To:

• Integrated care board (ICB) chief executives
• Trust chief executives

cc.

• Regional directors

Dear colleagues,

As we get to the end of the year it’s worth taking a moment to reflect on your leadership response to the challenges we’ve faced over the last year – dealing with the £4.5 billion deficit, embracing the broader financial reset, completely changing the operating model and genuinely creating a renewed sense of ambition about what we can achieve, together.

The fact that we are now within a cat’s whisker of delivering our key operational imperatives on referral to treatment (RTT) and urgent and emergency care (UEC), having landed the money in 2025/26, and navigated industrial action (IA) and winter is pretty extraordinary. It was also genuinely encouraging to see this reflected in last week’s British Social Attitudes survey which showed that, while we still have a long way to go, our patients have seen and felt a big improvement this year after two terrible years. So, well done for everything you have done, and continue to do, and I hope you can take pride in this.

Looking forward, we now have plans that work in aggregate on the key metrics for 2026/27 and outline plans for the two following years. Regional teams will continue to refine these with you over the coming weeks and, through the new Intensive Recovery Programme, start working with colleagues with the most stubborn challenges to develop sustainable solutions to these long-standing problems.

What we absolutely need to avoid is the risk that, while we are rightly focused on making 2026/27 a success, we miss maximising the opportunity the multi-year planning process gives us to stretch ourselves over the medium term and really bring the benefits of the 10 Year Health Plan to life.

So, to enhance and augment the plans that you have submitted, we would like you to build out your strategic commissioning narratives to describe better how, as commissioners and providers, you intend to do this together, with particular emphasis on:

• what strategic commissioning means in your local system and how you intend to develop this over the next 3 years
• how you intend to develop neighbourhood care, what your strategic ambition is and how this links to your key challenges
• whether you would like us to agree changes to financial flows and/or payment systems to help deliver this and, specifically, what these changes are
• whether there is anything further we need to do at the centre to help accelerate the pace of change locally, including getting out the way where necessary

The key in all of this is to maintain the momentum, energy and discipline on delivery we’ve generated in the last year and equally apply it to shaping a more sustainable future model.

To help with this, we’ve been working through some key priorities that will support the next set of “big leaps”, such as a full reset of outpatient care and bringing scheduling and appointments into urgent care. I’ve attached an overview of these areas in Annex A and we’ll have a chance to talk them through at the regional roadshows in the second half of April.

We would like each ICB to provide us, via regional teams, a single document to summarise the above, by Friday 15 May. In doing so, we expect all local partners to work together to ensure a strong degree of alignment and clear identification of gaps and barriers that can be worked through together, and how you intend to do so.

Hopefully, all this makes sense. As always, get in touch with your regional director or any of us here at the centre if you need to.

Finally, and seriously, thanks for all you have done this last year and for your support and challenge throughout. The progress made is starting to be visible and palpable for our patients, so I hope you can take confidence from all of this to continue building a service we can be proud of in the future.

Thanks and keep going…

Sir Jim Mackey, Chief Executive Officer NHS England

Annex A

Building on stronger foundations

Eight key areas where, collectively, we can make a big difference this year and beyond:

1. Outpatient transformation – shifting away from traditional outpatient models through a major expansion of Advice and Guidance and a reduction in unnecessary follow‑ups.

2. A step‑change in reducing hospital bed‑days for highest‑risk cohorts – with neighbourhoods playing a central role in implementing proactive care models for high‑risk groups.

3. Scheduling and access reform for urgent care – making it easier for patients to book urgent care appointments in GP practices, urgent treatment centres, or other appropriate settings, reducing avoidable ED attendances.

4. Technology‑enabled productivity improvements – expanding the deployment of Ambient Voice Technology and a suite of tools to improve theatre utilisation, discharge flow, RTT validation, community waiting lists, Advice and Guidance, electronic prescribing in all trusts, and crisis response.

Nationally, we will be taking action to support these and related improvement efforts, including:

5. The NHS App – accelerating efforts to expand the role of the App as the digital front door into the NHS, supporting more convenient and effective triage and navigation for patients.

6. Payment reform – realigning the payment system to the service changes you are seeking to deliver, including new payment models for urgent and emergency care.

7. Quality – putting quality back at the heart of everything we do, including the publication of a new quality strategy, the development of modern service frameworks focused on mental health, sepsis, cardiovascular disease and frailty, and testing new delivery models for secondary prevention to tackle variations in the uptake of high-impact CVD and diabetes interventions.

8. Capability building and a focus on our people – launching the new Leadership College, which will be the most radical change to leadership development and talent management that the NHS has seen in over a decade.

Publication reference: PRN02464