NHS England Medium Term Planning Framework 2026/27–2028/29: Strategic Implications, Operational Mandates and the Financial Feasibility of Reform

Nelson Advisors
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NHS England Medium Term Planning Framework 2026/27–2028/29: Strategic Implications, Operational Mandates and the Financial Feasibility of Reform

Executive Summary: Synthesis of the Three-Year Mandate

The NHS England Medium Term Planning Framework (MTPF), officially published on 24 October 2025, establishes the operational and financial roadmap for Integrated Care Boards (ICBs) and providers for the three-year period spanning 2026/27 to 2028/29.

This document represents a fundamental shift away from the legacy of crisis-driven, short-term annual planning toward a medium-to-long term system designed to foster local innovation and support long-term sustainability.

The MTPF is designed as the critical link, bridging the immediate pressures faced during recovery with the deeper, systemic reform required for the National Health Service (NHS).

Core Principles and Alignment with the 10-Year Health Plan (10YHP)

The framework is predicated on accelerating the strategic objectives set out in the 10 Year Health Plan for England (10YHP), which articulated three foundational shifts for system transformation. These shifts are central to all mandated planning activities across the MTPF period.

From Treatment to Prevention: Emphasis is placed on primary and secondary prevention, including supporting preventative care through the GP contract and locally agreed delivery plans for screening and vaccination, aligning with approaches such as Core20PLUS5.
From Analogue to Digital: Full utilisation of digital tools and infrastructure is mandated to drive efficiency, standardise care, and improve patient experience.
From Hospital to Community: This necessitates the aggressive development of Neighbourhood Health Service models to reduce demand on acute services and enable care to be delivered closer to home.

The Recovery/Reform Dual Imperative

The MTPF is arguably the most ambitious plan published in a generation, aiming not just for incremental improvement but for a complete restoration of constitutional performance standards by 2028/29. Its successful implementation hinges on achieving unprecedented operational improvements alongside simultaneous, complex systemic reforms.

The publication timing in October 2025 provides significantly more lead time for local leaders to construct robust multi-year integrated plans, contrasting sharply with previous annual cycles. However, this longer planning cycle does not mitigate the scale of the required transformation, which includes structural changes to commissioning and primary care models.

Key Findings and High-Level Recommendations

The analysis of the MTPF highlights critical structural dependencies and inherent financial risk. Despite a positive multi-year financial settlement from Spending Review 2025 (SR25), the framework mandates that all ICBs and providers must achieve financial balance or surplus, underpinned by a highly challenging 2 per cent annual productivity gain.

This productivity requirement is essential for reversing the trend of workforce growth outpacing activity growth post-2019/20. The successful delivery of the MTPF is thus fundamentally tied to the ability of ICBs to rapidly and effectively implement the Neighbourhood Health Service models, the primary mechanism for demand reduction, thereby creating the necessary margin to meet the stringent financial mandates without compromising quality or safety.

The New Architecture of NHS Planning and Governance

Transition from Annual Cycles to Medium-Term Planning (2026/27–2028/29)

The MTPF sets targets and requirements for NHS organisations over the next three and five years, marking a deliberate move away from short-term planning. The three-year planning cycle (2026/27 to 2028/29) is enabled by the corresponding three-year revenue and four-year capital settlement confirmed during Spending Review 2025.

This framework is explicitly designed to unleash the ambition of local teams and provide a platform for NHS leaders to drive necessary change. The operational planning guidance for 2025/26, published in January 2025, served as the initial step, demanding aggressive recovery and efficiency (eg. 4% savings); the MTPF now extends these pressures into structural reform over the medium term.

The framework attempts to streamline national direction by reducing the number of headline success measures to 15 over the three-year period, down from 18 in the 2025/26 guidance and 133 in 2022/23. This welcome focus is intended to allow local leaders greater clarity and agency in resource allocation. However, the commitment to publish at least 20 additional guidance and resource documents in the following months, covering areas from neighbourhood health to integrated health organisations, signifies significant central direction that will shape local plan execution.

Devolved Accountability and Central Direction

The MTPF emphasises greater devolution of funding and decision-making to systems, removing most ring-fences to allow local leaders to innovate and use scarce resources effectively. Correspondingly, the NHS Oversight Framework requires ICBs and providers to focus intensely on performance areas like finance, urgent and emergency care, elective, and mental health. While ICBs are currently not segmented due to significant changes undertaken, provider capability assessment and performance management (tiering) activities will continue to be undertaken by NHS England regional teams for underperforming organisations.

A close examination of the framework reveals a nuanced strategy: while the rhetoric supports local empowerment, the mechanisms of delivery are heavily dictated by centrally defined blueprints. This means local leaders are delegated the responsibility for difficult implementation decisions and financial risk management, but the core architectural design of system change remains tightly controlled via prescriptive guidance such as the Strategic Commissioning Framework and the Model Neighbourhood Framework. For local systems, success hinges on skillfully adapting and executing these prescribed models, not on creating fundamentally divergent local strategies.

Structural Guidance: Strategic Commissioning and Delegated Responsibilities

Fundamental structural changes to commissioning are mandated through the MTPF. The Strategic Commissioning Framework (SCF) was published in October 2025, providing ICBs with a clear scope for their evolved role and building upon the Model ICB blueprint. ICBs are required to implement this SCF as part of their shift toward multi-year planning.

A major functional shift is the delegated commissioning responsibility for vaccination and screening services, which will move from NHS England to ICBs, likely from April 2027, subject to the passage of necessary legislation. In preparation, NHS England will develop a new commissioning and contracting framework in 2026/27. This shift is strategically linked to increasing prevention and access; for example, NHS England will enable community pharmacy to deliver vaccinations off-premises where commissioned, subject to regulatory approval, leveraging primary care assets to drive preventative goals.

Further governance models are anticipated later in 2025, including a draft foundation trust framework released for consultation in November and a Model Integrated Health Organisation (IHO) framework. Concurrently, a new Management and Leadership Framework is expected in autumn 2025 to set standards and competencies for leaders across five levels.

Timeline of Key MTPF Implementation Guidance and Policy Shifts

Guidance/Framework	Expected Publication/Implementation Date	Impact and System Requirement	Source
Medium Term Planning Framework (MTPF)	24 October 2025 (Published)	Sets targets and requirements for 2026/27 to 2028/29.	^NHS
Strategic Commissioning Framework	October 2025	ICBs to implement; forms basis for their evolved commissioning role.	^NHS
Technical Guidance: Multi-Year Revenue and Capital Allocations	Autumn 2025	Provides details on financial assumptions and funding levels.	^NHS
Draft Foundation Trust Framework	November 2025 (For consultation)	Outlines standards and governance for Foundation Trusts.	^NHS
Model Neighbourhood Framework	Expected November 2025	Sets foundations for scaling community-based care models.	^NHS
New Management and Leadership Framework	Autumn 2025	Sets standards and competencies for clinical and non-clinical leaders.	^NHS
Delegated Commissioning of Vaccination/Screening	Likely April 2027 (Subject to legislation)	Full shift of commissioning responsibility to ICBs.	^NHS

Financial Discipline and the Productivity Imperative

Analysis of the Spending Review 2025 (SR25) Settlement

The MTPF is framed against the backdrop of the SR25 settlement, which provides a defined multi-year financial envelope, enabling the shift away from annual planning. Revenue funding is set to increase by 3 per cent in real terms over the SR25 period, culminating in £226 billion in 2028/29. Capital spending also sees an uplift, increasing from £13.6 billion in 2025/26 to £14.6 billion in 2029, representing a 3.2 per cent real-terms increase over the period. This is supplemented by a commitment of up to £10 billion for NHS technology and digital transformation by 2028/29.

However, the perceived value of this financial settlement is moderated by significant underlying cost pressures. The 2025/26 planning guidance noted that a 4 per cent nominal spending uplift would feel closer to a 2 per cent real-terms increase for most systems once specific cost pressures are accounted for. The strategic ambition of the MTPF must therefore be achieved primarily through improved efficiency rather than substantial new expenditure.

The Mandate for Financial Balance and Productivity

A foundational requirement of the MTPF is stringent financial discipline. All ICBs and providers are expected to deliver a balanced or surplus net system financial position in 2025/26 and subsequent years. The long-term objective is to operate without reliance on deficit support by 2029.

Crucially, this financial stability is predicated upon achieving 2 per cent annual productivity gains. This requirement is intended to reverse the troubling trend where NHS workforce growth has significantly outpaced activity growth since 2019/20, a dynamic identified as unsustainable for the long-term health of the service.

Furthermore, this 2% annual mandate follows the highly challenging 4 per cent efficiency savings demanded of providers in the 2025/26 operational planning guidance. ICBs and providers are explicitly asked to "close the activity/WTE gap against pre-Covid levels".

The mandate for 2% sustained annual productivity gains presents the most significant structural risk to the MTPF. Historical data suggests providers achieved an average of only 0.9% efficiency gains per year in the decade preceding the pandemic. Successfully achieving a rate more than double this historical average requires profound, systemic, and recurrent savings, which must be realised quickly from the structural reforms outlined, particularly the shift to digital and community-based care. If these reforms yield slow benefits, systems will face intense pressure to rely on non-recurrent cost improvement programmes (CIPs), which may compromise long-term quality and recovery efforts.

Expenditure Management and Waste Reduction

To support financial balance, the MTPF reiterates a forceful mandate to reduce waste, most prominently through expenditure control. ICBs and systems must reduce agency expenditure as far as possible, with a minimum required reduction of 30% on current spending across all systems. This reduction is critical to ensuring savings are directed back into frontline services.

Providers are directed to improve operational and clinical productivity through targeted initiatives.These include optimising medicines value, reducing unwarranted variation in prescribing through implementation of Low Value Prescribing Guidance, and maximising the use of best value biological medicines where bio-similars are available. Furthermore, trusts are expected to optimise energy value through green plans and utilise the new national contract developed with Crown Commercial Services for energy procurement.These measures are integral to achieving the required efficiency factor and living within the allocated budget.

Medium Term Planning Financial Mandates and Spending Review (SR25) Commitments

Financial Metric	MTPF Expectation/Target	Associated Planning Period	Supporting Information
Revenue Funding Increase (Real-terms)	3% increase over SR25 period	Up to 2028/29	Revenue funding up to £226 billion in 2028/29
Capital Spending Increase (Real-terms)	3.2% increase over SR25 period	Up to 2029	Increase from £13.6bn (2025/26) to £14.6bn (2029)
Annual Productivity Mandate	2% annual productivity gains	Each year of the MTPF (2026/27 onwards)	Required for delivering financial balance/surplus
System Financial Position	Deliver a balanced net system financial position	2025/26 and subsequent years	All ICBs and providers expected to deliver balance/surplus
Agency Expenditure Reduction	Minimum 30% reduction on current spending	Across all systems (2025/26 guidance)	Part of wider mandate to reduce waste

Restoring Constitutional Standards: Elective, Cancer and UEC Targets

The MTPF commits to ambitious escalation targets across all major constitutional standards, designed to return services to much better health by the end of the planning period.

Elective Care Recovery and the RTT Trajectory

The framework sets a highly accelerated trajectory for referral to treatment time (RTT) performance. Following the challenging 2025/26 target of 65% nationally, the MTPF mandates significant medium-term improvements:

2026/27 Target: The national performance target for RTT is set at 70% of patients waiting no longer than 18 weeks for treatment. Every trust is expected to contribute by delivering a minimum 7 per cent improvement in 18-week performance or achieving a minimum of 65 per cent performance, whichever is greater.
2028/29 Target: The ultimate goal is to achieve the constitutional standard that at least 92% of patients are waiting 18 weeks or less for treatment. This ambition is supported by the goal of achieving 2.5 million fewer patients waiting more than 18 weeks by March 2029.

Furthermore, systems must continue the immediate focus on eliminating the longest waits. The proportion of people waiting over 52 weeks for treatment must be reduced to less than 1% of the total waiting list by March 2026.

Cancer Standards: Faster Diagnosis and Treatment

Performance against cancer constitutional standards remains a core priority. Improvement strategies focus on maximising care for low-risk patients in non-cancer settings and improving productivity within cancer pathways.

Faster Diagnosis Standard (FDS): Performance against the 28-day FDS must be maintained at the new threshold of 80% throughout the MTPF period.
Treatment Standards: By March 2027, every trust is required to deliver 94 per cent performance for 31-day standards and 80 per cent performance for 62-day standards. This builds significantly on the 2025/26 operational target, which aimed for 75% for the 62-day standard by March 2026.

Urgent and Emergency Care (UEC) Improvement

Performance targets for UEC are closely linked to patient flow initiatives derived from the shift to community care. Following the 2025/26 operational target of a minimum of 78% of patients seen, admitted, discharged, or transferred from Emergency Departments within four hours, the MTPF escalates this requirement: every trust must maintain or improve performance to 82 per cent by March 2027.

Ambulance performance is targeted by improving Category 2 ambulance response times to an average of 30 minutes across 2025/26. Local plans must show how systems will meet the maximum 45-minute ambulance handover time standard, improve flow, and eliminate corridor care, with a particular focus on reducing 12-hour waits. For diagnostics, every system must deliver a minimum 3 per cent improvement in performance against the DM01 diagnostics 6-week wait standard (or 20 per cent performance, whichever is greater) to move toward the national objective of no more than 14 per cent waiting over six weeks.

The rapid escalation of these performance target, particularly the trajectory toward 92% RTT, creates a profound operational challenge, especially when coupled with the mandated financial efficiency. The ability of the NHS to meet these ambitious targets while simultaneously delivering 2% annual productivity gains depends entirely on the timely and effective deployment of digital tools and the Neighbourhood Health Service models. If these structural reforms fail to deliver immediate, scalable demand reduction and throughput improvements, systems will be caught between the critical demands of clinical constitutional standards and the uncompromising mandate for financial balance.

Key Performance Targets: Comparison of Operational and Medium-Term Framework Goals

Clinical Domain	2025/26 Operational Target (Baseline for MTPF)	2026/27 MTPF Target	2028/29 MTPF Target
Elective Care (18-week RTT)	65% national target	70% national target	92% national target
UEC 4-Hour Standard (A&E)	Minimum 78% by March 2026	Maintain or improve to 82% by March 2027	Constitutional Standard (Implicit)
Cancer 28-day Faster Diagnosis Standard (FDS)	80% by March 2026	Maintain performance at 80%	Constitutional Standard (Implicit)
Diagnostics (6-week wait)	N/A (Focus on improvement)	Minimum 3% improvement (towards 14% max wait)	Constitutional Standard (Implicit)
Community Health Services (18-week RTT)	N/A (Focus on productivity/scaling)	At least 78% of activity within 18 weeks	At least 80% of activity within 18 weeks

System Transformation: Community, Primary Care and Mental Health

Implementing the "Hospital to Community" Shift: Neighbourhood Health Services

The strategic core of the MTPF is the acceleration of the "Hospital to Community" shift through the development of Neighbourhood Health Service models. ICBs and providers are mandated to develop these models immediately to reduce demand on hospitals and prevent long and costly admissions.

The forthcoming Model Neighbourhood Framework, expected in November 2025, will provide the structural blueprint for standardising and scaling key components of this care model. The initial focus for 2025/26 is on preventing people from spending unnecessary time in acute settings, particularly for adults and Children and Young People (CYP) with complex needs. The long-term vision requires strengthened primary and community-based care, reduction in avoidable long-term residential care admissions, and improved coordination with wider public services and the Voluntary, Community, and Social Enterprise (VCSFE) sector.

A critical underlying assumption of the MTPF is that decentralizing care will yield cost efficiencies. However, the history of previous health plans shows that transferring care closer to home requires significant upfront investment in local infrastructure and staffing, meaning care in the community is not inherently "care on the cheap". For the Neighbourhood model to succeed in delivering both improved care and financial balance, ICBs must execute a fundamental shift in resource allocation, moving funding away from high-tariff acute provision and into community capacity before the full benefits of reduced acute demand are realised.

Primary Care Access and Prevention

Improved access to general practice is a key success measure, assessed through metrics such as patient experience captured by the ONS Health Insights Survey. ICBs are expected to target support to practices based on their ability to provide timely appointments and positive overall patient experience. A significant commitment in the framework is the improvement of access to urgent dental care, requiring ICBs to commission an additional 700,000 urgent dental appointments.

In line with the shift from treatment to prevention, the MTPF mandates robust, locally agreed delivery plans for preventative services such as screening and vaccination, leveraging the GP contract and the expanded role of community pharmacy. The Oversight Framework reinforces this by monitoring ICB performance across key prevention metrics, including cancer screening rates, pregnant women who quit smoking, and obesity programmes.

Mental Health, Learning Disabilities, and Autism Care

Mental health improvement is focused on accelerating patient flow, improving productivity, and reducing reliance on inpatient settings. A core success measure is the reduction of reliance on mental health inpatient care for people with a learning disability and autistic people, with a mandated minimum 10% reduction.

This is supported by specific capital allocations to reduce Out-of-Area Placements (OAPs). ICBs must ensure high-quality and accessible community infrastructure is in place, aligning with proposed Mental Health Act reform, to ensure that admissions are reserved only for assessment and treatment that definitively requires an inpatient setting. Furthermore, targets are set to increase the number of CYP accessing services to meet the national ambition of providing services to 345,000 additional CYP aged 0–25 compared to 2019 levels. The framework seeks to achieve 100 per cent coverage of Mental Health Support Teams by 2029/30.

Community Health Services Capacity

The MTPF introduces specific, quantifiable targets for community services, essential for supporting the Neighbourhood model and avoiding acute admissions. ICBs must proactively increase community health service capacity to manage a projected 3 per cent expected annual growth in demand. Performance metrics for community service RTTs require systems to ensure at least 78 per cent of activity occurs within 18 weeks by 2027, rising to 80 per cent by 2029, alongside a commitment to develop a plan to eliminate all 52-week waits.

Productivity enhancement in community settings is also mandated, requiring the use of digital tools, the expansion of point-of-care testing, standardizing core service provision, and scaling the use of digital therapeutics, particularly for musculo-skeletal (MSK) treatment.

Enablers of Change: Digital, Capital and Workforce Reform

Digital Transformation: The "Analogue to Digital" Shift

Digital capability is recognised as a fundamental enabler for achieving both productivity and system reform.The MTPF is backed by a substantial commitment to technology investment, contributing to the overall £10 billion allocated by 2028/29. In the next financial year, £596 million will be allocated to drive frontline digital transformation and operational capability enhancement, supplemented by a further £400 million specifically aimed at productivity-improving technology initiatives.

Key digital mandates include advancing the adoption of the Federated Data Platform (FDP) and supporting the transition to fully digitised systems. Significant progress has been made on the foundational Electronic Patient Record (EPR) infrastructure; by March 2026, 98% of trusts are forecast to have an acceptable EPR. Digital funding will also be allocated via competitive bidding frameworks for enhanced cybersecurity measures.

Capital Planning and Investment Priorities

The capital guidance supporting the MTPF mandates a stringent approach to investment, intended to ensure alignment with financial sustainability goals. Systems must engage in joint governance to balance system-specific priorities with collective responsibility.

Capital proposals are rigorously assessed against several criteria: they must outline expected improvements in clinical or constitutional standards (performance impact); they should ideally finish within 2025/26 (timely completion); and, critically, they must be demonstrably revenue improving or revenue-neutral.

This requirement ensures projects manage revenue costs, including capital charges and depreciation, within existing revenue settlements, placing a high bar on transformative capital schemes that require significant sustained operational funding uplift.

This capital constraint is particularly acute for the "Hospital to Community" shift. If crucial infrastructure projects for Neighbourhood Health Services, such as community diagnostic or primary care hubs—require an upfront revenue investment for new staffing or higher running costs before acute savings are secured, the "revenue-neutral" rule may inadvertently inhibit the very structural change the MTPF aims to achieve. To mitigate this, £75 million has been specifically allocated in 2025/26 to support localised mental health infrastructure, targeting the reduction of OAPs in acute care, psychiatric intensive care units (PICUs) and rehabilitation placements far from home.

Workforce and Leadership Development

Workforce efficiency is directly addressed through mandated reforms designed to decouple workforce growth from service delivery growth. The pressure to reduce agency expenditure (minimum 30% reduction) places emphasis on optimising core staffing utilisation.

A major reform for productivity is the implementation of new consultant job planning structures. Systems must ensure that 95% of medical job plans are signed off annually in line with business cycles.

Furthermore, rigorous system monitoring and assurance of job planned activity must be enacted by the end of 2026/27, with full-year tracking achieved by the end of 2027/28. By 2028/29, this must extend to multi-professional service level activity and job planning. These mechanisms are central to converting clinical time into measurable activity and sustaining the 2% productivity target. The new Management and Leadership Framework, expected in autumn 2025, will further standardize competencies and ethics, providing ICBs and providers with guidance for leadership recruitment and approval.

Conclusion and Critical Assessment

The NHS England Medium Term Planning Framework (MTPF) 2026/27–2028/29 represents a necessary strategic evolution, shifting the service toward long-term integrated planning built upon the foundational principles of the 10 Year Health Plan. It offers a clear, if narrow, path toward simultaneous performance recovery, aiming for 92% RTT compliance by 2028/29 and structural transformation via the Neighbourhood Health Service models.

The primary determinant of the MTPF’s success is the financial feasibility of the transformation. The mandate for all systems to achieve financial balance underpinned by a sustained 2 per cent annual productivity gain creates a highly demanding operational environment. Given historical efficiency rates, achieving this target requires that the investments in digital transformation and the structural shift to community care must immediately yield systemic savings in acute demand and workforce utilisation. If reform benefits are delayed or insufficient, the financial imperative will clash directly with the operational goal of restoring constitutional standards, forcing local leaders into impossible trade-offs.

Strategic Recommendations for System Leaders

Prioritise Neighbourhood Revenue and Reallocation: Integrated Care Boards must proactively utilize the flexibility afforded by the MTPF to model and enforce the reallocation of revenue resources from high-cost acute capacity into the staffing and development of Neighbourhood Health Service models. This structural funding shift must be executed based on the guidance in the Model Neighbourhood Framework (November 2025) to accelerate demand reduction and validate the MTPF’s financial assumptions.
Focus Digital Investment on Productivity: The targeted technology funding (the £400 million stream dedicated to productivity) should be strategically deployed on digital solutions that directly support and measure clinical efficiency gains, particularly those integrated with the consultant job planning reforms.This ensures digital investment translates into quantifiable efficiency improvements needed to meet the 2% mandate.
Proactive Financial Resilience and Contingency Planning: Recognizing the historical difficulty of achieving high annual productivity, system leaders must develop robust contingency plans for recurring efficiency savings that exceed the 2% annual target. This requires early identification and management of low-value activity and a rigorous approach to expenditure reduction (e.g., the 30% agency spend target) to absorb inevitable cost pressures and maintain the mandated balanced financial position.

Source: https://www.england.nhs.uk/wp-content/uploads/2025/10/medium-term-planning-framework-delivering-change-together-2026-27-to-2028-29.pdf

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