Classification: Official

To:

• Integrated care board (ICB) and NHS trust/foundation trust:
  • chief executive officers
  • chairs

cc:

• NHS England regional directors

Dear colleagues,

Building on our progress in the second half of 2025/26 

When we met on 16 September, I committed to writing out to summarise the key priorities that we discussed for the rest of this year.

Firstly, to reiterate my thanks to each of you and your teams for the tireless efforts to drive improvement and reform across the NHS on so many fronts, and at the same time as having to manage significant change. This is an unprecedented time, both in terms of the depth of the challenges we face and the scale of the actions that we need to take to address them.

As I outlined when we met, progress since April has been astonishing. To move from a predicted end year deficit of £6 billion to the system position being in balance in final plans and at Month 5, whilst at the same time, continuing to improve waiting times in electives, cancer and for emergency care, has required a herculean effort for which I am hugely grateful.

As we look to the rest of this year, the pace, ambition, and determination which you have demonstrated in the first half of the year must continue. This letter seeks to provide clarity on the expectations of all providers and every system in key areas of finance and performance, and in relation to laying the foundations for longer term reform and delivery of the 10 Year Health Plan. It explains how we will work within our new operating model to support and challenge you to deliver, guided by the new Oversight Framework.

Maintaining financial discipline 

Thank you for your continued professionalism and grip, which has been instrumental in ensuring the NHS is broadly on financial plan at Month 5. We recognise that many plans are backloaded and so a continued focus is essential to maintain delivery momentum through the second half of the year.

The half-year mark is a critical point. Boards must have a clear view of actual spend, run rate, and the underlying drivers of financial performance. Where run rates are off-plan, now is the time to act decisively and take the decisions that will enable you to manage risk and implement credible recovery trajectories.

From close working with the chief executive officer (CEO) and chief financial officer (CFO) communities, we understand that organisations falling behind are typically struggling to deliver planned efficiencies or manage unplanned workforce costs – these remain key pressure points that need decisive executive action and board support.

The mid year review process outlined below will test assumptions in plans and seek assurance that steps are being taken to maintain financial discipline to the end of the financial year.

Delivering our priorities 

Following a strong start to the year, elective and urgent and emergency care (UEC) performance has drifted a little over the summer, and we need to take urgent action to ensure delivery returns to plan by the end of quarter 3. While industrial action has made a significant contribution, it is not the only factor in this drift, which insight and analysis from providers and systems shows is also being driven by higher than expected demand, financial pressures, and challenges on rates of pay.

On electives, trusts that are significantly off plan on activity, referral to treatment (RTT) and long-waits standards will be required to submit revised trajectories for return to plan by December. While maintaining their focus on 18 weeks performance and managing the size of the list, all providers are expected to eliminate their remaining 65 week waits by mid-December and meet the planning guidance requirements for 52 week waits by the end of March 2026. ICBs will be required to ensure there are plans in place to address demand growth above that assumed in activity plans, and also ensure that Advice and Guidance is optimised across their system. At a regional level, control totals will be set for waiting list size and long waits, and the leadership across the region collectively held to account for delivery of activity plans.

On UEC, we need to improve our position on 4 hours, 12 hours, and ambulance handovers ahead of winter. As part of the winter planning Board Assurance Statement (BAS) process, you will already be confirming that existing trajectories are deliverable in conjunction with winter surge. However, for those trusts consistently off-track, the key actions that sit behind the BAS will need to be submitted to NHS England and they will be tested through the mid-year review process to ensure there are realistic plans in place to return to trajectory. Where aspects of the plan are reliant on community and mental health providers, we know you will be working together on your collective system response. As discussed in Tuesday’s event, we all need to step up our focus on 4 hours again, and make some significant shifts in this so that we can start to impact on crowding in our emergency departments (EDs). This will be followed by a separate communication on next steps.

Continuing our focus on access to primary care is an important part of managing system pressures. Patients need to be able to contact their GP practice by phone, online or by walking in, and for people to have an equitable experience across these access modes. As part of dealing with the 8am scramble, from 1 October 2025 practices will be required to keep their online consultation tool open for the duration of core hours for non-urgent appointment requests, medication queries and admin requests. ICBs should ensure practices are following these requirements.

In addition, ICBs should also continue to support community pharmacy to meet the thresholds of performance for Pharmacy First.

On dentistry, the government’s manifesto commitment is that the NHS will deliver an extra 700,000 urgent dental care appointments. ICBs should urgently ensure that all necessary capacity is commissioned to meet their share of this commitment, that local pathways are in place to effectively match capacity with demand (for example, through 111), and that contractors are delivering on their obligations.

On these key primary care priorities, NHS England will be following up with systems in the coming weeks.

Mid-year review process 

Led by regions, and underpinned by the Oversight Framework, NHS England will be carrying out mid-year reviews with ICBs and providers over the next 6 weeks. For a small number of systems and providers, I will personally carry out their mid-year review.

These discussions will focus on where you are on our key priorities, where there might be risks that need mitigation and opportunities that could be expedited. They will focus on the range of priorities that we all share including finance, quality and performance.

You should prepare for this scrutiny, ensuring that, at organisation and system level, you are ready to articulate a clear and credible financial position for the remainder of this year which delivers operational standards.

Positively, all but one system has confirmed their expectation that they can deliver the operational performance targets set for this year within their financial envelopes, and so, through mid-year reviews, we look forward to exploring assumptions.

Resilience during winter 

You have been working hard to prepare for this coming winter during the summer months and testing your plans during a series of regional exercises held over the last 2 weeks. We would like to thank you for the time and consideration that you have put into this preparation.

We now have data from the UK Health Security Agency suggesting this winter we may experience circumstances similar to the moderate to severe scenario that we tested in the winter planning exercise. This means that fine tuning our plans and completing preparation is critical.

Over the next 2 weeks, plans must be tightened up and any gaps exposed during the exercise need to be closed, with Board Assurance Statement completed and returned by the end of September.

Working with the chief operating officer (COO) and emergency preparedness, resilience and response (EPRR) communities, key areas of learning for providers and systems that we have identified include:

• the need for robust plans to maximise vaccination rates across all cohorts, including health and social care workers, and achieve our collective aim of improving frontline staff uptake by at least 5 percentage points
• having a paediatric specific plan for when respiratory viruses cause a surge in demand for primary care, 111 and A&E
• ensuring primary care access is maintained over the Christmas period
• engaging with local authorities and social care providers so that discharge capacity surges at times of peak demand
• having senior clinical decision-maker enhanced rotas in place ready to be activated
• targeted occupancy reductions in the run-in to the Christmas period
• stepping up personal visibility and leadership, including from CEOs, chief medical officers (CMOs), and chief nursing officers (CNOs), to help lead and support our people through a challenging winter

As we move into delivery of our winter plans, we are asking that a special focus is placed on reducing bed occupancy to below 80% ahead of the Christmas period to give ourselves the best chance of managing the early weeks of January.

During periods of pressure, operational pressures escalation level (OPEL) action cards should be consistently applied, and critical incidents only used for short periods to get ahead of further escalation.

To support providers and commissioners, and ensure join up across the system, NHS England will commence its own national and regional operational coordination response 7 days a week from 27 October. This will use data and intelligence to maintain an overview of ambulance response times, OPEL levels, and long waiting times, moving to support when systems are not able to decompress in a timely way.

We know that this will be a challenging period, but we also know that personal leadership – in particular from chief executives, medical and nurse directors, as well as the senior operational team – makes a significant impact on flow, safety and performance. We ask that you make this a priority throughout winter, but particularly during the Christmas, new year and early January period.

Leadership and our people 

We discussed on Tuesday the need for us all to step up and lead our people through this challenging period. We have specific actions in place regarding the implementation of the 10 Point Plan for resident doctors between now and the end of the year, but we need to redouble our efforts to be mindful of the experience of all staff, especially during periods of high demand and pressure. The best performing organisations make this an organisation wide priority and I would like us to make this more of a central focus for all of us, sitting alongside the focus on patient experience set out in Penny Dash’s work and the 10 Year Health Plan.

More will follow on this but, in the meantime, please ensure that this is a central focus for your board and broader leadership team. We all know the impact that regularly walking the floor and spending time in A&Es and other pressured areas of your organisation has on staff morale, and your ability to understand and manage services.

Looking ahead to 2026/27 

As you continue to implement your plans for 2025/26, closing gaps where you have fallen behind, you also need to be shaping your strategy for the following years and how we bring the intent of the 10 Year Health Plan to life.

We shared the foundational elements of the Planning Framework over the summer, and further elements will be published in the coming weeks. Ahead of that, now is the time to begin to prepare for next year and beyond.

In particular, we encourage you to plan for the crucial local service transformations that are needed to improve outcomes and deliver your longer-term plans, informed by the demand and capacity analysis that you have been doing over the summer.

Technology and digital solutions are going to be vital for longer term transformation and unlocking our productivity. Cutting back on investments in these areas to help with short-term challenges will undermine longer-term sustainability and improvement.

On workforce transformation, we are working with you to build the 10 Year Workforce Plan that will enable the delivery of the 10 Year Health Plan. That will be ready in the coming months and will help us all to plan for the longer term.

Finally, and as discussed on Tuesday, you have responded so well to the challenges we faced together in the spring and you should take pride and hope from that. We all know that there is still a lot to do, and we must ensure that we can deliver our short term operational and financial imperatives while also building for the future. The spirit and energy in the room on Tuesday was very powerful, and I know from many conversations over recent weeks that you really want to engage and shape this all locally with your teams and partners.

Thanks for all you have done so far. Let’s all continue to pull together to deliver what we have discussed and set out in this letter, and in the way we have worked together over these past months.

Keep going…

Yours sincerely

Sir James Mackey, Chief Executive Officer, NHS England

Publication reference: PRN02187