NHS England published its Medium-Term Planning Framework earlier last month, setting out how the system intends to operationalise the latest iteration of the Long-Term Plan. The framework places renewed emphasis on improving provider-sector performance and accelerating the shift towards an out-of-hospital care model, with a particular focus on integrated local care and the realisation of neighbourhood-level service delivery.
The Acute Sector Challenge
The pressures facing the acute sector are well-established: a structurally rising cost base driven in large part by sustained substantive workforce growth, combined with declining productivity across many clinical pathways. These dynamics, themselves symptoms of entrenched patient-flow constraints, continue to challenge the sector’s operational resilience.
Against this backdrop, the framework reiterates the imperative of restoring performance against constitutional standards. Yet a critical question remains: what levers will realistically enable the system to deliver these access commitments at scale?
NHS England sets out a series of ambitious targets, including:
- Elective care: 92% of patients treated within 18 weeks by 2028/29
- Cancer: 80% compliance with the Faster Diagnosis Standard; treatment performance of 96% (31-day) and 85% (62-day)
- Urgent care: 85% of A&E attendances seen within four hours
- Primary care: Same-day access for 90% of urgent cases
These standards reflect not only operational aspirations but also a system-wide expectation that care becomes more responsive, streamlined, and integrated.
Digitally Enabled Models of Care
The framework’s explicit pivot towards a digitally led operating model is a positive step. Digital tools and platforms – when deployed effectively – can reduce friction, minimise avoidable handoffs, and improve both patient experience and pathway efficiency.
In the elective domain, scaling straight-to-test pathways and piloting a digital PIFU (patient-initiated follow-up) model have the potential to reduce unwarranted demand at the ‘front door’ of the pathway. These approaches could also contribute significantly to reducing the elective waiting list, which remains above six million. Alongside these reforms, the continued digitisation of outpatient specialty service models presents an opportunity for a radical redesign of pathways to reduce length of stay and unlock productivity gains essential for meeting recovery targets.
Urgent and Emergency Care: The Local Shift
In urgent and emergency care, the framework advances a neighbourhood-driven ‘left shift’ -strengthening preventative, community-based interventions supported by improved population-health management. While directionally sound, the scale of change required is significant.
Integrated Care Boards (ICBs) are being asked to deliver this transformation while undergoing material reductions in headcount and assuming increased responsibility for coordinating services at place-level. This transition is taking place while acute providers continue to develop and refine same-day emergency care models, expand virtual ward capacity, and deliver multiple pathway changes.
A Balanced Appraisal
There is much to welcome in the Medium-Term Planning Framework. It offers clarity of direction, articulates tangible performance ambitions, and sets a more coherent narrative for how organisations should orient themselves around long-term population needs.
However, its limitations become more visible when considered in the context of wider system realities. Are these objectives achievable given current financial constraints, workforce reductions, and the extensive clinical redesign required? The framework outlines what the system must deliver, but provides fewer answers on how the underlying challenges will be resolved to make this transformation possible.
