Update from Sir James Mackey, CEO, NHS England

Introduction

At our latest national meeting of CEOs and primary care leaders on 16 September, the main focus of discussion was the priorities for the remainder of the year, and how we are setting ourselves up to start delivering on the 10 Year Health Plan for England in earnest from April.

On the remainder of this year, I’ve since written to colleagues confirming the task ahead of us. And on planning for the future, we have now published the Medium Term Planning Framework, setting out the national asks of systems for the next 3 years, but more importantly how we will rewire the NHS – through our Operating Model and Financial Framework – to give you as leaders the freedom, incentives and support to innovative and achieve the strategic shifts we all want to make.

We can all be genuinely encouraged by the progress we’ve made over the last 6 months – particularly in stabilising the financial position and improving performance in key areas. The task over the next 6 is maintaining grip on finances, accelerating recovery in elective and urgent care, and preparing for winter pressures, and we’re making our way around systems now performing mid-year reviews, kicking the tyres again on plans to make sure they are holding up, and to support corrective actions where necessary.

Again, this needs visible leadership from all senior colleagues, particularly over the winter peak – getting out into services, supporting colleagues and solving problems so we can all keep pushing forward together and end this year in as good a position as possible. Achieving that is the platform on which we can then build for the future.

While the Framework is now yours to begin planning, it’s not entirely over to you. I’m determined we will play our part and deliver on the remaining guidance and reforms which will create the conditions for your success.  As I and David Probert set out in previous editions, groups of senior leaders have been working at pace over the summer to codesign many of these products, and the bulk of our time on the 16 September was spent discussing and getting broader feedback on that work.

My Exec colleagues expand on some of that work below, and over October we brought finance, medical and nursing directors and chief operating officers together to have similar conversations ahead of finalising some of those key enabling deliverables.

Finally, I also wanted to mention the new, digital first NHS Online, announced by the Prime Minister earlier this month. This will be a huge step forward for the NHS and will deliver millions more appointments by the end of the decade, offering a real alternative for patients and more control over their own care, and playing a role in bringing waiting times down.

It’s something we’ve been working on for several months behind the scenes, and it’s good to now be able to engage NHS leaders, staff, patient groups and industry over the coming months on how we make it work, and ensure that nobody gets left behind.

Thanks again, and keep going.

Sadly, I do also want to include in this update a tribute to all our colleagues involved in the response to the appalling attack at the Heaton Park synagogue on Yom Kippur.

As they always do, NHS teams reacted with bravery, calmness and professionalism, and I want to share my thanks to all those who provided and coordinated care.

The nation’s thoughts are with the families of those tragically killed and injured, but I know the impact will be felt much wider – including by many colleagues in the NHS. It’s also the case that many of our colleagues have been directly or indirectly affected in recent weeks by other instances of hate, prejudice and intimidation – and this also came up at the NHS leadership meeting we held on 16 September.

The NHS has always attracted people from a broad range of communities, cultures and countries, but we haven’t always looked after each other as well as we should. It’s part of the leadership challenge to model behaviours which ensure all our staff feel welcome and safe at work, and all our patients feel like they will receive fair, equitable and respectful treatment.

So let’s make doubly sure now that we’re looking after each other, and those we serve, and we wrote recently to outline some specific actions on racism and antisemitism in particular.

Reinvigorating quality in the NHS

Professor Meghana Pandit, National Medical Director and SRO, 10YHP for Quality

As a national health service, quality must be our organising principle. The ambition in the 10 Year Health Plan – to make the NHS the most transparent, high-performing healthcare system in the world – is an important commitment to every patient, every clinician, and every community we serve.

The Quality workstream has been meeting over the summer to develop 5 key priorities to support this ambition – now carried through into the Medium Term Planning Framework:

1. Revitalising the National Quality Board (NQB) – With refreshed membership and terms of reference, the NQB will act as the single authority on quality, setting the tone for governance and strategic alignment across the system.
2. Developing an NQB National Quality Strategy – Due by March 2026, this strategy will define what high-quality care looks like in the context of the 3 shifts, and set out improvement priorities, roles and responsibilities, and the levers for change.
3. Modern Service Frameworks (MSFs) – Co-designed with clinicians and people with lived experience, MSFs will provide consistent, evidence-based pathways for conditions – like cardiovascular disease, severe mental illness and sepsis – where we know there is too much variation in outcomes across the country. They will set high ambitions from the outset, and continue to evolve with innovation and best practice.
4. New Care Delivery Standards – A clinically led review of standards is underway to ensure care provision remains relevant and deliverable to address patient needs. Updated standards will support improved patient experience, productivity, safety and outcomes.
5. Maternity Outcomes Signal System (MOSS) – Rolling out nationally by November 2025, MOSS will use near real-time data to identify safety risks in maternity services, helping us reduce avoidable harm and improve outcomes.

These programmes are underpinned by transparency. Patients will soon be able to search and compare providers based on quality data via the NHS App, including patient-reported experience and outcome measures. AI-enabled tools will support early warning systems, and reforms to the CQC will ensure regulation is intelligence-led and data-rich.

Quality is not a standalone concept – it is the thread that runs through every reform. Getting this work right is really important, but so too is leaders having the curiosity – and open eyes and ears – and the honesty needed to turn over all the stones and address what we find there. Only if we do that can we build a health system that is safer, fairer, and more responsive to the needs of our patients.

Next Steps on Neighbourhood Health

Dr Claire Fuller, National Medical Director and Co-SRO, Neighbourhood Health Group

As I’ve written here before, the 10 Year Health Plan – and now the Medium Term Planning Framework – sets out a bold vision for a modern NHS that is more preventative, more personalised, and more rooted in the communities we serve.

At the heart of this transformation is the Neighbourhood Health workstream: a fundamental shift in how we deliver care, moving from hospitals to homes, from episodic treatment to proactive support – not a new layer of the system, but the system reimagined.

Thanks to the work that many colleagues have already been doing over the last couple of years to show what is possible, we are in some ways further on than some of the other groups in terms of the thinking. But now we’re taking that to the next level.

Firstly, 43 places have now been selected to join the National Neighbourhood Implementation Programme, unleashing local ambition and providing valuable learning to support wider adoption. A co-produced ‘Model Neighbourhood’, National Neighbourhood Framework and a set of model system archetypes will be published, providing clarity on what good looks like and how to get there. These will support local systems to align PCNs with geographies that make sense to local people, agree neighbourhood geographies, and accelerate our journey towards more joined up and integrated care.

We are also looking to develop new incentive contracts for over-75s and remodelled outpatients, designed to reward outcomes rather than activity, for testing through 2026/27, with potential national rollout from April 2027. They represent a critical step in aligning financial flows with the left shift – supporting care closer to home, reducing avoidable admissions, and improving patient experience.

Neighbourhood Health Centres will be the visible face of this change, and we’re also well into work with our estates colleagues to produce archetypes for what they might include, and how we can deliver the infrastructure needed.

We know this is complex work. It requires new ways of contracting, new workforce models, and new relationships with local government and communities. But the potential is transformative: improved access, reduced pressure on hospitals, and better outcomes for our most vulnerable citizens.

As ICB and provider leaders, your role is pivotal. This is your opportunity to shape the future of care in your communities. Thank you for your continued support and engagement over the summer, but there is more to do. Neighbourhood Health is not a pilot; it’s the future. Let’s build it together.

Empowering local leadership

Glen Burley, Financial Reset Director and Accountability Director, and Co-SRO, Oversight and Operating Model Group

As NHS leaders, we know that delivering high-quality, sustainable care requires more than central edicts – it demands a system architecture that enables autonomy, accountability, and innovation. The Oversight and Operating Model workstream of the 10 Year Health Plan is designed to create just that.

As I’ve written in The Month before, this reform agenda is about shifting power closer to patients and communities. It’s about creating a more agile, responsive NHS – where ICBs and providers are clear on their job card and trusted to get on with it, supported by a streamlined centre and a smarter oversight regime.

Key changes are already in motion. The merger of NHS England and DHSC will reduce central headcount by half by 2027, simplifying governance and aligning strategy with delivery. In the last couple of weeks we’ve moved further on that, with appointments to key positions in the new Joint Executive Team, and by the time of the next edition teams across both organisations will have realigned themselves to those posts.

We’ve also shared with colleagues the Model Region Blueprint, and completed the process of confirming leadership arrangements for the ICBs that have chosen to cluster. As discussed with ICB CEOs last week, we’ll shortly be publishing the Strategic Commissioning Framework, and we will move closer to the new ways of working over winter.

Perhaps the most important part of this work however, is how build in the right encouragement and reward for innovation and high performance. The new Foundation Trust Framework will be central to this, and we’re hoping to put that out to consultation in the coming weeks. As set out in the 10 Year Health Plan, the ambition is for every NHS provider to become a Foundation Trust (FT) by 2035, with the first wave designated by April 2026. These new FTs will benefit from greater freedoms, including financial autonomy and strategic flexibility, in return for core expectations around performance and collaboration locally.

Similarly, we’ll shortly be sharing an Integrated Health Organisation (IHO) blueprint, setting out how we will enable ICBs to contract providers to improve health outcomes across different settings – driving the shift from hospital to community, and supporting more integrated, preventative care.

As ever, please do share your thoughts when these documents land. It’s crucial we get this right and get it implemented as quickly as possible, and the feedback of colleagues has been instrumental in every aspect of this work so far.

Powering the NHS of the Future

Dr Vin Diwakar, Clinical Transformation Director and Co-SRO, Innovation and Technology Group

Meeting the objectives on quality and neighbourhood health Meghana and Claire set out above, and the wider ambitions of the 10 Year Health Plan, will rely on our seizing all the available tools which can help us rethink not just how we do things, but what we do.

Our patients staff and communities experience the NHS through technology every day. Put simply, better technology means improved quality outcomes, safer services and excellent experiences for patients and staff, cuts out waste and improves productivity. The Innovation and Technology workstream has set itself up to deliver the foundations for further improvement – and for wider economic growth on which the NHS depends.

We’re making more progress on the NHS App all the time; over the coming weeks the first community trusts will be able to message patients, and we’ll be switching on the capability for 2-way messaging so patients can communicate with their care teams.

But there is a wider group of key technologies we’re also developing delivery plans for. That includes a procurement framework and associated technical and clinical guidance to support the rollout of ambient voice technology to reduce administrative burden, and a roadmap for implementing single sign-on and a Master Staff Index to streamline access to systems.

We’ll also develop a proof of concept for the Single Patient Record – starting with maternity – as the next milestone to enable patients access to all the information they need in one place. And we’ll continue to work with you to fully deploy the NHS Federated Data Platform, so that clinicians do, too – and everywhere is able to share in the benefits the first organisations are already seeing.

We are also transforming how we scale innovation. A new “Rules-Based Pathway” will provide clarity and speed for digital and device approvals for industry and innovators. The Innovation Passport will help systems identify and adopt proven technologies which benefit patients faster. And a national implementation model will ensure that frontline teams are supported to realise the full benefits of digital change.

But this is not just a national endeavour. Local leadership is going to be critical in maximising the benefit of the tools we’re able to provide or guide you on. We recognise the challenges – particularly around workforce capacity, funding, and change bandwidth, so we’re investing in implementation support, business change expertise, and clinical pathway redesign.

What we will need is bold, system-level leadership to embed these technologies in ways that improve outcomes, enhance productivity, and transform the patient experience. Innovation is not an add-on – it’s the engine of the NHS’s future. Let’s make it work for every patient, every clinician, and every community.

A 10 Year Workforce Plan to deliver the 10 Year Health Plan

Jo Leneghan, Interim Director General, People, and Co-SRO, Workforce Group

Over 270,000 members of the public and staff contributions shaped the 10 Year Health Plan. This enthusiasm for designing a sustainable future for the NHS resulted in a plan setting out 3 key shifts our health system needs to make:

• hospital to community,
• analogue to digital,
• sickness to prevention.

These shifts require a health and care workforce to meet future needs rather than one designed to deliver our present model.

We need a workforce that flexes and develops over the next decade as our population ages, digital technology becomes an ever greater part of our lives, and we adapt to new attitudes to work.

A workforce that is as comfortable with new digital technology and automation as it is with the compassionate care and treatment it will free up time to deliver.

We need an NHS that backs its workforce by becoming an excellent, modern, and inclusive employer which is attractive to new generations whilst upskilling, supporting and retaining our best people.

A new cadre of leaders who have grown up with technology and understand the NHS needs to change to protect the core principles of a universal health service free at the point of care according to need.

And we need a workforce where people are able, and supported, to work to their full potential, knowledge, and skills in multidisciplinary teams built around the needs of patients not professions.

To help shape this future, NHS England and the Department of Health and Social Care launched a national call for evidence to inform the development of a 10 Year Workforce Plan. It is open until 7 November, and we need you, your colleagues, and your system partners to make your views and voices known.  

Please take part in the call for evidence and help us build a workforce that is ready to deliver world-class care for decades to come.

Strengthening our approach to temporary staffing

Thank you for the significant progress made in recent years to reduce agency and bank spend across the NHS. Last year, spending on temporary staffing reduced by more than £1 billion and plans in place for this year aim at reducing this further by almost double that again.

As we look ahead, it is vital we sustain this momentum and deliver the plans set out, with a particular focus on controlling medical bank rates.

Trusts are responsible for managing the right workforce mix and there is strong evidence that doing so can significantly contribute to improving their productivity. At the same time, we must deliver on the ambition set out in the Medium Term Planning Framework to eliminate all agency usage by the end of this Parliament. Substantive and bank solutions should be prioritised, while options for insourcing should only be considered where these deliver clear efficiency and clinical benefit.

Below are the actions we now need you to take.

Medical agency and bank rates

Providers with significant medical agency and bank spend must be working collaboratively with system partners to align and control rates. This remains one of the biggest opportunities for improvement. We continue to see scope for shifting workers from agency to bank arrangements, removing unnecessary margins and ensuring better value, as outlined in our correspondence of 2 June.

Insourcing

Insourcing spend is increasing and must be managed consistently. We ask all providers to review current contractual arrangements against national guidance to ensure compliance. NHS England’s national and regional teams will be focusing on this area in the coming months. All insourcing procurement must be via the established framework, and pass-through resource costs, which sit outside controls, should not be used. Guidance is available on the NHS England website.

Band 2 and 3 agency restrictions

Following consultation and evaluation, we will be updating the NHS agency rules. From November 2025, providers will no longer be permitted to procure agency staff for Bands 2 and 3 roles. Provisions to break the glass will remain to safeguard patient and service user safety. These changes will support a more sustainable and efficient workforce model, and we expect all providers to comply with the new requirements. New guidance is available on NHS Futures.

Next steps

Your continued leadership and collaboration are essential to delivering a more efficient and sustainable workforce across the NHS. Thank you once again for your commitment and for the progress already achieved.

Planned care updates

Driving rapid transformation in cancer pathways

Professor Peter Johnson, National Clinical Director for Cancer, and Professor Tim Briggs, Chair of the GIRFT Programme

Cancer performance has improved in recent years, but too many people still face long waits. In June and July we saw a slow-down in progress and now need a renewed focus to ensure we deliver our improvement targets against the 28-day Faster Diagnosis Standard and 62-day cancer performance.

To support providers to achieve this, we are launching a new call to action on cancer performance across our existing core pathways: skin, lower GI, gynaecology, urological and breast cancers, with a particular focus on the diagnostic pathway, and the treatment end of the lung cancer pathway.

We are asking all providers to work with their Cancer Alliances to review further opportunities for performance improvement across these pathways. Providers in the bottom quartile nationally for these pathways should revisit their plans with a particular focus on:

• Better utilising CDC capacity for diagnostics on cancer or related elective pathways where this is available.
• Opportunities to go further and faster on key pathway development deliverables including:
  • teledermatology
  • FIT triage for the lower GI pathway
  • alternative pathways for low-risk patients such as breast pain and post-HRT unscheduled bleeding
  • non-medical biopsy capacity for the prostate pathway.

Support on these specific pathways is being offered by the Getting It Right First Time (GIRFT) programme. Providers and Cancer Alliances can request specific support from Professor Tim Briggs and team by emailing Caroline Ager. GIRFT clinical leads will be invited to the existing cancer Pathway Implementation Groups to offer support to any challenges brought to those forums. GIRFT teams are working with designated Cancer Alliance leads to collate best practice pathways for the key tumour groups. Content will be shared through facilitated sessions and on the GIRFT website. Information from the SWAG cancer alliance on the Urology pathway is already live.

With GIRFT’s support, we are aiming to drive rapid cancer pathway improvement with an ambition to:

• deliver and exceed the FDS target of 80% in the next 3 months, and go even further by the end of 2025-26
• reduce the gap in FDS performance between patients who have cancer ruled out and those diagnosed with cancer
• embed lasting, patient-centred improvements that reduce delays and save lives

As well as this focused reset for the remainder of 2025/26, we are also asking all providers to look ahead to the festive period. We know that patients often decide to defer non-urgent appointments until the new year instead of having treatments such as surgery before Christmas. Please ensure frontline teams are aware of the importance of booking cancer patients throughout the festive period to ensure they get the care they need as quickly as possible and to make best use of the capacity that is available.

Improving diagnostic performance

Miss Stella Vig, Deputy National Medical Director (Secondary Care) and National Clinical Director, Elective Care

Diagnostic services are essential to delivering our public commitments on elective, cancer and urgent and emergency care. Systems and Trusts will therefore want to make sure that they maintain a focus on improving diagnostic performance for the rest of the year so that they achieve the monthly system level trajectories previously agreed on 6-week waits and diagnostic activity. Where CDCs are behind plan on activity, every effort should be made to recover.

NHS England has a range of ways that we can support you including:

• help to unblock local or national planning or construction barriers to ensure that diagnostic capital investment schemes are fully completed
• clinical support to adopt and adapt best practice approaches to help you fully utilise your existing diagnostic assets, establish straight to test pathways or optimise demand
• a range of improvement collaboratives and other support offers to help improve operational performance
• support on business case preparation to enable diagnostic networks to become financially self-sustaining 

NHS Online: a strategic leap forward

David Probert, Interim Director General, Performance, and SRO for NHS Online

As system leaders, we’re all focused on the challenge of expanding capacity, reducing waiting lists and delivering safe, high-quality care for patients. Incredible work is happening up and down the country to manage high standards and volumes of care within an increasingly pressurised environment. 

We also know that long waiting times and unwieldy processes are not matching patient and public expectations. They rightly expect faster and more responsive care in line with the service they see in other parts of their lives. 

We are always looking for new ways to deliver significant improvements for patients.  The Prime Minister’s recent announcement of a new online hospital, NHS Online, is an opportunity to do exactly this. The ambition behind the concept is to transform the way patients nationwide can access specialist care.  From 2027 NHS Online will deliver up to 8.5 million appointments in its first 3 years focusing on non-complex cases, allowing existing NHS trusts to concentrate their specialist expertise on patients who need it most.

NHS Online will be developed in partnership with the system as well as patients. We know we are building here on some really great local innovations, particularly on remote patient initiated follow-up (PIFU), and we absolutely don’t want to get in the way of that work continuing. So we will engage closely with trusts and ICBs to ensure it works within existing pathways and complements local services.

We are exploring the best way of setting up the online hospital but I am clear that NHS Online needs to have national reach, consistent standards and a dedicated focus on safe, efficient and high-quality digital elective care.  Whatever model we adopt needs to enable clear governance, accountability and innovation at scale.

NHS Online will require only a small proportion of the overall NHS clinical workforce to commit some of their additional time to working in the online hospital. Clinicians will follow standardised pathways, helping reduce variation, improve safety, and cut avoidable hospital stays. That means better outcomes for patients and more predictable demand for your services.

By shifting appropriate care online, we can ease pressure on physical services and free up local capacity for complex cases and face-to-face care. This is a smarter use of NHS resources and a better use of patients’ time. This is a novel and exciting example of the NHS using its national scale to full effect – a strategic leap forward which will deliver more care, more efficiently, while reinforcing the foundations of our health service for the long term.  We’ll be building on these discussions in the weeks ahead, and we’re confident you’ll bring the same ambition to your local plans

Other updates

In case you missed it

• 10 Year Workforce Plan call for evidence – NHS partners and stakeholders are asked to contribute to a call for evidence to support the development of the 10 Year Workforce Plan. Our aim is to create a plan that empowers staff, delivers world-class care, and secures the future of the NHS. Closes 11.59pm, Friday 7 November.
• Identifying restrictive practice – This resource has been developed to raise awareness among staff of the range of restrictive practices that are used within mental health inpatient services and their impact on patients.
• Agenda and papers for NHS England’s Board meeting of 23 September
• Update on an important change in national policy regarding subsidiaries – Letter from Glen Burley, Financial Reset and Accountability Director, NHS England, updating on proposed changes to policy on establishing new subsidiary companies.
• Jess’s Rule – this is a primary care initiative to encourage GPs teams to rethink a diagnosis if a patient presents 3 times with the same symptoms or concerns, particularly if symptoms unexpectedly persist, escalate, or remain unexplained.
• Guidance and role specification: Senior lead for resident doctor experience – This guidance for NHS trusts sets out the responsibilities and expectations of the senior lead for resident doctor experience all providers are asked to implement as part of the 10 Point Plan for Resident Doctors, and provides a sample role specification.
• NHS oversight framework: NHS trust performance league tables process and results – As part of our commitment to transparency and improvement, NHS England has launched a new interactive dashboard as part of the NHS oversight framework 2025/26. The dashboard provides a view of how NHS trusts are performing in key services including urgent and emergency care, elective services, mental health and more.
• For urgent action: campaign to vaccinate all frontline healthcare staff – This letter explains that the staff flu vaccination campaign is a national priority and sets out next steps to support leaders and their teams to deliver a high impact programme this year.

Coming up

• 29 October – UKHSA report on bloodborne virus testing in emergency departments report
• 30 October – NHS England Annual Report and Accounts 24/25
• 6 November – Armed Forces national education and training programme launch
• 7 November – 10 Year Workforce Plan call for evidence closes
• TBC – Strategic Commissioning Framework published