1. Quality in the NHS: what this strategy sets out to change

Quality is central to the NHS’s work. It determines whether care is safe, effective and experienced as compassionate, co-ordinated and responsive.

It applies system-wide, guiding national bodies, NHS leaders, the wider healthcare workforce and partners whose actions influence the quality of care in local communities.

While social care is outside the strategy’s scope, it recognises the need for strong partnerships between health and social care to improve quality where services meet.

What we mean by high-quality care

The strategy uses a consistent definition of high-quality care based on the 3 core domains of quality: 

• safety – reducing the risk of unintended or unexpected harm to patients arising from the provision of healthcare
• effectiveness – delivering evidence-based care that optimises the outcomes that matter to people using services  
• experience – co-ordinated, compassionate and responsive care, delivered by staff who are skilled, supported and able to do their job well  

The strategy focuses on improving performance across all 3 domains, recognising their interdependence in delivering high-quality care in practice.

Annex C gives further details on the definitions for each domain.

Legal and regulatory foundations

The NHS’s approach to quality is grounded in law. This legislative framework includes:

• the Health Act 1999, which introduced a specific duty of quality for NHS bodies (but now replaced by the legislation set out below)
• the Health and Social Care Act 2008, which established quality standards and the Care Quality Commission
• the Health Act 2009, which introduced quality accounts
• the National Health Service Act 2006, as amended by the Health and Social Care Act 2012 and the Health and Care Act 2022, which places duties on the Secretary of State, NHS England and clinical commissioning groups – now integrated care boards (ICBs) – as to securing continuous improvement in the quality of NHS services
• the NHS provider licence, provided for by the 2012 Act, which imposed conditions on providers relating to quality and governance

This strategy builds on these legal foundations by setting a clear, consistent approach to improving quality in practice. It also reflects Lord Darzi’s 2008 review – High Quality Care for All – that first called for quality to be repositioned as the NHS’s organising principle.

Why this strategy is needed now

Recent reviews and data show a mixed picture of care quality across the NHS in England.

Lord Darzi’s Independent investigation of the NHS in England (2024) concluded that while there have been notable improvements in some care processes and outcomes, there remain significant and persistent challenges to the delivery of high-quality care.

More than a year on, updated figures, where available, continue to reflect this variation. Some encouraging gains have emerged – for example, continued improvement in early lung cancer diagnosis and a partial recovery in the timeliness of cancer treatment.

However, these gains are modest, and other core quality indicators have stagnated or worsened. For example:

• healthy life expectancy at birth in the UK has decreased to its lowest level since 2011
• only 43% of people with type 1 diabetes and 58% of people with type 2 diabetes receive the 8 NICE-recommended care processes
• an estimated 28% of people with hypertension remain undiagnosed, and around 31% of those diagnosed have not had successful treatment to control it

In addition, overall public satisfaction with the NHS remains below pre-pandemic levels, even though the British Social Attitudes Survey (2026) shows an increase compared with recent years and an easing of the previous year-on-year decline.

Our understanding of care quality is also incomplete and uneven. Inconsistent availability of timely, robust outcome data makes it harder to assess where improvements have been made, and further action is needed.

Attention has also tended to focus more on hospitals, secondary care services and individual organisations than on primary, community, mental health settings or whole care pathways. This is despite general practice delivering almost 400 million appointments each year – more than 1.5 million every working day – making it the part of the NHS with which most people have contact.

Annex C provides a summary of the evidence base across the 3 quality domains for this strategy.

It is accompanied by a technical annex, which presents the latest available data on trends, variation and inequalities for each of the strategy’s quality metrics, providing a baseline picture of quality in England.

A strategic, value-based approach to quality

The 10 Year Health Plan for England set out a system-wide commitment to delivering consistently high-quality care for everyone with a strong emphasis on:

• transparency
• strengthened patient and staff voice
• clearer responsibilities and accountabilities
• a focus on tackling healthcare inequalities

Alongside this, Dr Penny Dash’s Review of patient safety across the health and care landscape (2025) identified several features of the current regulatory system that must change if this vision is to be realised.

The review found duplication, fragmentation and unclear accountability across national bodies. It highlighted the need for a more consistent, co-ordinated and unified approach to improving quality across all care quality domains. It also identified insufficient focus on leadership and management of care delivery, alongside a decline in the effective use of resources. 

To address these issues, the review called for a more strategic, value-based approach to quality – focusing resources on interventions that deliver the greatest overall health benefit and improved productivity.

What high-quality services achieve

This strategy recognises that high-quality health services:

• support improved healthy life expectancy and quality of life at a population level
• provide timely access to care, with people receiving care at the right time in the right place
• are fair, inclusive and equitable, reducing inequalities in access, experience and outcomes
• deliver value for money by improving outcomes, avoiding waste and using resources sustainably

While this strategy does not set new access standards, it acknowledges that timeliness and accessibility remain prerequisites for high‑quality care. They enable early diagnosis and prompt intervention, which reduces risk, keeps people healthier for longer and, ultimately, reduces demand for emergency and high‑cost care.

It identifies the need to:

• anchor quality within the 3 shifts of care set out in the 10 Year Health Plan:
  • hospital to community
  • analogue to digital
  • sickness to prevention
• take a value-based approach to planning and delivering all NHS-funded healthcare services

The role of the National Quality Board

The Dash review included a central proposal to reform and strengthen the National Quality Board (NQB) to lead the new, strategic approach to quality.

The revitalised NQB brings national partners together around a shared ambition, building on and updating the existing shared commitment to improve the quality of care across the health and care system. Its strengthened role is designed to:

• improve oversight
• support transparency and public confidence
• ensure robust public protection
• reinforce accountability to Parliament

This strategic approach is also underpinned by wider reform to the NHS operating model and by the commitments set out in the 10 Year Health Plan, which make clear that responsibility for quality sits at every level, from individual professionals and frontline teams to providers, commissioners, regulators and national bodies.

What needs to be in place locally

To deliver this approach, accountability must be matched by capability. This includes ensuring:

• visible and effective leadership
• a well-planned, supported and engaged workforce with the skills and capacity to deliver high-quality care, with all staff and learners playing an active role in quality improvement
• the use of technology and meaningful data
• organisational capacity for robust quality management, including the use of a quality management system

Every local organisation and place needs the operational foundations to consistently manage quality. These include:

• standardised operating processes and service models
• strong operational capability across areas such as workforce, procurement and estates
• high-quality frontline clinical care

2. Priorities for this strategy

This strategy does not introduce a new set of requirements for the NHS or specific targets for particular services, patient cohorts or conditions.

Instead, it sets a deliberate, initial focus on where clear standards and the application of proven approaches will deliver the greatest improvements in outcomes, equity and value, based on current evidence (detailed in Annex C).

As a 10‑year strategy, the priorities are not intended to be static. As progress is made and risks, outcomes and population needs change, priorities will be reviewed and updated through the governance and prioritisation processes set out in Setting clear priorities for quality improvement section.

The priorities align with the commitments of the 10 Year Health Plan and build on significant work already underway. They are intended to guide national, system and organisational action, supporting a more consistent, equitable and value-driven approach to quality across the NHS. 

Improving outcomes and reducing variation

The NHS will need to work in partnership with people using services, their families, unpaid carers and communities to deliver the commitments in the National Cancer Plan, alongside implementation of the first modern service frameworks for:

• cardiovascular disease
• sepsis
• severe mental illness
• frailty and dementia
• palliative care and end-of-life care
• children and young people’s health

This will support earlier diagnosis and more consistent delivery of evidence-based care across pathways. It will also help reduce unwarranted variation across major conditions, which account for the greatest burden of poor health, premature mortality and avoidable harm, particularly among Core20PLUS5 priority groups who often experience poorer quality of care and outcomes.

Making sustained improvements in maternity and neonatal services

The strategy also prioritises action in areas where quality concerns are most acute. A main focus is embedding sustained improvements in maternity and neonatal services, building on national action already underway.

This action includes a National Maternity and Neonatal Taskforce, established by DHSC to:

• develop a new national action plan based on the findings and recommendations from the independent National Maternity and Neonatal Investigation
• hold the maternity and neonatal system to account for the implementation of the new national action plan and for achieving improvements in outcomes, experiences and reduction of inequalities for women, babies and families

Other actions include:

• the National Institute for Health and Care Research (NIHR) Maternal Disparities Challenge, which will focus on inequalities before, during and after pregnancy
• the national rollout of the Maternity Outcome Signal System (MOSS) to provide earlier warning of emerging risks
• new national standards to reduce maternal deaths
• the rollout of a perinatal equity and anti-discrimination programme to every trust by the end of 2026
• the development and implementation of a new maternity and neonatal patient reported experience measure (PREM), enabling all women and families to provide feedback on their care  

Managing patient safety across all settings

The NHS will continue to implement the NHS Patient Safety Strategy across all settings and improve patient safety in primary care as set out in the Primary Care Patient Safety Strategy.

The NHS Patient Safety Strategy will be reviewed and refreshed following the publication of this strategy. This will build on existing priorities and support the system to:

• respond to safety issues more effectively in real-time
• balance risk as patients move through the system
• address the call for greater transparency and openness highlighted in the 10 Year Health Plan

Improving experience of care and restoring trust

Improving experience of care across all sectors and settings is essential to restoring trust in the NHS.

National action will include:

• the establishment of a Directorate of Patient Experience in the restructured DHSC to strengthen national leadership on experience of care
• reform of complaints regulation to make processes more effective and transparent
• publishing guidance that will provide a consistent, evidence-based approach to improving experience of care across the NHS, by setting out what good looks like and how it is delivered and supported. NHS England and DHSC will support implementation of this guidance by publishing a delivery plan in spring 2027
• publishing minimum standards for planned patient care

Together, these will support systems and organisations to improve:

• the systematic collection and use of feedback and complaints to inform learning and improvement
• communication and co-ordination
• shared decision-making
• person-centred care
• identifying, involving and supporting unpaid carers

Reducing inequalities across all 3 quality domains

Reducing healthcare inequalities is a core national priority across safety, effectiveness and experience. This must be reflected across all measures of quality within those domains.

NHS organisations must continue to systematically implement the Core20PLUS5 approach for adults and children, focusing action where gaps in access, experience and outcomes are widest, including for people with disabilities and inclusion health groups.

The NIHR Inequalities Challenge will continue to fund research to better understand and reduce health inequalities, focusing on the groups most affected and using the Core20PLUS5 framework to guide where this work will have the greatest impact.

Monitoring clinical and population health outcomes

There will be a more consistent approach to monitoring clinical outcomes – at provider, unit and neighbourhood level, as well as population outcomes across systems.

Boards and leaders will be held accountable for performance, supported by improved visibility of data and outcomes.

3. Creating the conditions for quality improvement: 10 enablers

Drawing on the 10‑Year Health Plan and the Dash Review, this strategy sets out 10 enablers that support quality improvement across the whole healthcare system:

• clarifying who is responsible and accountable for quality at every level of the healthcare system
• setting clear priorities to improve the quality of care while adopting a transparent, co-ordinated and value-based approach
• strengthening leadership and management capability to create the right culture and conditions for improvement
• listening to and working with people and communities on what matters to them
• using data to manage quality, inform decisions and support accountability at all levels
• increasing transparency, making the NHS the world’s leading healthcare system for public access to information on care quality
• developing and embedding technology to underpin quality management and improvement
• aligning incentives and rewards with accessible, high-quality and productive care
• promoting innovation and research to support continuous improvement in both clinical care and how the NHS operates
• creating a more co-ordinated and improvement-focused approach to regulation

4. Clarifying who is responsible and accountable for quality

Quality management is a shared responsibility across the system, but accountability for quality management and outcomes must be clear and sit at organisational level.

Boards, executives, practice partners and clinical leaders are ultimately accountable for the quality of care their organisation plans, commissions or delivers, including day‑to‑day oversight, proactive improvement and responding when things go wrong.

Leaders must actively measure, manage and improve quality. This accountability must be exercised locally through robust governance, transparent reporting and effective oversight, with national leadership ensuring that quality management is recognised as a core responsibility that results in action and improvement.

Clear roles and accountabilities are essential to delivering high‑quality care across the NHS, within the context of the new NHS operating model. This will help realise the wider ambition for a clearer, more streamlined approach to managing quality.

National and regional leadership and oversight

The Secretary of State has a statutory duty to exercise functions in relation to the health service with a view to securing continuous improvement in the quality of NHS services.

The National Quality Board (NQB) brings together NHS, regulatory and professional bodies to oversee quality and transparency, providing a single, reliable view of quality across the healthcare system. It supports the Secretary of State in discharging their statutory duty and is accountable to them for overseeing quality across the system and recommending improvements.

It does not replace or duplicate the statutory responsibilities of its constituent member organisations.

NHS England and DHSC are responsible for providing strategic leadership on:

• quality strategy and policy
• maintaining national oversight of quality
• supporting capability development

Regional teams support effective quality management, including identifying and responding to risk. In line with the new operating model, regions are responsible for quality oversight of both NHS providers and ICBs, as well as overseeing public health performance. They:

• provide leadership for quality
• assess ICBs in their commissioning functions
• oversee provider performance
• work with local government partners
• co-ordinate improvement and intervention where necessary

Strategic commissioning

Integrated care boards (ICBs) have a distinct role as strategic commissioners, responsible for:

• commissioning high‑quality services that meet local population needs
• improving outcomes and reducing inequalities by:
  • allocating resources effectively
  • commissioning care pathways that improve outcomes
  • holding providers to account for delivery
• applying value‑based principles to allocate resources effectively, using evidence to decide which services to secure, change or discontinue. This includes:
  • systematically using cost, quality and outcomes data
  • benchmarking against best practice
  • ensuring decisions are consistent and aligned with NICE guidance on clinical and cost‑effectiveness
• overseeing the quality of primary care and neighbourhood health services, including holding general practice and wider primary care providers to account for the delivery of high-quality care

ICBs exercise accountability for quality by understanding population needs, setting a clear strategy to improve health outcomes and defining best-practice care pathways.

They work with providers (including general practice and wider primary care providers) to deliver these pathways, using contract management and oversight to monitor the quality and performance of commissioned services. ICBs should use contractual and improvement levers to respond and intervene where quality concerns arise, with regional teams providing support where risks cannot be managed contractually.

To support the commissioning of high-quality services, ICBs should:

• appoint a designated executive lead, accountable for ensuring commissioning improves quality and delivers better healthcare value
• establish clear, streamlined governance and escalation processes for quality oversight, with the board or a designated committee (either a standalone quality committee or an integrated committee) gaining assurance that services are commissioned in a way that supports continuous improvement
• share intelligence across the system, including through system quality groups, to identify risks and improve services

Delivery of care

Service providers are responsible for delivering high‑quality care and demonstrating continuous improvement, with greater autonomy for how to achieve this within a clear set of rules.

They are accountable for:

• the quality of the services they deliver, including clinical outcomes, experience and safety
• ensuring care meets professional standards, regulatory requirements and agreed contractual expectations, supported by effective clinical and corporate governance

In primary care, individual providers are responsible for quality, but as there may be limited organisational infrastructure, collaborative working through primary care networks (PCNs), federations or other local networks – supported by ICBs – is essential to:

• share learning
• maintain effective communication across organisational boundaries
• support early identification of risks or variation across practices and pathways while preserving practice-level flexibility and efficiencies

Managing quality across organisational boundaries

Managing and improving quality depends on how effectively organisations work together at key interfaces of care, including:

• the point of discharge
• transition between children’s and adult services
• at the boundaries between the health and the care system

This requires proactive, early sharing of intelligence, effective communication and improved co-ordination of care between settings, providers and sectors. Primary care plays a central role in this, providing continuity of care, co-ordinating across services and supporting early identification and management of risk.

This is particularly important for older people living with frailty or for people with dementia, where poor co-ordination across services can lead to harm. The forthcoming Frailty and Dementia Modern Service Framework will strengthen joint accountability for improving quality across health and social care, including at the interfaces between them, supported by shared data standards.

Neighbourhood health approaches and integrated neighbourhood teams are vital for supporting this joined‑up working and co-ordination across whole care pathways, including between the NHS, local authorities and other partners.

Quality governance and risk escalation in the new NHS operating model

All health and care organisations are accountable for quality and have a responsibility to work together to proactively share intelligence, drive improvement and mitigate and escalate quality risks.

ICBs will be expected to maintain system quality groups (SQGs) as a forum for partnership working and intelligence sharing to support the management of quality across organisational boundaries by:

• identifying early warning signs of issues or deterioration within health services
• co-ordinating the system action required for improvement of quality

Current NQB guidance recommends that system quality groups include representation from a range of system partners, including, ICBs, local authorities, regional teams, CQC, primary care, maternity and patient safety.

System quality groups could play a stronger role in improving public health outcomes through, for example, using UK Health Security Agency (UKHSA) risk signals to improve early detection of public health risks, including outbreaks, trends in healthcare‑associated infections and antibiotic resistance, and environmental hazards.

In 2026/27, NHS England will provide support to system quality groups to build their effectiveness and maturity.

As the new NHS operating model continues to evolve, NHS England will update and publish new NQB quality governance arrangements and associated guidance in 2026/27. This includes:

• NQB guidance on system quality groups (SQGs): updated guidance will align SQGs with the new operating model; in the meantime, ICBs may adjust their SQG footprints to reflect new merged or cluster ICB footprints and review membership to ensure all relevant provider representatives are included
• NQB guidance on quality risk response and escalation: future updates will align the guidance to this strategy and the new operating model, including complex multi-provider pathways, advanced foundation trusts and integrated health organisations, and clarify expectations for working with regulators
• guidance to support leaders to balance risk across and within systems, using principles of healthcare value

Regulation and national standards

Statutory regulators support quality across every level of the system by:

• setting standards (including professional standards, developing evidence-based guidance and quality standards)
• monitoring compliance (such as through inspection and data gathering)
• modification (for example, through enforcement action)

The Medicines and Healthcare Products Regulatory Agency (MHRA) is responsible for ensuring healthcare providers and patients have access to safe and effective medicines, devices and blood products.

NICE provides standards for clinical and cost-effective care. Its role includes:

• maintaining up-to-date guidance
• supporting the reduction of unwarranted variation
• providing the evidence base that underpins commissioning, regulation and quality improvement

5. Setting clear priorities for quality improvement

The National Quality Board (NQB) has a pivotal role in setting national direction on quality, shaping the conditions for local organisations to plan, commission and deliver high-quality services.

Central to the NQB’s refreshed approach is a transparent, co-ordinated and value-based method of prioritisation and decision-making. This ensures national focus is directed to where improvement will have the greatest impact.  

Co-ordinating recommendations and action

The NQB will create and maintain a repository of national recommendations arising from reports, reviews, inquiries and investigations. In doing so, it will operate as a recommendations hub, supporting:

• co‑ordination and prioritisation of recommendations
• assessment of likely impact, cost‑effectiveness and alignment with strategic priorities
• clearer national and local action on what matters most

This approach will prevent the introduction of unfunded mandates being placed on providers without proper scrutiny. Where a mandate is set and agreed, the NQB will help close the gap between agreed recommendations and implementation.

Where appropriate, the NQB will oversee delivery of prioritised recommendations and monitor and evaluate their impact, with the formal register held by DHSC.

During 2026/27, the NQB will establish the repository’s governance arrangements and pilot methodologies to test tracking, costing and prioritising the recommendations.

Shaping future quality improvement priorities

In 2026/27, the NQB will develop a set of principles or criteria for agreeing future quality improvement priorities. These will be shaped by the prioritisation process used in the recommendations repository work. This will help ensure that resources and effort are directed toward interventions with the highest return on investment.

Translating priorities into practice

Future updates to the Medium Term Planning Framework will communicate national quality-improvement priorities and standards, alongside operational and financial expectations.

ICBs and providers will be required to set out how their plans address these priorities and submit them for review and assurance by the NHS England and DHSC regional teams.

The priorities identified by the NQB will also inform topics for future CQC system reviews.

To maximise impact, the NQB will work in partnership with colleagues across the NHS – through the royal colleges and other bodies – to ensure priorities are clinically owned and consistently translated into practice.

6. Strengthening leadership and management capability

Effective, visible and consistent leadership and management are essential for building organisations that continually improve. Leaders set priorities, model behaviours and shape how teams make decisions and work together.

They also put in place the systems and expectations that help organisations measure, monitor and improve the quality of care. This ensures that ongoing feedback, learning and improvement are a routine part of everyday work.

Creating an open, curious and compassionate culture

Leadership creates organisational culture. When leaders define and reinforce cultural principles – such as compassion, respect, curiosity and continuous improvement – staff feel trusted, valued and able to use their professional judgement in pursuing quality improvement.

This is reflected in how leaders listen to staff and people using services, respond to concerns, create space for speaking up without fear of inappropriate blame, and support collaboration, learning and innovation. Evidence across health and other sectors shows that staff experience is closely linked to outcomes for people using services and sustained improvement.

Focusing on people’s experience of care

Leaders should foster a culture that treats people’s experience of care as a core measure of quality. This means supporting staff to build trust, involve people in decisions and work in partnership with people using services, their families, unpaid carers and communities, using feedback to improve the quality of care.

Making quality everyone’s responsibility

Leaders must model taking personal responsibility for quality.

They should set clear expectations that all staff actively engage in research, learning and improvement to better understand the needs of the people and communities they serve. This helps build cultures where high-quality care is everyone’s responsibility.

Well-led services demonstrate strong governance and data‑driven decision‑making. Clinical and operational leadership should ensure quality is prioritised in day-to-day practice and in wider system decisions.

Strengthening leadership locally

In line with the new operating model and the move to a more devolved health service, responsibility for creating the right conditions for high‑quality care lies with local organisations (Annex B).

Existing Insightful board guidance supports boards in using insight and governance effectively to assure quality, identify risk early and drive continuous improvement.

Board development

NHS England and DHSC will introduce a board development programme. This will help boards to:

• develop the culture, skills and behaviours needed for consistent quality improvement
• understand and act on healthcare inequalities
• deliver safer care and improve outcomes, experience and efficiency across their organisations

For ICBs accessing the programme, this will include a specific focus on strengthening strategic commissioning skills.

Strategic commissioning

As set out in the Strategic Commissioning Framework, ICBs are accountable for securing the greatest possible health outcomes within the resources available.

To support ICBs in this work, including discharging their commissioning responsibilities for quality in primary care, the strategic commissioning development programme will include:

• a self-assessment development toolkit, outlining the required competencies, data requirements and maturity indicators for strategic commissioning, including value optimisation and quality oversight
• a structured action-learning programme, focused on areas such as predictive analytics, value-based commissioning and healthcare economics

Setting standards for leadership

The new NHS College of Leadership and Management has been established to define and work towards excellence.

The college has launched a new NHS Leadership and Management Framework, which sets a code of practice and consistent, professional standards across all levels of NHS management (clinical and non-clinical). These include the competencies needed to deliver high-quality care.

Local organisations should use the NHS Leadership and Management Framework in recruitment, appraisal and development processes. It is also expected that the framework will be included in future CQC well-led assessments as evidence of good practice.

NHS England and DHSC will explore future opportunities to align accountability and management frameworks (including job descriptions, objectives, supervision and appraisals) with agreed quality goals and priorities.

Alongside the NHS Leadership and Management Framework, the NHS College of Leadership and Management will provide a national development curriculum aligned to the code, standards and competencies.

A new set of core leadership and management development modules will be introduced to equip managers with the skills needed to deliver and improve care and meet national priorities, including quality improvement, productivity and efficiency.

Staff experience standards

The DHSC and NHS England have also introduced new staff standards to set minimum expectations of employment, raise the profile of staff experience and support a positive workplace culture.

These standards:

• set expectations of management and leadership
• link to the NHS Leadership and Management Framework
• will be reflected in a composite metric in the NHS Oversight Framework, acting as an early warning signal of poor performance for the CQC

Clinical team rewards

The 10 Year Health Plan set out plans to give providers new flexibilities to make additional payments to teams that deliver consistently high clinical outcomes, achieve excellent patient feedback or significantly improve care.

From 2027, NHS providers can start using these flexibilities in areas with the highest health need, with wider rollout by 2030. During 2026/27, NHS England will work with partners to develop initial guidance to support boards to implement this.

See the section on Aligning incentives for further details of incentives for quality improvement.

Education and training

NHS England will implement a refreshed NHS Education Quality Framework, aligned to relevant professional regulator standards, to ensure high-quality education and training for all learners. This will also help make sure educator capacity is protected to develop a future workforce focused on care quality and improvement.

NHS England will provide data to drive continuous improvement in education and training, such as:

• the National Education and Training Survey (NETS)
• GMC National Training Survey
• Educator Voice Survey

National support and oversight

NHS England and DHSC will establish visible, expert leadership across all domains of quality with a clear mandate and organisation-wide influence. This includes the creation of a Directorate of Patient Experience in the restructured DHSC to ensure feedback is used to improve care.

The CQC Well-led framework will continue to be used to assess management, leadership and organisational culture, ensuring organisations are capable of delivering consistent, high-quality care.

7. Listening to and working with people and communities on what matters to them

Quality must be improved with input from people, not designed in isolation. Organisations need to understand what matters to people and communities and ensure that services reflect their experiences and local priorities.

Putting engagement principles into practice

The statutory guidance Working in partnership with people and communities sets out how the NHS meets its legal duties on public involvement.

In 2026/27, NHS England and DHSC will provide further support by:

• sharing practical examples of how the 10 engagement principles set out in the statutory guidance can be applied in practice
• highlighting what supports effective engagement and partnership working
• enabling systems and organisations to share learning and adopt approaches that give communities a meaningful and influential voice

Using insight from feedback and complaints

Feedback from people using services, along with patient‑reported outcome measures (PROMs) and experience measures (PREMs), provides essential insight into what most matters to people using services, their families and carers.

Although the NHS collects more feedback than ever before, there are still gaps in our understanding. Digital tools could help analyse and share feedback in real time, so issues are identified and addressed earlier.

NHS England has commissioned a Future of Patient Feedback project, which will engage staff and people who use services to set out how feedback, PREMs and other insight can be used more effectively. This work will be supported by a new Directorate of Patient Experience within the restructured DHSC.

Our ambition is that, within the next decade, people’s experiences are routinely used to inform service design, clinical governance and public accountability across all providers. 

To deliver this, NHS England and DHSC will:

• produce a roadmap for the technical infrastructure required to collect, process and present both qualitative and quantitative feedback in meaningful ways, including dashboards for providers and linking feedback to other quality measures   
• design a new comprehensive model for collecting feedback, including PROMs and PREMs, to support improvement and choice
• work with stakeholders to develop and test new ways of collecting a PREM for maternity and neonatal services  
• test and roll out a new way to collect PREMs, PROMs and self-care indicators from people living with multiple long-term conditions through the National Neighbourhood Health Improvement Programme, linking this to wider data on health needs and services being offered and used by local people
• reform complaints regulation and processes, so the NHS can prioritise learning and improving from complaints insight

Organisational roles in collecting and acting on feedback

Commissioners and providers are expected to collect feedback from people using services, families, unpaid carers and bereaved people, and use it to:

• shape services
• inform staff training
• build ongoing relationships with communities

Providers must share feedback they have received and outline how improvements have been made by working with people and communities.

NHS England and DHSC will support this through clear guidance, shared tools and national co-ordination.

Inclusive research

The National Institute for Health and Care Research (NIHR) will continue to focus on inclusive research. By ensuring diverse and underserved groups are represented, we can better understand their health needs and develop treatments and interventions that are effective across the whole population.

8. Using data to manage quality

The NHS collects large amounts of data and reports thousands of national quality metrics. Yet, coverage is incomplete and gaps remain. These include data on patient‑reported outcomes and experience, and safe care outside inpatient settings.

The current data landscape has evolved incrementally, resulting in a system where links between datasets are not always coherent or easy to navigate. Data availability and quality also vary across settings. This makes it harder to build a clear picture of quality and use data to support timely action and effective improvement.

A more joined-up, balanced approach

The National Quality Board (NQB) will oversee work to establish a standardised, aligned national approach to quality data and reporting. This will draw from a range of qualitative and quantitative quality data. The NQB will use this alongside other intelligence, so that decisions don’t rely on metrics alone.

This will complement existing regulatory oversight and reporting mechanisms, including:

• accountability to Parliament and government
• the CQC’s annual State of Care reports
• scrutiny by the National Audit Office

A core set of quality metrics

Aligned with this strategy, the NQB will introduce an initial set of quality metrics to review and oversee progress across all 3 domains of quality.

Developing the metric set in 2026/27

During 2026/27, the NQB will work across all member organisations to further develop and enhance this metric set, including by:

• integrating a comprehensive suite of metrics covering population health, health protection and treatment outcomes, including measures that reflect quality at the key interfaces between health and social care
• establishing common definitions and a shared understanding of quality across arm’s-length bodies
• identifying gaps and developing new measures where appropriate

What the metric set will support

This work will:

• provide a menu of approved metrics and standards to support the NHS Oversight Framework and delivery commitments
• align with the Future of Patient Feedback project by strengthening experience measures used for quality assessment
• lay the foundations for using research, innovation and technology, including AI and predictive analytics to identify risks earlier
• ensure alignment and consistent use of data across regulatory assessment and inspection frameworks

Governance to support the metric set

The NQB will establish governance to support the metric set, including sub‑groups that provide clinical and analytical leadership for its development, maintenance and ongoing review.

These groups will work closely with people using services, clinicians and professional leaders to agree or develop valid outcome measures across specialties and address gaps in the existing data.

Using the metrics in practice

During 2026/27, NHS England will strengthen how the quality metric set is used by:

• producing accessible quality insights that focus on the most important issues at national, regional and local levels
• improving data sharing and access, and standardising data visualisation and reporting, so quality can be tracked from provider, neighbourhood and system levels through to national population outcomes
• developing predictive insight and early‑warning capabilities – for example, building on the Maternity Outcomes Signalling System (MOSS) launched in 2025 and the Mental Health Early Warning signs tested throughout 2025 – to identify emerging risks such as rising healthcare-associated infections, unexpected mortality patterns or worsening waits linked to harm

The role of the Federated Data Platform

The Federated Data Platform (FDP) will collect, process and link data from multiple sources – including various quality frameworks – to:

• provide robust, scalable and timely insights
• improve benchmarking
• enable more efficient information sharing across the NHS

The role of NICE quality standards

NICE quality standards translate evidence-based guidance into clear, measurable priorities. They help shape data collection so that datasets across the health system reflect best practice. They also provide a framework for measuring and comparing performance, helping organisations:

• identify gaps
• track progress
• improve the quality and outcomes of care

How local organisations, teams and staff use data

Local organisations, departments, teams and staff should use national and local data to identify emerging risks in real time, supported by robust, nationally agreed systems for recording, collecting and using quality data. This includes:

• embedding quality oversight into everyday governance and management processes 
• supporting clinicians, staff and learners to identify and act on insights
• using data at the right level: providing granular, actionable information for frontline teams and clinicians while giving leadership access to high‑level trends so they can anticipate risks and steer improvement – for example, through tools such as Early Warning Signs metrics available in the Model Health System quality of care compartment
• segmenting and monitoring data to spot unwarranted variation, including outcomes across population groups (for example, the Core20PLUS5 groups, which include people with disabilities and inclusion health groups) and geographies (for example, local authority boundaries and neighbourhoods), and early signs of quality concerns
• bringing together evidence from multiple sources, including epidemiological and surveillance insight
• reviewing outcomes across whole pathways, including NHS-funded care delivered by independent sector providers 
• supporting system leaders and ICB boards to use data to routinely review quality in primary care and take action to improve performance and reduce variation
• using data to drive continuous improvement
• holding leaders to account for delivering improvements based on data

9. Increasing transparency

Making the NHS the world’s most transparent health system is a main commitment in the 10 Year Health Plan.

More open, accessible and meaningful data helps staff understand performance and supports people in making more informed decisions about their care.

Transparency is not only about accountability; it is central to improving quality. It enables earlier risk detection, reduces unwarranted variation and supports research. It also helps create a culture that is open, honest and focused on learning, including being open with people when things go wrong and learning from incidents, in line with the statutory Duty of Candour.

It helps teams at every level to take timely, evidence-based action.

An open-by-default approach

An open-by-default approach will be adopted for publishing data about the quality of care. Data will be published unless there is a clear, legal, privacy or governance reason not to do so.

This will make the transparency of quality data routine, rather than an exception.

A single public gateway for quality data

The NHS England public data gateway currently provides access to:

• the NHS Oversight Framework segmentation and provider league tables, presented as publicly accessible profiles
• acute provider performance indicators reflecting the priorities of the Medium Term Planning Framework
• outcome data and sentinel metrics at specialty and provider unit levels, starting with interventional specialities from the GIRFT programme through the Model Health System

Building on existing data tools

NHS England will expand and improve how quality information is shared and used through the public gateway. This will provide a single point of public access to aggregate, non-disclosive data about the quality of NHS-funded care.

Data will be presented in an accessible, easy-to-understand format for staff, people using services and the public.

It will include:

• indicators from the National Quality Board core metrics
• published statistics on NHS performance and outcomes relevant to each quality domain
• headline clinical improvement insights from the Getting It Right First Time (GIRFT) programme
• headline clinical audit and registry data
• Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs), as these are developed in line with the commitments set out in the section on Listening to and working with people and communities on what matters to them
• key measures on primary care, GP access and neighbourhood health

Alongside this, the Open Model Health System allows people to access and compare providers and services without needing to log in.

Together, the public data gateway and the Open Model Health System allow users to search for quality and outcomes data for services in their area. NHS England will further develop this capability so that it is easier to find and link to data at the postcode and provider levels.

Oversight and governance

The NQB will oversee the development of this national data gateway and support this work by:

• providing clear guidance and shared tools
• setting technical standards
• ensuring robust privacy and governance safeguards

This will help make openness about quality a routine expectation across the NHS.

Making experience data visible

In line with the commitments in the Listening to and working with people and communities on what matters to them section, NHS England and DHSC will make PROMs and PREMs data publicly available and include them in the information available to people when choosing a provider on the NHS App.

Transparent reporting of audits and registries

Clinical audits and reviews provide important evidence on whether care meets agreed standards and where improvement is needed. They also inform the CQC’s intelligence-led regulatory approach. However, their impact has been limited by inconsistent publication and use.

To address this, NHS England and DHSC will:

• consolidate, report and benchmark all audit and registry measures within a central, open tool, such as the Open Model Health System
• improve access to timely audit and registry data for researchers, improving the evidence base for quality improvement
• invest in the delivery of the Outcomes and Registries Directions 2024 to improve data collection, analysis and sharing
• continue to expand and maintain the Medical Devices Outcomes Registry (MDOR) to support:
  • monitoring of device performance and complication rates
  • emerging safety signals across the system
  • innovation and research
  • integrating PROMs with existing patient, procedure, provider, clinician and device information
• set and implement common standards for locally‑ or speciality‑led audits and registries, ensuring they are openly available and clearly signposted
• ensure audits follow whole pathways, improving linkage of data across primary, secondary and independent sector care
• set clear expectations and requirements as part of audit and registry contracts and commissioning, so common standards are adopted, and data is shared in transparent and timely ways

The NQB will also oversee work to improve access and integration of clinical audit, registry and wider quality data. This will include:

• building on the Clinical audits and registries best practice guide
• maintaining and publishing a central register of these datasets
• committing to open benchmarking of summary statistics accessible to the public through a single, central portal

Providers and commissioners will be expected to capture and make available high-quality data from routine administrative records while complying with relevant data-collection and information standards.

Supporting public access and understanding

Publishing data is not enough. It needs to be clear and usable by the public.

NHS England will work with people using services to develop new tools that present quality information in ways that support understanding of service performance and informed choice.

To deliver this, NHS England will:

• improve public-facing provider league tables by expanding available indicators and improving the technology behind interactive dashboards
• present data in formats designed for and with different audiences
• explore ways for third parties to build on NHS data, supporting innovation and wider dissemination

Role of commissioners and providers

Commissioners and providers will be expected to ensure that data is accurate, timely and made available in formats that support public understanding of how providers are performing and improving.

This should include:

• making information about care quality visible within clinical settings
• using national tools and platforms
• working with NHS England and the DHSC to identify local priorities for public-facing data and transparency

To support this, the government is committed to reframing Quality Accounts so they better reflect the principles set out in this strategy, strengthening transparency at provider level.

Revised Quality Accounts will provide clearer, more meaningful information on safety, effectiveness and experience, including how organisations respond when things go wrong.

10. Developing and embedding technology to underpin quality management

Greater use of technology, including AI, must be central to our efforts to deliver consistently high-quality care. Used well, it can:

• enable safer, more person-centred care across every setting
• support consistent care across pathways
• capture real-time patient insight and strengthen quality management
• reduce unwarranted variation
• support a continuously learning healthcare system

Technology offers the greatest improvements in safety, effectiveness and experience when it is designed around how clinicians work and how people use services, and embedded in practice. It must also be used to reduce – rather than exacerbate – healthcare inequalities.

Design, adoption and safe use of technology

All clinical and non-clinical staff need the right support to use digital services confidently. Providers should continue to adopt all NHS App features as quickly as possible and build digital maturity and capability across their organisations to deliver high-quality care through technology.

The forthcoming 10 Year Workforce Plan will set out reforms to ensure clinicians and operational leaders have the digital skills and support they need to lead the design, implementation and safe adoption of digitally enabled services and pathways.

This leadership needs to be underpinned by an organisation-wide approach to digital transformation that places greater emphasis on implementation, including:

• process re-engineering
• early involvement of digital clinical safety expertise, alongside training and safe adoption
• ongoing optimisation, assurance and monitoring, ensuring that digital solutions continue to deliver benefit rather than harm

At a national level, products and services will continue to be clinically assured and meet relevant regulations and best practice, ensuring technology is led by clinical need and improves care.

Priority opportunities across the 3 quality domains

The following priority areas will be the focus for improving safety, effectiveness and experience. Given the pace of technological change, these priorities will be reviewed and updated to ensure their continued contribution to improving the quality of care.

Safety: spotting risks earlier and learning faster

AI and other advanced digital technologies can help the NHS learn more quickly when things go wrong and identify emerging risks earlier. When the right clinical, technical and governance safeguards are in place, they can transform how patient safety is managed and improved.

Integrating digital safety into the updated National Patient Safety Strategy – and aligning with patient safety roles, training and governance – will help ensure that technology consistently supports safer, higher-quality care while minimising the risk of harm.

Learning from patient safety events

The National Patient Safety Team is developing and evaluating AI models to analyse data from Learn from Patient Safety Events (LFPSE), helping spot discrepancies, emerging themes and unusual risk patterns earlier.

This will support a more responsive early warning capability across the NHS by enabling faster detection of outliers and supporting human-led safety assessment.

Predicting deterioration and preventing harm

The NHS will increasingly use AI to analyse unstructured data to support system-wide learning. For example, an AI tool that predicts risks such as falls and viruses is being rolled out across more than two-thirds of ICBs, with 97% accuracy and the potential to prevent as many as 2,000 falls and hospital admissions each day.

Improving identification across care pathways

The Scan4Safety programme links patients, products, places and processes across care pathways using barcode technology. It ensures accurate patient identification and supports the use of the right product for the right patient at the right time.

Evidence shows it can reduce harm, free up clinical time and save money. For example, by introducing scanning in their pharmacy, the Royal Cornwall Hospital NHS Trust has reduced potential dispensing errors by 76%.

Connecting medicines information to reduce harm

The continued adoption of electronic prescribing and medicines administration, alongside barcode scanning and closed-loop processes, is improving the reliability of the end-to-end medicines process and reducing errors across prescribing, dispensing and administration.

Bringing this information together across care settings reduces fragmentation and the need for manual reconciliation, a common source of risk. As this becomes more consistent, clinicians have a clearer view of treatment, supporting:

• safer decisions
• earlier identification of high-risk medicine use
• more consistent system-wide learning to prevent harm

Strengthening surveillance of medicines and devices

The Medicines and Healthcare products Regulatory Agency (MHRA) will work with national partners to strengthen how it monitors the products it regulates, such as medicines and devices. This includes:

• improving access to data already provided by Clinical Practice Research Datalink (CPRD)
• speeding up analysis
• connecting systems, such as Yellow Card, to national platforms so adverse events can be reported more easily, starting with NHS Login

Embedding NICE evidence standards

NICE’s evidence standards for digital health technologies will be embedded into the national approach to digital clinical safety and technology adoption.

NICE will lead on assessing the clinical and cost effectiveness of digital tools, AI-enabled technologies and health technologies, ensuring that innovation is safe, effective and delivers value.

Effectiveness: improving outcomes and productivity

The modern service frameworks will support the NHS in putting into practice the 10 Year Health Plan’s ambition for digital-by-default healthcare by shifting care towards digital service models where appropriate.

Earlier diagnosis and more efficient pathways

AI tools will be used to assess and triage patients more quickly.

For example, an AI tool developed by Skin Analytics is being rolled out across the NHS to assess potentially cancerous skin lesions using a smartphone camera and dermoscopic lens attachment. Based on its findings, it can recommend discharge or referral. Around 30% of patients on the suspected skin cancer pathway (nearly 200,000 patients) could be discharged using the tool, leading to more efficient and timely diagnosis and treatment for other patients awaiting care.

AI-supported screening

A new national cloud platform is being built to enable the development and scaling of new lifesaving AI-based screening tools, such as an AI tool to screen mammograms for breast cancer. This has the potential to reduce diagnosis delays and associated adverse outcomes.

AI telephone calls

Multiple services now use AI to telephone patients – sometimes in multiple languages, improving accessibility – to provide information on issues ranging from whether appointments are still required to medicine adherence. These tools are already being trialled in multiple NHS trusts and have the potential to boost outcomes, keep patients informed and either reduce costs or free up staff to undertake more value-adding work.

Creating smarter workflows

Technology can reduce inefficiencies in clinical and non-clinical workflows, improving productivity, access and outcomes.

For example, a ‘process mining’ system at University Hospitals Coventry and Warwickshire NHS Trust uses advanced analysis to optimise the timing of text message reminders, helping to avoid around 1800 missed outpatient appointments each week.

AI, including novel agentic and clinical decision support tools, will become a routine part of clinical practice. These tools can save staff time and support them to make better decisions across the breadth of healthcare. 

Enabling people to take control of their health

We will enable people to take control of their health by providing access to cutting-edge technology and a better understanding of their own health data, delivered in the NHS App. For example, the AI Health Coach will help people to better understand and address the causes of ill health and form long-lasting, healthier habits.

The integration of biometric data from sensors and smart devices (including blood pressure monitors and wearables) through the App will support a shift towards proactive, personalised care, enabling tailored health advice and earlier intervention in the event of deterioration.

Optimising medicines use to improve outcomes and productivity

Medicine is one of the most digitally mature areas of care, with structured prescribing data, electronic prescribing and the NHS App providing a strong foundation for improving how medicines are used.

Clinical decision support and AI can help identify variation, risk and opportunities for optimisation. This supports more consistent prescribing, better patient engagement with medicines, and helps reduce avoidable demand by getting treatment right first time.

Experience: more control for people using services

The NHS App will become the digital front door to the NHS, making it easier for people to:

• access services and ensure they attend the right service for their need
• receive advice for non-urgent conditions
• manage their medications, test results and appointments seamlessly

While the App will play a central role, it is only one part of a wider system, complementing non-digital services that remain essential for people who do not have access to, or confidence in, digital tools.

The NHS App is being designed with inclusion in mind, with tailored information and accessibility features. NHS England is working with community, charity and industry partners, using inclusive design approaches and testing with diverse, seldom-heard groups to ensure the App works for everyone.

A partnership with libraries is in place across England, enabling people to get in-person help setting up and using the NHS App. There will also be continued support for people and communities who are digitally excluded or need alternative ways to access care, so that digital transformation does not widen health inequalities.

Further development of the NHS App

Using the NHS App, people will be able to:

• compare providers, using information on waiting times, journey times and outcomes
• book tests directly, where appropriate
• communicate with the clinicians involved in their care

More advanced features will follow. For example, by the end of 2026/27:

• GPs will be able to refer patients to NHS Online, with patients able to view and manage their appointments directly in the NHS App
• AI will be deployed in the NHS App, helping patients navigate selected direct access or self-care pathways and access the most appropriate care in a timely way
• digital patient initiated follow-up (PIFU) will be enabled in the NHS App for prioritised Getting It Right First Time (GIRFT) Further Faster pathways, reducing unnecessary follow-up appointment

Patients will begin to have access to approved digital tools through the NHS App to help manage or treat their conditions. By summer 2027, local services will be able to select from a range of nationally approved apps via the ‘NHS HealthStore’ marketplace, enabling clinicians to routinely “prescribe” approved digital tools that support patients to manage their health.

In addition, patients will begin to access at-home diagnostic tests through the App, starting with HIV testing, with a long-term goal of patients carrying out diagnostic tests at home whenever possible and where they choose that method.

Making giving and understanding feedback easier

Digital developments are making it easier for people to give feedback and for staff to analyse and use it. For example, in 2026, people have been able to complete the GP Patient Survey through the NHS App for the first time.

Streamlining administrative processes

Technology will reduce the burden of administrative processes, increasing productivity and improving responsiveness.

AI can help manage complaints more efficiently by uncovering themes and recurring issues, allowing faster investigation and action. 

Referrals will be triaged and processed digitally, improving experience of care, as patients move into the appropriate pathways more quickly and reliably, with fewer administrative delays. Using automation and operational data more effectively will also support improved Referral to Treatment (RTT) performance.

Giving people greater visibility and control of their medicines

Prescriptions are one of the most widely used services in the NHS App, with increasing use of repeat prescription management and access to medicines information. This makes it easier for patients to manage treatment day-to-day, supporting greater confidence and involvement, which can help improve adherence and reduce unnecessary contact with services.

Cross-cutting opportunities across all quality domains

High-quality services must be fair and inclusive. Our approach to technology use will reflect differences in access, skills and trust, building on the principles in inclusive digital healthcare and ensuring support for people who are digitally excluded or face barriers to using digital approaches. 

Provider use of the Federated Data Platform (FDP)

Providers are expected to use the Federated Data Platform (FDP) and associated tools to collect and analyse data to allocate resources and staffing more efficiently.

For example, a surgical scheduling tool built in the FDP has increased theatre capacity by up to 15% at Chelsea and Westminster Foundation Trust, with the potential to significantly reduce surgical waiting times.

The Cancer 360 tool, which unifies patient data from multiple sources into a central interface, is enabling people to move through cancer pathways and receive a diagnosis faster.

In inpatient care, the implementation of a digital discharge planning tool in the FDP is enabling people to leave hospital more quickly, with an independent evaluation showing a reduction in unnecessary bed days of up to 23%.

Provider use of ambient voice technology

Ambient voice technology (AVT) can reduce the need for manual note-taking during consultations, improving both experience and safety by allowing clinicians to spend more time with people and less time on administration.

When safely deployed, AVT can reduce errors and omissions in clinical records and improve system flow by supporting more efficient consultations. This may increase capacity and reduce waiting times in emergency and urgent care settings.

In line with the Medium Term Planning Framework, providers should consider deploying AVT at pace, following NHS England guidance on its use.

Using the Single Patient Record

The Single Patient Record (SPR) will improve both safety and experience by enabling clinicians to access up-to-date information about their patients across geographical, service or provider boundaries. This ensures that clinical decisions are made safely and consistently, and relieves people from the frustration of having to repeat their story across different appointments and services.

The role of the Health Data Research Service

The new Health Data Research Service will support quality by allowing researchers to better understand the causes of inequity in outcomes across services, using the breadth of health data collected across the NHS to both improve safety and reduce unwarranted variation in effectiveness.

11. Aligning incentives

The 10 Year Health Plan highlights the need for clearer incentives to improve value, outcomes and quality of care. Transparency is an important part of this, but it must be combined with other levers that reward high performance and address poor practice.

The National Quality Board (NQB) will oversee how these incentives and levers are designed, used and evaluated. This includes those set out in the 10 Year Health Plan.

Wider payment reform

NHS England will use payment approaches that support the 10 Year Health Plan’s ambition of shifting care closer to home by moving to neighbourhood health models. This includes testing a new payment model in 2026/27 that incentivises reductions in avoidable non‑elective care for high‑priority patient groups.

Linking experience and provider payment

During 2026/27, NHS England and DHSC will work with stakeholders to develop options to link experience more directly to provider payments. They will start with services where evidence shows that not listening to people has led to poor experience and outcomes.

This builds on commitments in the 10 Year Health Plan to test ways for patient voice to more directly influence payment in specific specialties and geographies. This includes ‘patient power payments’, where providers’ payments reflect service users’ feedback.

As announced in the Renewed Women’s Health Strategy for England, gynaecology services will be the first area to test this approach.

Best practice tariffs

NHS England will expand best practice tariffs (BPTs), introducing around 30 additional BPTs in the 2026/27 NHS Payment Scheme. These will focus on shifting care to less resource‑intensive settings and supporting elective recovery and waiting‑time priorities, including straight‑to‑test activities and one‑stop clinics.

NHS England will develop and review best practice tariffs to support the adoption of technology and innovation and to ensure they continue to incentivise high-quality care and the adoption of best practice.

Advanced foundation trusts

The Advanced Foundation Trust Programme will reward and incentivise good performance. Applicant trust boards must self-certify and show they have:

• effective systems for managing quality
• strong leadership and a culture of quality improvement
• robust arrangements to engage staff and communities to shape decisions and improve experiences and outcomes

Advanced foundation trusts will also take on greater local and national leadership roles, including sharing best practice and innovation and supporting improvement with other providers where appropriate.

Contractual requirements

Expectations will be set for quality management and improvement across provider contracts by:

• considering how best to embed new quality improvement and quality management expectations in future GP contract reforms, including modern service framework priorities and metrics, alongside those incentivised through the Quality and outcomes framework (QOF)
• introducing a funded 3-year quality improvement programme in dentistry, including activities such as structured audits and peer reviews focused on nationally determined priorities
• exploring new approaches to embed quality improvement and quality management expectations in the Community Pharmacy Contractual Framework (CPCF), alongside the possibility of new incentives to support quality improvement through the Pharmacy Quality Scheme
• reviewing and consulting on strengthening provisions on quality management and improvement in the NHS Standard Contract, including setting out agreed rewards, incentives and requirements to meet new service models and standards, such as modern service frameworks, in the contract and/or the NHS Payment Scheme
• consulting on amendments to the NHS Standard Contract to require providers to share data through the Single Patient Record and other agreed mechanisms, subject to legal, privacy and information governance safeguards
• embedding robust quality‑management requirements in new integrated health organisation and neighbourhood health contractual models
• reviewing and strengthening provisions on quality management and improvement in the NHS Education Funding Agreement and commissioned education contracts, including setting out agreed expectations of all providers for high‑quality education outlined in the Education Quality Framework
• subject to legislation, reforming quality accounts so that these act as an effective accountability mechanism

Incentivising engagement in improvement activities

Alongside recognition and reward for individual or organisational performance, NHS England will support commissioners and providers to enable improvement at scale, systematically share best practice and adopt standard processes where evidence shows they work.

In 2026, the new NHS Excellence Awards were introduced to recognise, encourage and share best practice across the healthcare system.

Learning and evaluation

The NQB will commission regular evaluation of a whole range of levers and incentives for quality improvement. This evaluation will support regular data-driven reporting and alerting.

The evaluation will:

• assess whether incentives and levers measurably improve safety, effectiveness and experience
• understand what works, and why, in different contexts and settings
• identify unintended consequences, considering trade-offs or negative effects
• feed timely insights back into decision-making, so approaches can be adjusted to support continuous improvement across the system

Reinforcing incentives for quality improvement

While financial, contractual and recognition mechanisms create incentives for quality improvement, oversight and assurance reinforce them by linking performance to accountability, support and intervention.

The CQC Assessment Framework will set clear expectations for providers, commissioners and system leaders, with updated sector‑specific assessment frameworks and simplify rating methodologies for 2026.

NHS England will continue to take regulatory action where quality leadership falls short, in line with the quality governance conditions set out in the NHS provider licence. Building on the priorities in this strategy, NHS England will also consult on changes to strengthen expectations for quality management and leadership as part of any wider changes to the NHS provider licence.

The NHS Oversight Framework will continue to consider quality alongside finance and operational performance, using measures across all 3 domains to inform a provider’s delivery segmentation.

As part of the NHS Oversight Framework and monitoring compliance with the NHS provider licence, NHS England will continue to assess provider capability, including leadership and quality improvement. The capability rating and delivery segment will be used to determine the level of oversight and appropriate support or intervention required.

From 2027/28, NHS England will include a capability rating as part of each ICB’s annual performance assessment which considers, amongst other things, how effectively ICBs have commissioned high-quality services that meet the needs of their local population. This rating will be used routinely, alongside each ICB’s segmentation data, to inform the level of oversight and support or intervention required.

NHS England will oversee and assure independent providers through the Independent Providers Risk Assessment Framework (IPRAF) and NHS‑controlled providers through either IPRAF or the NHS Oversight Framework, as appropriate. NHS England will also review and strengthen arrangements for overseeing quality governance at independent providers that are hardest to replace.

ICBs are responsible for commissioning and assuring the quality of primary care (general practice, dentistry, community pharmacy and general optometry) services. To support this:

• from 2026/27, ICBs are required to put in place action plans to continue to improve contract oversight, commissioning and transformation for primary care and tackle unwarranted variation. This includes:
  • reducing variation in QOF standards for cardiovascular disease, diabetes, chronic obstructive pulmonary disease (COPD), mental health conditions and dementia, and increasing the percentage of patients with diabetes who received all 8 elements of the diabetes care process bundle, as reported in the National Diabetes Audit
  • the forthcoming pharmacy professional assurance framework will set expectations and standards for all registered pharmacy professionals delivering NHS-commissioned community pharmacy services
  • in 2026/27, NHS England will review the existing Dental Assurance Framework and aim to replace it with a new clinical quality framework featuring targeted, evidence‑based indicators to assess and measure the quality of dental services

Local authorities remain accountable to local elected leaders for their public health functions, but government also has an important assurance role. DHSC is funding a new programme of Public Health Peer Reviews, delivered by the Local Government Association (LGA) from June 2026. The programme will initially run for 3 years and will support councils to:

• strengthen their approach to quality
• make better use of wider local authority spending and the Public Health Grant
• deliver their statutory health improvement duties and public health priorities

12. Promoting innovation and research

As health needs evolve and technologies advance, the NHS must remain agile, evidence-led and open to new approaches that improve both the quality of care and the productivity of the services that deliver it.

Research and innovation are also essential for health protection and prevention, helping anticipate and respond to emerging risks and reduce avoidable illness.

National leadership and infrastructure

NICE will play a central role across all stages of research and innovation, including horizon scanning, evidence evaluation and adoption.

For each modern service framework, NICE will:

• help identify evidence gaps
• set the evidence requirements for new technologies and interventions
• support consistent and transparent assessment of emerging innovations

DHSC, through the National Institute for Health and Care Research (NIHR), funds and enables research to improve quality across the NHS.

Its programmes underpin national priorities, such as prevention, tackling inequalities and shifting care closer to home, ensuring innovation is grounded in evidence and real‑world impact.

As part of this, NIHR is funding 6 patient safety research collaborations that bring together universities and NHS trusts to translate research into improvements in frontline care.

Discovery: identifying priorities for research and innovation

Discovery focuses innovation and research on the most pressing system needs. Below outlines what this looks like in practice.

Horizon scanning and demand signalling

Systematic horizon scanning at national and ICB levels identifies technologies, service models and medicines to address gaps highlighted in modern service frameworks and quality improvement plans. This signals priorities to funders, academia and industry. For example:

• the Medicines and Medical Devices Access (MMD) initiative, which supports system readiness by co-ordinating medicines horizon scanning with partners
• HealthTech horizon scanning is being established within the National HealthTech Access Programme and the NIHR HealthTech research centres

Research‑active services delivering better care

Research-active hospitals deliver better outcomes, lower mortality rates and improved service user experience.

The Medium Term Planning Framework now requires reporting of research activity at board level, with a metric included in the NHS Oversight Framework 2026/27.

Alongside this, as part of the Research Workforce Implementation Plan, NHS England and DHSC will develop education modules to improve understanding of the importance of research across the workforce.

Strengthening the evidence base for quality improvement

To improve care, it is essential to understand which quality improvement initiatives are effective and can be scaled across the NHS.

Programmes such as the NIHR Health and Social Care Delivery Research programme support evaluation of initiatives to improve quality, access and service design.

The NIHR has also invested nearly £800 million in 20 Biomedical Research Centres across England (2022 to 2028) to:

• translate scientific breakthroughs into new treatments, diagnostics and technologies
• strengthen research capacity and capability
• attract further investment

Inclusive, population‑relevant evidence

Research participation and study design must reflect the needs of diverse communities and care settings.

For example, NHS DigiTrials is supporting more representative recruitment, helping ensure findings apply to the populations served.

Partnering with people and communities

Co‑design, participatory research and acceptability testing should be embedded early.

NIHR is a leader in public and patient involvement and engagement (PPIE), with patients, carers and the public involved at every stage of research. This helps ensure research is relevant, inclusive and delivers meaningful impact.

NIHR funding requires studies to be inclusive by design, with population diversity considered in both participation and study design, so that research reflects the needs of different communities.

Data foundations for a learning system

Timely and secure access to data through the NHS Research Secure Data Environment (SDE) Network supports faster learning and quality improvement.

The Secure Data Environment model enhances data quality, allowing data sources to be linked at scale and providing tools for standardised analysis. With over 500 projects either completed or in progress, the Secure Data Environment Network is accelerating research by providing secure access to linked datasets from over 57 million health records.

Alongside this, the Health Data Research Service (HDRS) will provide a single, secure point of access to NHS health data, supporting faster research and enabling the development of new treatments and care pathways.

Development: ensuring innovation meets consistent standards

Development ensures promising innovations meet consistent standards, generate evidence for decision-making and can be implemented in practice.

Below outlines what this looks like in practice.

Regulation and standards coherence

Clear pathways are needed for devices, diagnostics and digital. Over the next 2 years, a new ‘innovator passport’ will allow new technologies assessed by a single NHS organisation to be adopted more easily by others.

The National Healthtech Access Programme will expand NICE’s technology appraisals programme to incorporate health technologies. As with medicines, a small selection of high-impact technologies will be reimbursed and made available across the NHS. This will reduce assessment duplication and support more consistent national guidance.

Clinical research delivery

Reforms have streamlined clinical trial set‑up and delivery by reducing bureaucracy and standardising processes.

Average set‑up times for commercial interventional trials have fallen from 169 to 122 days over 12 months, with further improvements expected. This supports faster, more predictable trial delivery, improving patient experience and enabling earlier access to new treatments.

Generating real-world evidence

Evaluations in representative NHS settings assess outcomes, safety, usability, equity and operational impact. Work is underway to build on 200 real-world evaluations already being supported by the Health Innovation Networks, with a £6.5 million fund focused on 3 key underserved areas:

• prevention
• frailty (all ages)
• women’s health

Workforce and pathway readiness

Impacts on skills, roles, workflows and training continue to be assessed, with research and innovation capability embedded as a core workforce skill.

Deployment: implementing innovation

Deployment enables systems to implement innovation safely, consistently and at scale, with the right leadership, resourcing and learning.

Below outlines what this looks like in practice.

System capability and capacity

Staff and systems need analytical, digital, innovation and evaluation skills to select, implement and monitor innovation. These skills are being developed through NHS InSites, the Health Innovation Network and the NHS Innovation Accelerator.

With over 3,000 innovations in the pipeline, the Health Innovation Networks also support local systems to prioritise innovations with the greatest impact.

Implementation support for priority innovations

Standardised pathway redesign guides and training assets will be developed for priority innovations. NHS England has published commissioning strategies and resources for chronic obstructive pulmonary disease, with further support planned for other areas.

NHS England is also providing direct support through programmes such as:

• AI Research Screening Programme – an NIHR‑funded, cloud‑based AI research screening platform, backed by almost £6 million in government research funding, which will support earlier and faster diagnosis
• accelerating the adoption of AI-based tools in dermatology – including an AI tool developed by Skin Analytics, improving clinical outcomes and productivity
• expanding access to digital therapeutics through the NHS App – testing a HealthStore model to understand whether the NHS App can safely and effectively distribute locally commissioned digital therapeutics, placing clinically proven digital health tools directly in the hands of patients

Adoption of innovation to improve health and economic growth

Through the health and growth accelerators initiative, NHS England is supporting 3 ICBs to deploy digital therapeutic interventions targeting mental health and musculoskeletal conditions. The initiative aims to reduce health-related economic inequality and support wider adoption.

Role of NIHR Applied Research Collaborations

Applied Research Collaborations (ARCs) fund and deliver applied research focused on the needs of local populations and systems across England. They bridge the gap between evidence and practice, translating research into actionable models of care that improve outcomes and help reduce inequalities.

Role of Health Innovation Networks

Health Innovation Networks (HINs) deliver hands-on support for pathway redesign, clinical engagement, evaluation, real-world evidence generation and scale-up.

They have led the full implementation of the Patient Safety Incident Response Framework (PSIRF), reforming the NHS’s response to patient safety incidents.

As implementation partners for Martha’s Rule, HINs are now supporting the roll-out to new care settings, including maternity and neonatal units, emergency departments, mental health and community settings.

Measurement and rapid learning

Analytics are used to track near real-time impact on safety, outcomes, access, experience, equity and productivity. Learning will be fed back into standards and commissioning.

Procurement and commercial levers

Procurement frameworks will be aligned to reward outcomes, interoperability and the development of local capability. DHSC has updated Intellectual Property guidance, supporting a commercial approach that improves care quality and outcomes.

13. Creating a more co-ordinated, improvement-focused approach to regulation

Oversight and regulation protect people and assure standards, but when national bodies act in isolation, they can create duplication, inconsistency and unnecessary administrative burden.

Greater alignment across regulators, oversight bodies and professional regulators will ensure that oversight:

• reinforces shared priorities
• strengthens accountability
• supports improvement

Aligned regulation means national bodies acting as a coherent quality ecosystem while retaining their distinct statutory roles. It requires:

• a shared view of quality
• proportionate, risk‑based oversight
• co-ordinated use of data and intelligence
• a joint commitment to using regulatory insight to support learning, not only to judge performance

A more aligned approach benefits people using services and those delivering care. Clearer, more consistent expectations enable regulators to act decisively when safety or quality concerns arise.

The role of professional regulators

Professional regulators play a vital role in maintaining public confidence, ensuring professional competence and setting standards for behaviour, ethics and training.

As part of an aligned regulatory approach, the National Quality Board (NQB) will work with professional regulators to:

• strengthen shared definitions of professional and organisational quality
• improve the interface between organisational regulation and individual professional concerns
• reduce duplication in data and information requests
• support consistent expectations for clinical leadership, safety culture and professional behaviours

Applying aligned regulation in practice

National bodies will work together to:

• ensure alignment between NHS England’s NHS Oversight Framework and the CQC Assessment Framework, so providers experience clear and consistent expectations
• produce co-ordinated regulatory schedules, so providers receive consolidated, sequenced requests rather than overlapping visits or assessments
• create shared data collections and intelligence to support aligned oversight and regulation, so frontline teams provide information once; for example, the Submit a Perinatal Event Notification (SPEN) portal, which allows reporting to 3 national organisations at once, reducing administrative burden and improving data quality
• use consistent quality frameworks (including common definitions of effectiveness, experience and equity) across organisational, professional and system‑level oversight
• share intelligence in real time to identify emerging risks earlier and act jointly to support improvement
• align priorities across programmes of work so that quality, safety, workforce and financial oversight reinforce rather than compete with each other

Regulators will draw on NICE evidence-based guidance and quality standards for clinical and cost-effective care as part of the wider evidence base used to assess the quality and safety of care.

Alignment between NICE, the CQC, NHS England and DHSC will help ensure that regulatory expectations reflect the best available evidence and that providers are assessed consistently against nationally agreed standards.

National Quality Board actions to support aligned regulation

To support a more coherent approach, the NQB will:

• promote alignment so that providers, professionals and systems receive clear, consistent expectations of what quality means and how it will be assessed
• use a common language for quality, drawing on the CQC assessment framework
• support alignment of national standards and definitions, particularly for effectiveness and experience
• provide system leadership for quality, enabling collaboration across regulators and addressing system‑level quality risks that fall beyond the remit of any single organisation
• champion an improvement‑focused approach, using shared intelligence to support learning and innovation while maintaining trusted, independent information for the public
• create a single, consistent view of quality informed by the core quality metrics set
• ensure that expectations for quality management systems and the core quality metrics set are aligned with the CQC assessment framework

Next steps in regulatory reform

The Dash review set out a series of recommendations to strengthen system safety oversight. They have all been accepted by the government and reflected in the 10 Year Health Plan. This includes:

• transferring the Patient Safety Commissioner to the Medicines and Healthcare Products Regulatory Agency (MHRA)
• abolishing the Health Services Safety Investigation Body (HSSIB) and transferring its functions to the Care Quality Commission (CQC)

The proposed transfer of the hosting arrangements of the Patient Safety Commissioner to the MHRA will enable the commissioner to focus on the statutory functions of improving how patients and services report complications from medicines and medical devices.

While hosted by the MHRA, the commissioner will remain independent of its management structures and continue to report directly to Parliament and will retain their statutory powers to:

• request information from relevant organisations that must comply
• publish reports and recommendations to which recipients must respond

Non-statutory functions, previously undertaken by the commissioner, will be incorporated into a new Directorate for Patient Experience within DHSC, strengthening the wider system’s focus on patient voice and quality.  

The proposed abolition of the Health Service Safety Investigation Body (HSSIB) and the transfer of its functions to an investigation arm of the CQC requires primary legislation. It will agree the scope of its investigations with the NQB, which will be responsible for prioritising recommendations. It should share learnings and retain its role in upskilling health organisations through its education function.

Together, these reforms will support a more coherent and proportionate approach to safety oversight. The NQB will play a central role in guiding and co-ordinating this next phase of regulatory reform.

Future direction

The NQB will champion regulatory approaches that evolve in line with innovation, digital transformation and new models of care.

As the regulatory landscape develops, the NQB will ensure transparency, public trust and the central importance of outcomes and experience remain at the heart of the system.

14. Using quality management systems to support improvement

The 10 enablers describe the conditions and approaches needed to improve quality and outcomes. Quality management systems (QMS) can help local organisations apply these in practice through a structured approach to planning, delivery, monitoring and continuous improvement.

Used well, they support a proactive approach, helping organisations to anticipate potential issues and address them before problems arise.

Evidence and best practice increasingly show that a QMS approach is an effective way to manage quality in complex systems. They are well established in many high-risk industries – including aviation, the military and utilities – and are now being adopted more widely in healthcare, particularly in secondary care and some high-risk services, including radiotherapy, oncology and pharmacy.

What a quality management system involves

A QMS includes, but goes beyond, quality improvement. It brings together 4 core, interconnected functions:

• quality planning
• quality control
• quality improvement
• quality assurance

These 4 functions must operate together to ensure quality is managed effectively and consistently.

Supporting quality management system implementation

We will shortly publish a Quality Management Systems Framework, which will set out how NHS organisations can embed a QMS approach. It will provide practical guidance to help organisations establish and operate a QMS and signpost additional resources and support.

As QMS approaches are embedded, they should remain aligned with the CQC Well-led framework and other regulatory judgements, supporting a coherent and consistent approach to quality across the healthcare system.

Safety management systems differ from QMS approaches. NHS England has described its position on the potential for safety management systems to improve patient safety.

15. Putting this strategy into action – a shared responsibility

Delivering high‑quality care depends on everyone working across the healthcare system. People want to make a difference – using their expertise, compassion, and skills to improve the lives of those they serve.

This strategy focuses on creating the conditions that enable staff to deliver high-quality care in partnership with people and communities, in environments where staff, learners and volunteers are trusted, supported and listened to.

National policy can set direction, but improvement happens in practice. Everyone has a role to play.

Individuals and teams must continuously learn and improve, using data and insight from across the whole team, alongside feedback from people who use services and communities, to identify opportunities for quality improvement.

Providers are responsible for delivering safe, effective care and a positive experience. Boards and leaders must create environments where quality is actively planned, monitored, improved and assured.

ICBs must put quality at the centre of commissioning, ensuring services meet local need, improving life expectancy and quality of life, reducing health inequalities and ensuring consistently high-quality care.

National bodies and their regions must lead by example. The National Quality Board and its constituent members will embed quality in national programmes, policies and decisions; direct resources to maximise health; set clear and consistent expectations; and provide tools that enable improvement.

Working together, we can create a system that delivers high-quality care everywhere and for everyone.

16. Annex A – core quality responsibilities of regions, ICBs and service providers

These responsibilities align with:

• the Model ICB and Region blueprints
• Strategic commissioning framework
• Neighbourhood health framework and accompanying guidance

The annex does not include detailed statutory responsibilities or NHS England’s directly commissioned services, which will be set out separately. 

Regions – core quality responsibilities

Quality planning

• Regional and cross-ICB planning to deliver high-quality, cost-effective care and reduce inequalities (for example, education and training, workforce and estates), with involvement of people using services, unpaid carers, local communities and staff.
• Support and assure ICB and provider responses to nationally mandated planning.
• Support the design of national planning products.

Quality improvement

• Support ICBs to prioritise value-based quality improvement as strategic commissioners.
• Co-ordinate regional improvement, including cross-ICB learning and capability development in providers and ICBs.
• Proactively manage and escalate risks in accordance with the National Quality Board guidance.
• Co-ordinate improvement support to address quality failures in providers and ICBs, where this cannot be managed through commissioner-provider relationship.
• Provide expert clinical and quality advice to providers and ICBs (including through the National Provider Improvement Programme).
• Lead regional implementation of national quality priorities and learning from inquiries and reviews.

Quality control

• Monitor quality across regions by bringing together core metrics, professional and regulatory intelligence and feedback from people using services and unpaid carers, identifying themes and areas for improvement.
• Chair regional quality groups to help share quality intelligence and support ICB System Quality Groups (in line with NQB guidance).
• Escalate concerns and risks to inform national policy development and improvement.

Quality assurance

• Provide holistic oversight of providers and ICBs, including through the NHS Oversight Framework, statutory annual assessment, provider and ICB capability assessments.
• Provide real-time operational quality oversight of providers and oversight of ICBs’ commissioning and statutory duties.
• Oversee statutory enforcement actions, discretionary requirements and undertakings where an NHS organisation is in breach of its licence.
• Work with regulatory bodies (such as CQC, General Medical Council, Nursing and Midwifery Council) to share intelligence and inform formal intervention, segmentation and undertakings.
• Undertake and support quality due diligence for transactions, foundation trust assessments and significant service reconfigurations.
• Deliver statutory quality functions at a regional level.

ICBs and strategic commissioners – core quality responsibilities

Quality planning

• Set strategic plans to deliver high-quality, cost-effective care and reduce inequalities for local communities, in collaboration with local authorities.
• Commission high-quality care, co-designed with people using services, unpaid carers, staff and local communities, including neighbourhood health services.

Quality improvement

• Use contractual levers (including the NHS Standard Contract) to support quality improvement and reduce variation.
• Support providers to implement national standards (for example, NHS Standard Contract and CQC requirements).
• Proactively manage and escalate risks in accordance with the National Quality Board guidance.
• Deliver statutory quality functions.

Quality control

• Monitor quality in contract management, including:
  • quality schedules and service development and improvement plans (SDIPs)
  • quality metrics, including PROMs and PREMs
  • minimum practice standards and guidelines
  • service user, unpaid carer, staff and learner feedback
  • Patient Safety Strategy
• Maintain quality oversight of neighbourhood health services.
• Chair System Quality Groups to share intelligence to inform improvement and risk management.
• Use data and intelligence to understand and improve the quality of strategically commissioned services, identifying themes and areas for improvement across services and pathways.
• Commission patient safety and independent investigations, ensuring actions and learning are implemented.

Quality assurance

• Put in place effective and insightful governance to ensure visibility of quality, including:
  • clinical leadership
  • use of data and insight, including feedback from users and staff
  • Equality and Quality Impact Assessments and assessments of cost-effectiveness
  • incident management, audits and risk reporting
• Specify and assess quality in procurement activities under the Provider Selection Regime.
• Comply with oversight and regulatory frameworks (including NHS Oversight Framework and ICB annual assessment).

Service providers – core quality responsibilities

Quality planning

• Set a clear vision and priorities to deliver high-quality, cost-effective care and reduce inequalities, involving people using services, unpaid carers, local communities and staff.
• Develop a credible integrated plan to deliver priorities, including robust demand and capacity modelling, with alignment across quality, finance, activity and workforce, and clear outcomes measures.
• Work in partnership with strategic commissioners to improve quality and outcomes, and reduce inequalities, including developing new neighbourhood health models.
• Ensure plans reflect agreed commissioned activity levels and align to overall ICB strategy.

Quality improvement

• Implement continuous improvement in line with annual planning, this strategy and legal and contractual requirements, including:
  • board capability and leadership development
  • improvement training for staff
  • involvement and feedback of people using services, unpaid carers and communities, for example, lived experience partners, patient safety specialists and partners
  • delivery of statutory quality functions

Quality control

• Maintain day-to-day operational management to monitor and sustain quality, including:
  • use of real-time and trend data to monitor quality and outcomes
  • incident recording and risk management processes
  • governance and escalation processes
  • communication (for example, structured handovers, such as SBAR, and huddles)
  • proactive, dynamic risk assessment to identify and respond to emerging risks
  • standardised processes developed with frontline teams to improve reliability and reduce variation
  • real-time corrections to processes and clear escalation routes

Quality assurance

• Put in place effective governance to ensure clear visibility of quality, including:
  • clinical leadership
  • use of data and insight, including feedback from users and staff
  • Equality and Quality Impact Assessments and assessments of cost-effectiveness
  • incident management and risk recording
• Commission and take part in patient safety investigations, audits and other learning responses (for example, peer and invited reviews), ensuring actions are implemented.
• Comply with minimum practice standards, oversight and regulatory frameworks.

18. Annex B – local actions to strengthen leadership and management capabilities for quality

Leadership 

Establish governance, accountability and behavioural standards: align job descriptions, objectives, supervision and appraisal to agreed quality and expected behaviours. This includes responsibility and timelines for actions and escalation to the organisation’s board.

Lead through system partnerships: build collective leadership with partners to ensure a whole-system approach to quality management.

Risk appetite and behaviours: set and review risk appetite and embed intelligent risk-taking behaviours aligned to quality goals.

Co-produce a strategy with people who use and deliver services: balance all 3 domains of quality and take a value-based, population-health approach to decision-making.

Enable data-driven improvement: resource teams and build capability to interrogate data and intelligence, manage quality and drive improvement.

Create the conditions for quality improvement: ensure teams have the time and capacity to undertake quality management and improvement activities.

Co-design services with people who use and deliver services, using evidence and innovation: apply the latest guidance, research and innovations.

Develop team leadership and performance: grow high-performing teams that practise collective leadership to deliver shared quality goals.

Assure education quality and protect educator capacity: meet education and training standards set out in the NHS Education Quality Framework and by regulators; sustain a workforce focused on care quality and improvement.

Culture

Provide leadership development for quality: equip leaders across organisations, networks and partners to build a shared listening and learning culture focused on quality.

Assess quality culture regularly: review team, organisational and network culture through routine governance activity to identify gaps and areas for improvement.

Strengthen quality culture through targeted support: provide timely and effective interventions to address identified gaps using approaches such as Patient Safety Incident Response Framework (PSIRF), Freedom To Speak Up and relevant staff survey insights.

Align HR and organisational development mechanisms to reinforce culture: ensure appraisals, mandatory training and improvement-focused development are consistent with the expectations set out in this strategy.

Apply NHS England’s best-practice guidance and the Experience of Care Improvement Self Assessment (formerly framework) to identify gaps and embed improvement actions.

Engagement  

Review staff engagement mechanisms: assess existing approaches, identify themes from feedback and intelligence, and develop plans to address gaps.

Monitor learner experience: act on insights from the National Education and Training Survey (NETS), GMC National Training Survey and Educator Voice Survey to drive continuous improvement.

Embed engagement insights in governance: ensure staff and learner feedback is routinely prioritised and addressed through business-as-usual management and governance arrangements.

Strengthen engagement practice through targeted support: provide timely and effective support to teams and networks to improve the effectiveness and impact of engagement activity.

Implement fair recognition and reward processes: ensure staff recognition and reward mechanisms are transparent and equitable.

20. Annex C – evidence and context underpinning this strategy

This annex brings evidence from national datasets, audits, reviews and policy documents to support this strategy. It is accompanied by a technical annex which shows:

• recent trends
• the current baseline for key indicators
• the drivers associated with those quality outcomes

This annex is not intended to provide a comprehensive synthesis of all evidence. Interpretation and prioritisation of this evidence are set out in the main body of this strategy.

Safety: context and evidence

Improving safety in healthcare involves reducing the risk of unintended and unexpected harm to patients, while recognising that all care carries some level of risk. It does not mean eliminating all risk or pursuing zero harm. Instead, it is about continuous learning and includes managing risks linked to:

• medicines, diagnostics and procedures
• recognising or responding to deterioration
• health threats requiring effective health protection measures, such as infection prevention and control, surveillance and early risk mitigation

What the evidence tells us

The NHS records around 3 million patient safety incidents each year from approximately 600 million healthcare contacts. Most cause no harm (64%) or low harm (30%), but a small proportion lead to severe harm (0.5%) or death (0.6%) (see the NHS England patient safety data).  

These risks are often highest at the point of transition between services and for people with complex or multiple needs, contributing to inequalities in safety outcomes.

Persistent safety challenges remain

National evidence continues to highlight longstanding and persistent safety risks. In particular:

• deaths related to venous thromboembolism (VTE) within 90 days of discharge occurred at a rate of 61.2 per 100,000 in 2023/24, similar to pre-pandemic levels
• 3 in every 100 hip fractures happen after a fall when the patient is already in hospital for another reason; the National Audit of Inpatient Falls (NAIF) looks at how hospitals might improve care to prevent such falls and injuries
• pressure ulcer rates in hospital inpatients remain at around 8 to 10% among hospital inpatients, broadly unchanged over time
• research indicates that missed, delayed or incorrect diagnoses are a significant source of preventable harm in general practice, accounting for the largest proportion of serious patient safety incidents in that setting
• evidence also suggests that diagnostic harm often arises from poor co-ordination, information sharing and follow-up, increasing the risk of delayed or missed diagnosis, especially for people with complex needs

Some groups face higher risks of harm

Evidence shows that patient safety incidents are not experienced equally. Some marginalised ethnic patient groups and those affected by unfavourable social determinants of health face higher risks of harm. These incidents can exacerbate existing healthcare inequalities.

Improvement opportunities and actions 

Recent national action to improve safety

Launched in 2019, the NHS Patient Safety Strategy sets the long-term direction for improving patient safety across the system. It recognises that safety is the responsibility of everyone within it. The strategy prioritises national action on 3 areas:

• improving the way the NHS learns about patient safety (insight)
• building capability and capacity to address safety challenges (involvement)
• focusing on key improvement priorities where additional national activity can add value (improvement)

Further detail on progress against the NHS Patient Safety Strategy can be found in the progress update, including:

• earlier identification of patients’ conditions deteriorating through the development of early warning tools and safety initiatives, such as Martha’s Rule
• implementation of medicines safety initiatives
• saving neonatal lives and preventing cases of cerebral palsy through safer care bundle interventions
• the development of national learning systems
• reforms to incident response, including the Patient Safety Incident Response Framework
• action to strengthen safety capability and leadership

There has also been targeted action to reduce health inequalities, with the introduction of the Patient safety healthcare inequalities reduction framework.

However, there remain areas where clear standards and the application of proven, consistent approaches will deliver the greatest improvements in outcomes, equity and value.

Medicines safety

The scale and complexity of medication use in the NHS create a risk of error and associated harm.

Research indicates that around 230 million medication errors occur in England each year, of which approximately 66 million are potentially clinically significant. Avoidable adverse drug events contribute to more than 1,700 deaths annually and cost an estimated £98 million each year.

Alongside this, recent surveillance data shows rising drug-related deaths that are increasingly linked to prescribed medicines. Adverse drug reactions account for around 1 in 6 hospital admissions, costing an estimated £2.2 billion per year. This points to a wider and growing burden of medicines-related harm beyond preventable error.

Weaknesses in how medicines information is created and shared across care settings contribute to harm. Around 167 million hospital medication orders are manually transcribed each year, increasing the risk of error, delay and loss of clinical time, particularly at admission and discharge.

National digital initiatives are improving the structured exchange of medicines data between systems, such as the expansion of the Electronic Prescription Service (EPS) into secondary care and improved availability of medicines information for clinicians and patients. This has generated improvements across the pathway and supports safer prescribing. Work is also underway to develop a Single National Formulary (SNF), which will further strengthen medicines safety by establishing a consistent national medicines data and knowledge standard, including:

• agreed terminology
• structured formulary content
• decision support rules that can be used within prescribing systems

These measures will reduce variation and ambiguity in prescribing and support safer, more consistent decision-making across care settings. However, they cannot alone eliminate medicines‑related error.

Since 2021, the national medicines safety improvement programme has shown that targeted, evidence-based interventions can reduce medicine-related harm at scale, including preventing over 1,900 deaths and over 13,000 significant harms. This has involved:

• a whole system community approach to chronic pain that reduces harm from opioids (see case study below)
• primary care reduction in harm from anticoagulants, anti-inflammatories and methotrexate
• changes in the prescribing and safety of valproate and other potent teratogens

Building on this evidence, the medicines safety programme is now focusing on time-critical medicines for people with long-term conditions.

Over 1 million people rely on medicines that must be taken at specific times. Evidence from Parkinson’s UK shows that delays or omissions in time‑critical Parkinson’s medication are associated with worse outcomes, including increased risk of complications, longer hospital stays (around 4 additional days), and, in severe cases, death.

Managing acute physical deterioration

Implementing the prevention, identification, escalation, response (PIER) approach supports early recognition of deterioration, enabling timely support and appropriate treatment. It helps prevent avoidable harm and ensures people’s wishes are respected through advanced care planning, treatment escalation plans and end-of-life care. 

Evidence from the Managing deterioration safety improvement programme shows that better management of deterioration and deconditioning in care homes can reduce emergency demand and avoidable admissions. For example, in the West Midlands, the introduction of deterioration management tools from January 2021 to September 2022 was associated with:

• 2,236 fewer 999 calls
• 3,232 fewer emergency admissions
• 34,900 fewer bed days

NHS England modelling suggests that, if scaled nationally across all 15,140 care homes in England, this could equate over a 21-month period to:

• 31,116 fewer 999 calls
• 44,969 fewer emergency admissions
• 485,654 fewer bed days

This represents a substantial cost-saving for the wider health and care system.

Another important element of PIER is the increasing use of early warning tools, such as NEWS2 and PEWS, as well as approaches that provide patients and families with clear ways to raise concerns, such as the introduction of Martha’s Rule.

To date, much of this work has focused on hospital settings. As more complex care is increasingly delivered in community and neighbourhood settings, there is an opportunity to extend proven deterioration-management approaches beyond hospitals, using a broad range of surveillance data and insights to support early identification of deterioration in the community. This will also be addressed by the Sepsis modern service framework. 

Medical devices

Recent high‑profile device safety issues and product recalls have highlighted the risks associated with medical devices. In addition, there has been a steady increase in device recalls and reported safety concerns, reinforcing the need for stronger system‑wide oversight.

In 2024, NHS England launched the Medical Devices Outcomes Registry (MDOR), a single national register of patients who have received medical implants. Under the Outcomes and Registries Directions (2024), NHS England is also required to operate an information system to collect and analyse information to:

• improve clinical safety and patient outcomes
• reduce variation in clinical practice
• support research and innovation and prevent future harm

MDOR supports a more robust national approach to device safety, including the ability to quickly notify patients affected by manufacturer‑led safety notices or recalls. Over time, the MDOR and wider Outcomes and Registries programme will also monitor device performance and outcomes.

In its first year, over 1.3 million devices were recorded, with volumes expected to increase significantly in 2025/26 to over 5.5 million devices, reflecting device expansion and increased uptake among NHS provider trusts.

MDOR remains a priority programme for NHS England, alongside the integration and support of related clinical registries, and transformation funding has been sought to support its ongoing development and sustainability.

Mental health services

In April 2026, 39% of mental health services were rated as ‘requires improvement’ or ‘inadequate’ in the CQC safety domain, and 25% as ‘requires improvement’ or ‘inadequate’ in the CQC well-led domain.

There are currently 4 public inquiries related to mental health quality failings, and a number of concerns identified in recent Health Services Safety Investigation Body reviews.

Since 2023, the mental health, learning disability and autism inpatient quality transformation programme has supported improvements by:

• helping each ICB plan and deliver inpatient services that are better tailored to local needs and based on up-to-date evidence
• introducing culture of care standards for mental health, learning disability and autism inpatient services, backed by a national culture change programme
• working with the sector to learn from serious quality failings, making improvements in governance and oversight arrangements

However, poor quality mental health care still persists. There is wide variation in outcomes, long waits in access to care, ongoing use of unsafe out-of-area placements, and high-profile quality failings, highlighting an urgent need to reset quality governance and oversight arrangements.

Maternity and neonatal outcomes

The National Maternity and Neonatal Safety Improvement Programme has contributed to significant improvements in outcomes, including:

• the adoption of the preterm optimisation safer care bundle, contributing to over 1900 neonatal lives saved and over 500 cases of cerebral palsy prevented
• wider use of tools to prevent, identify, escalate and respond (PIER) to maternal and neonatal deterioration, including the Maternity Early Warning Score (MEWS) and the Newborn Early Warning Trigger and Track (NEWTT2)

Although maternity and neonatal outcomes have improved over the long term, progress has slowed and variation persists. Increasing acuity, intervention rates and complexity of care mean that services are now more demanding and resource‑intensive than ever.

Inequalities remain marked. The MBRRACE-UK Perinatal Mortality Surveillance Report 2023 reports that neonatal mortality rates have increased in the most deprived communities in recent reporting periods and remain more than twice as high as in the least deprived communities. Babies of Black ethnicity remain more than twice as likely to be stillborn as babies of White ethnicity, and neonatal mortality remains higher for babies of Asian and Black ethnicity than for White babies.

Maternal mortality has also increased in recent years. MBRRACE-UK data for 2021 to 2023 reports a UK maternal mortality rate of 12.82 deaths per 100,000 births, a 21% increase since 2009 to 2011. Black women are around 2.3 times more likely to die during or shortly after pregnancy than White women, Asian women are 1.3 times more likely, and women living in the most deprived areas face almost double the mortality rate of those in the least deprived areas, as reported by MBRRACE-UK Saving Lives, Improving Mothers’ Care 2024.

Recent enquiries continue to identify recurring safety issues, including:

• delays in recognising and responding to deterioration
• gaps across maternity and neonatal pathways
• weaknesses in communication and escalation
• women and families not being listened to or involved in decisions about their care
• workforce, capacity and cultural challenges that affect the consistent delivery of safe and compassionate care

In maternal death inquiries, assessors judged that improvements in care may have made a difference in around 45% of cases. Recent reviews have also highlighted the importance of strong leadership, effective governance and cultures that support learning, improvement and accountability. Together, these findings reinforce the imperative to reduce harm through more consistent delivery of proven safety approaches.

Clinical effectiveness: context and evidence

Clinical effectiveness refers to the extent to which NHS care improves health outcomes by delivering timely, appropriate and evidence-based care that makes a positive difference to individuals’ health and wellbeing and reduces avoidable ill-health, disability and death.

Improving effectiveness means ensuring care makes a meaningful difference to people’s health and lives, both for individuals and across the population as a whole.

It also involves measuring outcomes that matter to people, including recovery, symptom control, functional ability and quality of life across physical and mental health.

Alongside this, it means understanding which pattern of investment in health interventions will have the greatest impact at a population level and prioritising health protection and early intervention, for example, through vaccination and screening programmes.

What the evidence tells us

Healthy life expectancy has fallen to its lowest level since 2011

Healthy life expectancy is the average number of years a person can expect to live in good health, based on current mortality rates and levels of self-reported health. Office for National Statistics (ONS) data for 2022 to 2024 suggests that healthy life expectancy at birth has fallen to its lowest level since 2011 to 2013: 61.3 years for women and 60.9 years for men in England.

There are also marked inequalities:

• women live longer but spend more years in poor health
• men have shorter lives and fewer healthy years overall
• people in the most deprived areas can expect over 10 fewer years of healthy life than those in the least deprived

This means people in more deprived areas not only live shorter lives but also spend more of those years in ill health, reinforcing inequalities in quality of life, independence and economic participation.

These differences are driven by higher exposure to risk factors, such as smoking and poor diet, and the higher prevalence and earlier onset of major conditions, including:

• cardiovascular disease (CVD)
• cancer
• chronic respiratory disease
• common mental health conditions

The growing impact of frailty, dementia, musculoskeletal conditions and multimorbidity further increases the burden of poor health, especially in more deprived groups.

The 10 Year Health Plan commits to reversing this trend by halving the gap in healthy life expectancy between the most and least deprived areas, while improving it overall. This means increasing healthy life expectancy in the most deprived areas to at least 61 years, up from 50.5 years.

Differences in access to healthcare, experience of services and uptake of services that help prevent illness also contribute to this gap. Reducing unwarranted variation through prevention, early intervention and the management of long-term conditions is essential to improving healthy life expectancy, with a focus on the populations and places with the poorest outcomes.

Premature mortality rates are improving

Premature mortality, defined as deaths before age 75, is a key indicator of the effectiveness of prevention, early diagnosis and healthcare interventions.

Following an increase during the COVID-19 pandemic, premature mortality rates have decreased for both males (394.6 per 100,000) and females (251.5 per 100,000). However, there are marked inequalities, with a deprivation gap of 241.2 per 100,000 for males and 151.0 per 100,000 for females based on 2024 figures.

More people are living with a long-term condition

A growing proportion of the population is living with chronic illness and multiple conditions, with around 41% of adults affected by at least one long-term condition.

Long-term conditions – including musculoskeletal conditions, common mental ill-health, chronic respiratory disease, and the cumulative effects of frailty and multimorbidity – are a major contributor to pressures on healthy life expectancy and increasing demand for healthcare services.

They lead to significant pain, disability and functional limitation, especially in later life. The impacts are not evenly distributed: people in more deprived communities experience substantially higher levels of long‑term illness and disability.

Variation in care can cause poorer outcomes

A main barrier to improving outcomes is often not a lack of effective interventions, but variation in access to and delivery of care. Further improvement also depends on earlier diagnosis, timely treatment and the adoption of new interventions through research and innovation.

National audits and reviews consistently show wide variation between systems and providers in the uptake of evidence-based care, contributing to avoidable complications, hospital admissions and premature death.

For example, National Diabetes Audit data shows that in 2024 to 2025, only approximately 43% of people with type 1 diabetes and 58% of people with type 2 diabetes received all 8 NICE-recommended care processes, with differences of more than 20 percentage points between the best and worst performing systems. Completion rates were consistently lower in more deprived areas.

Variation reflects a range of clinical, behavioural and organisational factors, including disease characteristics and patient circumstances. It also represents a significant opportunity to improve outcomes and reduce inequalities.

Improvement opportunities and actions

Cardiovascular disease (CVD)

Up to 70% of CVD is preventable, driven by modifiable risk factors including:

• physiological risk factors, such as high blood pressure and cholesterol
• behavioural risk factors, such as smoking, poor diet and physical inactivity
• environmental risk factors, such as cold homes and air pollution

The government aims to reduce premature mortality from heart disease and stroke by 25% over the next 10 years. The Cardiovascular Disease Modern Service Framework will accelerate progress towards delivering this ambition by:

• identifying the best-evidence interventions, focusing on those that can deliver the greatest value and equity
• setting standards on how interventions should be used
• providing a clear strategy to support and oversee uptake by clinicians and providers, above and beyond the scope of the original national service frameworks
• setting out ‘challenge areas’, where it is anticipated significant progress is possible, but where innovative ideas and products are needed
• providing a plan to partner with the life science eco-system, to support the creation, adoption and spread of new ideas

The DHSC is funding research to address CVD, including through the NIHR Cardiovascular Disease Inequalities Challenge Consortium, which, in partnership with the British Heart Foundation, is focused on tackling inequalities among higher-risk groups. It also seeks to address inequalities in CVD outcomes between women and men.  

Cancer

The National Cancer Plan for England set an ambition that 75% of people diagnosed with cancer will survive for at least 5 years by 2035. Achieving this will require earlier diagnosis through expanded screening, improved access to treatment and continued advances in therapeutics and diagnostics.

Reducing deprivation‑linked inequalities in incidence, stage at diagnosis and survival is vital to this ambition.

Respiratory disease

Respiratory diseases are a significant contributor to morbidity and mortality. It is the third biggest cause of death in England and a major contributor to premature mortality, and is associated with high levels of emergency hospital admissions.

Respiratory diseases continue to be a significant cause of health inequalities, with higher prevalence and poorer outcomes linked to deprivation and less well-served communities. Smoking is the leading preventable risk factor, responsible for around 40% of respiratory deaths, worsening conditions such as asthma, and increasing the risk of serious infections, including pneumonia and tuberculosis.

National policy includes commitments to reduce smoking prevalence. This includes providing smoking cessation support as part of routine care, particularly in hospital settings, and post-discharge support through community pharmacies and Stop Smoking Services.

Alongside this, there are significant opportunities to improve respiratory outcomes through innovation. These include delivering asthma and COPD treatment in neighbourhood health settings, as well as providing access to new biologic medicines that can improve outcomes for people whose current treatment is not working well enough.

The new Respiratory Transformation Partnership has been established to bring together expertise from across localities, government and the pharmaceutical industry to expand provision and understand the real-world impact of these innovations.

Vaccine-preventable disease

The national immunisation programme has significantly reduced the incidence and impact of vaccine‑preventable diseases across the life course. However, inequalities in access to vaccination and in immunisation outcomes persist between and within population groups, limiting the programme’s benefits for those who need them most.

National vaccination programmes are a core population health intervention, with a central role in preventing infectious disease and reducing the burden of vaccine‑preventable illness. Quality standards for the national vaccination programme emphasise:

• proactively identifying and inviting eligible populations
• supporting higher uptake and more consistent coverage
• developing a well-trained workforce to foster trust, support informed consent and provide vaccines safely
• co-ordinating the programme at a population level, to support providers and ensure programme design and delivery is effective and equitable

Improving delivery against these standards is important for improving population outcomes and reducing persistent inequalities in immunisation uptake.

Severe infection and sepsis

Infections and sepsis are a leading cause of hospital admission and death. Infection-related admissions are nearly twice as high in the most deprived areas, and deaths associated with infection are similar to those for ischaemic heart disease.

Antimicrobial resistance (AMR) is increasing, with 22% of common bloodstream infections now resistant to key antibiotics – an increase of 13% between 2019 and 2024.

The AMR National Action Plan sets out the NHS’s commitments to address AMR and the sustained action needed to achieve them.

The forthcoming Sepsis Modern Service Framework is designed to improve the prevention and treatment of severe infection and sepsis across the pathway. It will be informed by improvements in the data we have on infection and sepsis, including work to commission a new national infection and sepsis audit.

Severe mental illness

People living with severe mental illness (SMI) have a higher risk of premature mortality than the general population, much of it driven by preventable physical illness (including cardiometabolic disease, respiratory disease and liver disease). National profiles show persistently higher under‑75 mortality rates.

Improving outcomes depends on a more consistent, equitable delivery of physical health checks, vaccinations, cancer screening and supported follow‑up for cardiovascular risk.

National policy and guidance sets out expectations in these areas, but delivery remains inconsistent across systems and pathways.

The forthcoming Severe Mental Illness Modern Service Framework will consider the role of mental health services in supporting people’s physical health as well, with the aim of addressing excess premature mortality among this group.

Common mental health conditions

National survey data show that around 1 in 5 adults in England experience a common mental health condition, with higher prevalence in more deprived areas (26.2% in the most deprived fifth compared with 16.0% in the least deprived).

These conditions are typically long‑term or recurrent and are associated with significant functional impairment.

To improve outcomes and prevent long-term ill health, it is important to:

• improve timely access to evidence‑based psychological therapies
• support sustained recovery
• improve integration with primary care and community services

The forthcoming Mental Health Strategy will support a fundamental shift towards prevention, treating people earlier and faster, and supporting those with mental health conditions to live a full life and stay active in education, work, family life and their communities.

The government has also launched a wider package of interventions to improve mental health services, such as the recruitment of additional mental health workers and the expansion of NHS Talking Therapies.

People with a learning disability

People with a learning disability often experience poorer physical and mental health than the general population and face barriers to accessing care. On average, they die around 20 years earlier than the general population, often from preventable or treatable causes. Inequalities are even greater for people from minority ethnic communities.

To address these issues, annual GP health checks and health action plans have been introduced as an established part of care for people on a GP learning disability register. These checks help support early identification of health issues and co-morbidities.

NHS England continues to support ICBs to tackle health inequalities and support health improvement for people with a learning disability and autism, including through the delivery of LeDeR reviews and application of learning to improve the quality of services.

Autism

Autistic people experience poorer health outcomes than the general population, including higher rates of mental health conditions and co-occurring conditions, such as epilepsy and ADHD.

Referrals for autism diagnostic assessment have significantly increased. Although access has improved, waiting times for assessment have increased. Timely assessment and diagnosis are important in helping people access the support they need to stay well.

In 2023, NHS England published the National framework and operational guidance for autism assessment services focused on improving outcomes and delivering more personalised, effective care across all-age autism assessment.

In December 2025, the government launched an independent review into mental health, ADHD and autism to examine what is driving the rising demand for services, including inequalities in accessing support. The review’s interim report was published in March 2026.

Frailty and dementia

Variation in how frailty and dementia are identified, diagnosed and managed leads to disjointed, costly and poor-quality care. This results in worse health outcomes and more years lived in poor health.

Improving the timeliness and co-ordination of dementia care would help slow functional decline for tens of thousands of people each year. This means ensuring that at least 92% of people with dementia receive a diagnosis within 18 weeks of referral and that everyone has an annually reviewed care plan and a named care co-ordinator.

To help achieve this, the Modern Service Framework for Frailty and Dementia is due to be published at the end of this year, informed by phase 1 of the independent commission into social care.

Musculoskeletal conditions

Musculoskeletal conditions are the leading cause of pain and disability in England. Musculoskeletal problems were the most commonly reported long-term health condition in the 2026 GP Patient Survey (22.5%). Patient‑reported outcome measures (PROMs) data show wide variation in pain, function and recovery after musculoskeletal (MSK) interventions, with poorer outcomes in more deprived communities. Improving early access to effective MSK pathways, reducing unwarranted variation in treatment and rehabilitation, and strengthening recovery and self-management support would help reduce the duration and severity of MSK-related ill health.

Nationally, the Further Faster programme for community MSK services is working with selected integrated care systems (ICSs) to:

• improve access to assessment and treatment
• standardise triage and referral processes
• reduce unnecessary hospital attendances and low‑value interventions
• strengthen rehabilitation and self‑management support

Children and young people

Significant challenges remain in child health, with children often experiencing poor quality care and outcomes, including:

• approximately 1 in 5 children and young people aged 8 to 25 years who have a probable mental illness
• around 1.7 million children living with long-term conditions, including asthma, epilepsy and diabetes
• in 2024 to 2025, 10.5% of children in reception and 22.2% of year 6 children were living with obesity; obesity prevalence was more than double in the most deprived areas compared to the least deprived areas for both reception (14.0% compared to 6.9%) and year 6 (29.3% compared to 13.5%)
• almost 1 in 5 children are not fully vaccinated when starting primary school and are vulnerable to catching serious illnesses

The forthcoming Modern Service Framework for Children will support ICBs and galvanise cross-system partners, including public health and local government. It will provide a delivery mechanism for raising the healthiest generation ever by supporting systems in prioritising evidence-based improvements for children.

Experience: context and evidence

Experience of care is shaped by everything that happens when people interact with health services. It includes:

• how easy it is to get care
• what it feels like to receive care – for example, whether people feel listened to, treated with dignity and respect, and are involved in decisions
• how well services communicate and co-ordinate care

It is based on the experiences of people using services, unpaid carers, families, healthcare staff, learners, volunteers and communities.

Experience is broader than satisfaction. While satisfaction reflects whether care met expectations, experience captures the full range of interactions across a care pathway and is a critical component of quality and equity.

What the evidence tells us

Evidence shows that people’s experience of NHS care remains mixed, with some clear areas of concern.

For example, NHS written complaints have continued to rise, reaching over 250,000 in 2024/25, up by more than 6% on the previous year.

At the same time, the British Social Attitudes Survey (2026) found that only 26% of people were satisfied with how the NHS runs overall, compared with 50% who were satisfied with the quality of care. While many people report positive experiences once they access services, dissatisfaction with access and waiting times continues to drive overall negative perceptions.

Administrative and communication problems are widespread

Research shows that administrative and communication problems are widespread and significantly shape how people experience care and whether they seek help in future. These issues include needing to chase test results, lack of information while waiting and not knowing who to contact. 64% of NHS users report at least 1 such issue in the past year.

According to The King’s Fund, these experiences undermine trust and care-seeking, with 42% less likely to seek care and 47% reporting reduced confidence in care quality.

People are not consistently involved in decisions about their care

Evidence-based care should involve shared decision-making and personalised approaches, in line with NICE guidelines. Yet, in practice, many people report that they have not been meaningfully involved in decisions about their care:

• 8.4% of respondents to the 2026 GP Patient Survey said they were not involved at all in decisions about their care
• the Care Quality Commission’s Community Mental Health Survey (2025) found that:
  • 23% of respondents were either not involved or were not aware of a plan for their care
  • 22% did not feel supported to make decisions about their care and treatment
  • 41% did not have care review meetings
• the National Audit of Care at the End of Life (2024) found that:
  • 56% of patients did not participate in personalised care and support planning conversations
  • 59% did not have their spiritual, religious or cultural needs assessed
  • only 38% of staff had had end of life care training in the last 3 years

Improvement opportunities and actions

Improving the fundamentals of access, communication, coordination, and involvement presents a major opportunity to improve people’s experiences of care.

While many people report positive experiences, differences remain between services and population groups, particularly for people with long-term conditions, disabled people, unpaid carers and some ethnic minority groups.

These differences reflect persistent issues with access, communication, continuity and responsiveness of care. For many disabled people, these barriers are compounded by delays, variation and fragmentation in the provision of disability equipment.

Addressing these issues will be essential to delivering more responsive, personalised and equitable care.

Administration and communication

Missed appointments reflect wider administrative and communications issues. In 2023/24, around 8 million of the 124.5 million NHS outpatient appointments (6.4%) were not attended – an average of around 670,000 each month.

This represents a significant loss of clinical capacity, with an estimated annual cost of £1.2 billion.

Evidence suggests that targeted interventions, such as effective communication strategies and early removal of barriers, can reduce non-attendance rates.

For example, sending reminders through NHS Notify for the 670,000 appointments missed each month would cost approximately £150,000, compared with £120 for each missed appointment. A reduction of just 0.2% in non-attendance rates would offset this investment.

Personalised care and support planning

Partnership with people and communities, including social care and voluntary, community and social enterprise (VCSE) organisations, is associated with better experience, outcomes and value. This includes:

• personalised care and support planning
• shared decision-making
• support for self-management

These approaches are particularly important for people living with multiple long-term conditions.

Around 30% of the population lives with 1 or more long-term conditions, yet national survey data shows that fewer than half report having an agreed care plan.

Where care planning is in place, people report substantially better experiences and outcomes. The 2026 GP Patient Survey found that over 43% people with long-term conditions had a conversation with a healthcare professional about what matters to them in managing their condition. Of those, around 46% had agreed a plan, and most (93.9%) found it helpful.

More personalised care can also reduce harm and waste. Optimising medication use through better advice, review and support improves adherence to treatment.

For example, an analysis by Asthma and Lung UK (2023) estimated that prompting routine review of inhaler use could save over £7 million per year and reduce hospital bed days for asthma by around 70%, with the greatest impact during winter months, when pressure on services is highest.

Working in partnership with unpaid carers

Unpaid carers play a critical role in supporting people to manage their health, avoid deterioration and remain at home.

Evidence suggests that many carers, particularly young carers, remain under‑identified. In 2024/25, 64,500 pupils were identified as young carers, yet 69% of schools recorded none, despite estimates that there are around 2 carers in every class.

Young carers carry immense responsibility, but their own needs may remain hidden:

• 27% of young carers say that they struggle to balance caring with school or college work
• on average, they miss 23 days of school every year, potentially impacting attainment and longer-term outcomes

Early identification and support for unpaid carers has clear benefits across the following areas:

• reduced pressure on health and social care services by preventing hospital admissions and delay transitions into residential care
• economic impact – the cost of unpaid carers leaving or reducing paid employment is estimated at £5.4 to £16.9 billion per year in lost productivity, tax revenue and increased welfare spending; evidence suggests that improved support could deliver:
  • £4.6 to £10.1 billion in additional household income
  • £0.3 to £4 billion in additional tax receipts
  • £2.5 to £7.2 billion to GDP through increased economic participation and spending
• return on investment – evaluations consistently show that unpaid carer support programmes deliver positive returns, primarily by reducing crisis interventions and improving unpaid carers’ health, wellbeing and ability to remain in work

Despite this, many unpaid carers report limited recognition, information and involvement from health services.

Improving how unpaid carers are identified, supported and involved in care therefore represents a significant and largely unrealised opportunity to improve experience for unpaid carers and those they care for, while reducing pressure on health and care services.

Publication reference: PRN01848_i