Executive summary and action required

The NHS England Board is asked to:

Discuss and endorse the proposed model for improvement for 2026/27. This includes the respective roles and functions to support locally led improvement and develop the NHS into a learning system.

Endorse the need for structured improvement approaches to support delivery of the key national priorities set out in the Medium-Term Planning Framework.

If the model for improvement proposed in this paper is endorsed, we will provide an update to the Board in March, outlining how we will support improvement in key national priorities. This will set out how resources would be allocated to support delivery and highlight key changes to structures and ways of working, building on the progress made during 2025/26.

Context

1. Building on the vision of the 10 Year Health Plan and the three strategic shifts, the Medium-Term Planning Framework outlined the performance targets and requirements for NHS organisations for the three years up to 2028/29, with local leaders empowered to drive accelerated change.

2. The new NHS operating model continues to develop and refine, establishing clearer roles for organisations and systems. We are returning power to the frontline and developing a new smaller centre, creating an environment for locally led improvement and transformation. Improvement is reaffirmed as a core responsibility of providers in the operating model, and the role of regions and the centre needs to shift to support this.

3. To drive transformational change, providers will be encouraged to explore ‘big leap’ improvement initiatives across whole pathways, and in doing so will convene place partners across primary care, social care, and voluntary and independent sectors.

4. During this year, local clinical and operational teams across the NHS have demonstrated how significant improvements and leaps in performance can be achieved. The Shrewsbury and Telford Hospital NHS Trust significantly reduced waiting times for patients in planned care, achieving a 17% improvement in 18-week referral to treatment performance in one year (November 2024 to November 2025). The Trust then used productivity improvements delivered in outpatients and operating theatres to fund expansion in urgent and emergency care capacity. In addition, The Princess Alexandra Hospital NHS Trust have delivered substantial improvements in urgent and emergency care services for patients, and achieved a 23% improvement in 4-hour performance in December 2025, compared to the same month the previous year.

5. Many of the proposals in this paper have been designed by a Task and Finish Group, led by Glen Burley and Sarah-Jane Marsh, and including colleagues from regional and national improvement teams, Trust Chief Executives, and Chief Operating Officers.

Resetting how we support and enable improvement

6. The new operating model provides the foundation for locally led improvement, supported and enabled by regions and the centre.

7. Crucially, improvement is reaffirmed as a core provider responsibility, with ICBs focusing on strategic commissioning. Providers are responsible for delivering high quality and efficient care, and improving productivity, for which the Board is accountable. Performance management and improvement in primary care is managed through contractual oversight from ICBs. For secondary and tertiary care providers, good performance and improvement is incentivised through earned autonomy. This is driven by a multi-year approach to planning, and subsequent provider oversight informed by the NHS Oversight Framework (NOF). It is expected that individual providers will drive this capability for themselves, but where this is not the case, there are opportunities to support improvement through performance management and targeted support.

8. These foundations provide an opportunity to shape the NHS into a learning system. This paper sets out NHS England’s role in the learning system and the proposed model for improvement, which is underpinned by the following design principles:

• All NHS providers should have a suitable improvement programme aligned to their objectives, plans, and range of challenges. Improvement resources should be suitably balanced at local level to reflect key national priorities and local initiatives. Providers are encouraged to explore improvement approaches across whole pathways, convening place partners in primary care, social care, and the voluntary and independent sectors. Patient and public involvement should be embedded across all improvement approaches.
• NHS England must enable improvement across all providers, including organisations in ‘the middle of the pack’ through universal offers and programmes, and maintain targeted time-limited support for the most challenged organisations. High performing providers have an important role in sharing learning and supporting improvement in more challenged providers.
• The disposition of improvement resource should be more equally balanced between sectors and across pathways, recognising significant transformation is required to drive primary care improvement and deliver the neighbourhood health model.
• ICBs must be supported to take on their refreshed role as strategic commissioners, to ensure the NHS consistently creates the best value for the public, aligned to population health needs.
• The model for improvement must support delivery of performance priorities in-year (including improved quality, productivity and access), as well as ‘big leaps’ and multi-year transformation in line with the 10 Year Health Plan.
• Support should be aligned with the NOF with clearer roles and responsibilities for all parts of the service. Our approach to tiering will be streamlined and made more consistent with our approach to national oversight. Enhanced support will continue for providers with specific performance challenges. Further information can be found in Annex A.

How NHS England adds value in the new model for improvement

9. NHS England’s role in the learning system consists of four key value-adding elements, focused on creating the conditions for locally-led improvement. The four key areas are:

1. Setting strategy, priorities, codifying standards and best practice and identifying opportunities for improvement.
2. Renewing and strengthening leadership and management for improvement across all staff.
3. Facilitating nationally designed, regionally supported and locally delivered improvement approaches to drive in-year and multi-year improvement.
4. Expert time-limited support to the most challenged providers as an adjunct to local improvement efforts.

10. Where the above activities are supported by tools / guidance, these should be digitalised and easily accessible to promote rapid adoption.

Setting strategy, priorities, codifying standards and best practice and identifying opportunities for improvement

11. The strategy and vision for the NHS have been set through the 10 Year Health Plan. NHS England sets priorities via the Medium-Term Planning Framework and will continue to provide quality data and insights, including patient experience data, to identify variation and opportunities for improvement, including through the Model Health System.

12. NHS England will provide national clinical leadership to set codified standards, including through Modern Service Frameworks (MSFs) and the Getting It Right First Time (GIRFT) programme, as well as identifying and sharing examples of innovative practice from other countries and industries. This will be supported by bottom-up ‘should cost’ methodologies and the publication of ‘model’ blueprints and improvement guides, including the Model Emergency Department.

13. NHS England will facilitate the rollout of ‘do once, do well’ technology and digital solutions to ensure opportunities are translated into tangible benefits and improvements in quality and productivity.

14. Where support is best provided by external consultancies, we will help providers make an informed choice through robust, nationally agreed specifications and procurement processes across key areas of improvement work.

Renewing and strengthening leadership and management for improvement across all staff groups

15. Improvement and transformational change programmes need to land in a receptive and capable context in organisations that are delivering and improving care. NHS England will empower frontline teams to lead improvement and provide support to develop skills and expertise, including digital and data capabilities and utilisation of the Federated Data Platform (FDP).

16. NHS England will therefore prioritise capability building, leadership development and training in quality improvement. We are currently developing a series of national training and development programmes which will adopt a ‘train the trainer’ approach, supporting organisations to spread learning and complementing local approaches to raise standards in improvement skills. Importantly, these programmes will equally target clinical staff, as well as operational managers and leaders – recognising that improvement is sustained when it is clinically-led. These programmes will include:

1. Board Development Programme (NEW) – working with providers and ICB boards to develop board effectiveness and leadership for improvement, drawing on existing best practice and guidance (e.g., the Insightful Provider Board and Well Led Framework). This programme would provide the only board development offer by NHS England. All other offers will be decommissioned.
2. Clinical and Operational Management Training (CONTINUED) – building on progress in 2025/26, we will continue to build a critical mass of clinical and operational managers to develop skills in operational management and improvement to better deliver the basics and lead improvement, focused on Band 6 – 8a staff.
3. Clinical and Operational Leadership Training (NEW) – training for clinical and operational senior managers and leaders in operational leadership and improvement, focused on Band 8b – VSM staff. This programme requires procurement, design and delivery in 2026/27.

17. Next year we will extend access to these programmes to build improvement capability in primary care, community care and explore potential rollout to social care, drawing on examples that already exist in these areas.

18. GIRFT is one of our biggest assets, and regional and national teams must have strong improvement expertise to enable improvement across the NHS. This includes staff with deep improvement expertise to support providers in real time, identifying examples of innovative practice, and helping to develop the NHS as a learning system. We are exploring how to attract people with the credibility, skills and experience to lead this work in 2026/27 within a smaller headcount.

19. The strategic commissioning development programme will be launched from April 2026 to support ICBs to develop as strategic commissioners and we will align this with the capability building programmes described above.

Facilitating nationally designed, regionally supported and locally delivered improvement approaches to drive in year and multi-year improvement

20. The role of Learning and Improvement Networks (LINs) will mature to support all providers to drive improvement. Led by Chief Executives with a strong track record of improvement and operating on a regional footprint, the networks already provide an opportunity to bring clinical and operational leaders together to learn from each other and share best practice.

21. In 2026/27, the LINs will continue to use improvement methodologies to support in-year improvement to reduce unwarranted variation, against key metrics using data insights, clinical leadership and provider collaboration. We also envisage that LINs will play a role in facilitating improvement on areas of national priority.

22. To support this advanced role for LINs, we will review leadership arrangements and areas of focus. We will also consider how wider networks can be streamlined, with a smaller number of provider collaboration networks achieving full national coverage, with a particular focus on Cancer Alliances and Imaging Networks.

23. A small number of national priorities will require a systematic ‘all-in’ improvement effort to improve care at scale across the NHS. This was a clear ask of Trust CEOs in the Task and Finish Group. In the paper to be brought to Board in March, we will set out how structured improvement collaboratives will support the NHS to drive improvement at scale in key areas of national priority. An overview of improvement collaboratives is provided in Annex B.

Providing expert time-limited support to the most challenged providers

24. During 2025/26, work has already been undertaken to strengthen and streamline NHS England’s existing targeted and intensive improvement offers. This will provide the foundation for effective targeted support into 2026/27 and beyond.

25. In 2026/27, we are proposing that providers in NOF segments 3 and 4, will continue to receive targeted support in UEC, elective, maternity and mental health, based on their specific performance challenges. This will be delivered primarily through the clinically led GIRFT programme, with deployment decisions to be predominantly led by regional teams. In coming months, national and regional teams will discuss how to operationalise this during 2026/27, building on the established GIRFT methodology and clinical leadership. It is proposed that work is undertaken to consider how the current ‘tiering’ approach can be streamlined, with support available for providers with specific performance challenges.

26. A small operational ‘HIT team’ will also be available through GIRFT for rapid deployment and stabilisation where organisations experience real time issues.

27. For the most challenged providers who require intensive support to develop the conditions for sustainable improvement, they will be escalated to NOF segment 5 and enrolled in the National Provider Improvement Programme (NPIP). The NPIP will be reserved for the most challenged providers, where an assessment will determine whether providers have the conditions in place to deliver sustainable improvement. Providers will then be supported by a deliverable integrated improvement plan.

Implementing the model for improvement and next steps

28. Following agreement from Board, we will develop a detailed implementation plan for 2026/27, which will be overseen by a working group involving national, regional, system and provider stakeholders. This group will ensure clinical engagement and patient involvement is built into the implementation plan from the outset. We will plan engagement with the service on the refreshed model for improvement, using established networks to communicate our approach and we will refresh our communications output.

29. In March, we will provide an update to the Board on implementation and set out how we will support improvement in key national priorities. This will include how resources would be allocated to support delivery and highlight key changes to structures and ways of working, building on the progress made during 2025/26.

30. Our next steps are to:

• develop an implementation plan and working group to oversee a phased transition to the new model in 2026/27 (during February)
• engage with the targeted improvement teams and regions to start planning deployment in Q1 2026/27 (during February)
• continue to design new elements of NHS England’s offer to renew and strengthen leadership and management for improvement (during February)
• engage with Learning and Improvement Network CEO leads and regional leads on the future role of LINs (by end of February)
• continue to align the model for improvement with the development of the new Quality Strategy (ongoing)