/27, a 30% reduction in agency use is required. Bank staffing must reduce by 10% year on year. Individual trust limits will be set in planning templates.

How will NHS pay be affected by these changes?

The framework focuses on operational planning rather than pay directly. However, workforce targets such as agency reduction and productivity requirements will affect staffing. NHS staff working under Agenda for Change can check the latest information on NHS pay bands for 2026 and the expected NHS pay rise 2026 to understand how their salary may change. Staff in Scotland should refer to separate guidance on NHS Scotland pay.