Introduction 

The 2027/28 NHS planning guidance may involve fewer changes to the basic planning framework than we have seen in recent years. The current Medium Term Planning Framework for 2026/27 to 2028/29 already sets multi-year expectations across performance, finance and reform, so we expect the next round to develop that framework rather than replace it. 

That does not mean there is little to look out for. Since the framework was last published, NHS England and the UK government have added much more detail on strategic commissioning, neighbourhood health, payment reform, oversight and the transfer of commissioning responsibilities to ICBs, all of which should start to feature more clearly in planning for 2027/28, alongside the level of financial and operational challenge. 

Last year also moved unusually quickly, with guidance published only nine months after the previous operational planning guidance and introducing a new three-year planning cycle. The 2026/27 round was also more explicitly phased, with an initial planning framework in September 2025 and the Medium Term Planning Framework in October setting the shape and main requirements, before the financial guidance, allocations and draft payment scheme that provide many of the key numerical inputs followed from November. 

Although the guidance will be labelled 2027/28, we expect it to remain a multi-year planning exercise. Last year’s framework required three-year numerical plans alongside five-year strategic narratives. If that approach continues, trusts and ICBs are likely to refresh numerical plans through 2029/30 and their wider strategic plans through 2031/32, rather than simply setting a plan for the next financial year. That also means the next framework will need to fill in a number of 2029/30 assumptions and targets where the current framework stops at 2028/29. 

That makes this year different in a useful way. Rather than absorbing another wholesale change in planning architecture, organisations should be able to spend more time improving, refreshing, and extending the plans they already have. 

We previously set out our initial view of the new framework in The NHS Medium Term Planning Framework 2026/27 - the key takeaways. Drawing on our work with trusts, ICBs and systems on operational, workforce and financial planning, this article focuses on the developments since then that we think are most likely to shape the 2027/28 guidance, and therefore to matter most for trusts and ICBs. 

The article covers six areas: 

1. Performance recovery: How demanding the 2027/28 trajectories could be on the way to the 2028/29 standards, and what may follow in 2029/30 
2. The financial envelope: Allocations, the withdrawal of deficit support and the assumptions that could still move 
3. Payment reform: Price rebasing and other changes that could redistribute income between services and providers 
4. Strategic commissioning: The growing role of ICBs and the transfer of NHS England's direct commissioning responsibilities 
5. Neighbourhood health: The new requirement for local neighbourhood health plans from 2027/28 
6. Digital: Delivery deadlines for national products and a stronger focus on productivity benefits 

We finish by setting out what we will be looking for when the guidance arrives. 

Once the guidance itself is published, we will review it in detail and publish a further blog covering what has changed, what has stayed the same and what it means for trusts and ICBs. We will link that update from this article and share it through The PSC on LinkedIn. 

1. Performance recovery will remain central and become more demanding 

The existing framework already sets most of the headline performance direction through to 2028/29. That includes restoring 92% performance against the 18-week referral-to-treatment (RTT) standard, alongside further improvement across diagnostics, cancer, urgent and emergency care and community services. 

A new Secretary of State could, in principle, bring more significant changes to these targets. Since her arrival in July, Yvette Cooper has highlighted other priorities, such as maternity and early years. However, with the direction already set through to 2028/29, the more likely outcome is a shift in emphasis or a small number of additional targets, rather than a rewrite of the existing ones. 

We would therefore be surprised to see the national destination change significantly in 2027/28. What is more likely to develop is the amount of improvement organisations are asked to deliver during the year and the expected route towards it. 

Given the size of the gap between the 70% 2026/27 18-week RTT performance target for March 2027 and 92% performance target for March 2029, we expect this year’s RTT trajectory to be considerably more demanding - with a likely national ambition of around 80%. Last year, individual trusts were expected to improve performance by at least 7% or reach 65%, whichever is greater. If NHS England continues to use the same combination of relative improvement and a performance floor, we would expect to see trust-level expectations of roughly 15% improvement or a minimum of around 75%. 

The catch is that this trajectory may not be deliverable. Health Foundation analysis suggests that on current trends the NHS will miss the 2029 target by a wide margin, and the NHS Alliance has told ministers it is “not going to happen”. If that view takes hold, DHSC and NHS England will need to decide whether to keep the current trajectory, or reset it to something more achievable. 

The step-up will likely extend beyond RTT. The 2026/27 Medium Term Planning Framework provided a 2026/27 target and a 2028/29 destination for several of the NHS's main access standards, leaving the 2027/28 trajectory to be set. If progress is spread reasonably evenly across the period, we might expect to see: 

• 31-day cancer performance rising from 94% to around 95%, given the 96% 2028/29 target 
• 62-day cancer performance rising from 80% to around 82-83%, given the 85% 2028/29 target 
• 28-day Faster Diagnosis Standard performance remaining at 80%, given that the current framework maintains the 80% target through to 2028/29 
• The proportion of patients waiting more than six weeks for a diagnostic test falling from 14% to around 7.5%, given the 1% 2028/29 target 
• A&E four-hour performance rising from 82% to around 83-84%, on the way to an 85% national average in 2028/29, although the published 2026/27 and 2028/29 measures are not directly comparable 
• Average Category 2 ambulance response times improving from 25 minutes to around 21–22 minutes, given the 18-minute 2028/29 target 
• The proportion of community health service activity delivered within 18 weeks rising from 78% to around 79%, given the 80% 2028/29 target 

These trajectories also start from a weaker position than planned. September’s A&E four-hour performance of 74.4% was below the same month last year and well short of the 82% target for March 2027, while Category 2 ambulance responses averaged over 31 minutes against a 25-minute target. This means that DHSC and NHS England will need to decide whether provider’s 2027/28 plans should starts from where performance is expected to be by the end of 2026/27, or from where it was meant to be. 

The position for 2029/30 is less clear. We have not yet seen a published 2029/30 target for most of these measures. For RTT, diagnostics and Category 2 ambulance response times, the 2028/29 targets represent restoration of existing standards, so maintaining those standards would be a reasonable starting assumption. A&E is different: the 85% ambition for 2028/29 remains below the 95% four-hour standard, so we would expect further improvement to be required, although no 2029/30 trajectory has yet been set. 

Cancer may also move beyond simple maintenance. The National Cancer Plan says that once the existing waiting-time standards are achieved by March 2029, they will be reviewed to determine whether they should be strengthened, making 2029/30 a plausible point for a new set of ambitions. 

As for the expected route to deliver, NHS England’s April 2026 update on planning and priorities gives a useful indication of that direction. It highlighted further work on outpatient reform, high-risk cohorts, hospital bed use, urgent care and technology-enabled productivity, suggesting that the next stage of recovery will rely increasingly on pathway changes rather than additional activity alone. 

For planned care, that keeps attention on areas such as Advice and Guidance, PIFU, follow-up redesign, diagnostics and theatre productivity. In urgent care, it points towards admission avoidance, discharge, length of stay and alternatives to hospital as well as performance within emergency departments themselves. 

2. The financial envelope is clearer, although some important assumptions can still move 

In addition to clarifying operational targets, the 2027/28 Medium Term Planning Framework will also provide detail on the financial challenge facing ICBs and providers. This will be key since, in our experience, the tension between delivering performance targets and staying within the financial envelope is the most common reason organisations go through multiple rounds of plan resubmission. 

The national funding position is more settled than it has been at the start of some previous planning rounds. The 2025 Spending Review set NHS England resource funding at £204.9 billion in 2026/27, £215.4 billion in 2027/28 and £226.1 billion in 2028/29. 

There is also considerably more local certainty than usual. NHS England has already published indicative ICB allocations for 2027/28 and 2028/29, including 2.9% and 3.2% base growth respectively, the movement of individual ICBs towards their target or ‘fair share’ allocations, a 2% planning cost uplift factor and a 2% general efficiency assumption. While those figures give organisations a stronger starting point, they should not all be treated as fixed and will likely be revised based on changing data and decisions - as we saw in 2026/27 when the pay award update lead to NHS England revising their cost uplift factor. 

The withdrawal of deficit support will make the underlying financial position increasingly important. Deficit support funding, worth £2.2bn nationally in 2025/26, is being phased out over the current planning period, with trusts and ICBs expected to reach breakeven without it by 2028/29. Organisation-level plans and published local trajectories suggest the remaining support in 2027/28 could be in the order of £0.7bn–£1.0bn nationally - although some of that reduction from prior years will reflect funding being moved into recurrent fair-share allocations rather than simply withdrawn. 

For ICBs, 2027/28 could be particularly important, from a financial perspective. Repayment of historic cumulative deficits has been paused while NHS England considers writing off historic deficits for ICBs that achieve breakeven positions in 2026/27 and 2027/28. 

The longer-term financial ambition goes beyond breakeven. The 10 Year Health Plan says that most providers are expected to generate a surplus by 2029/30, so the outer year of the next plan may require many organisations to move from eliminating their underlying deficit towards a sustainable surplus position. One specific 2029/30 cost target is already known: the current framework requires trusts to work towards zero agency spend by 2029/30, with the ambition to eliminate agency staffing by August 2029. 

3. Payment reform could matter more than the headline allocation 

NHS England has been unusually explicit that this is expected to be a more substantial reform year for NHS payment schemes. The 2026/27 scheme was set for one year only because it expects bigger changes from 2027/28, including a full recalculation of prices and further implementation of the 10 Year Health Plan. 

The price recalculation could be particularly significant. HFMA reported in July that NHS England is planning to base 2027/28 prices on 2023/24 cost and activity data, replacing the 2018/19 data that still underpins most current prices. This would be the first full post-Covid rebasing and could materially change price relativities where pathways, case mix and clinical practice have changed, although 2024/25 cost data is expected to be used as a quality-assurance check on any large movements. NHS England is also considering an update to the Market Forces Factor using 2024/25 data, creating another potential source of redistribution between providers. 

NHS England is also considering whether some prices should reflect “should-be” costs from selected groups of providers rather than the average across all providers, as part of the 10-year plan’s movement to tariffs based on best clinical practice. It is also considering extending national prices to areas such as adult critical care and some mental health activity delivered in acute hospitals, alongside adding more outpatient attendance currencies. 

Urgent and emergency care is another area to watch. The 2026/27 blended payment model combined a fixed payment with a variable element set at 20% of the national price for activity above or below plan. NHS England has already said that the percentage will be reviewed for 2027/28, and it is also looking at stronger incentives for Same Day Emergency Care and a gain-share framework for virtual wards. 

There may also be further changes to outpatient payments. NHS England has said it will consider whether payment arrangements need to change to support the reduction of routine, clinically low-value follow-ups. This would build on the current approach, under which first outpatient attendances are paid through the variable element while follow-ups remain within the fixed payment, with prices also frontloaded towards first attendances in many specialties. 

For mental health, community and maternity services, the direction is likely to be towards greater transparency rather than an immediate return to activity-based payment. NHS England is running a further ‘deconstructing the block’ exercise for mental health and community, comparing existing contract values with activity multiplied by indicative prices, with the findings expected to inform 2027/28 arrangements. It is also exploring a return to more activity-based payment for maternity services, although this appears to be at an earlier stage of development. 

A full rebasing of prices, changes to the Market Forces Factor and further deconstruction of fixed payments could therefore redistribute income between services and providers even if the overall national funding envelope changes relatively little. Taken together with the move towards population-based and outcome-based payment, this may make the relationship between activity, cost and funding much more visible and give commissioners and providers less scope simply to roll forward historic financial flows. 

4. Strategic commissioning should become much more visible 

Strategic commissioning is one of the most important developments since the 2026/27 to 2028/29 Medium Term Planning Framework was published. The Strategic Commissioning Framework is clear that ICBs should play a more active role in deciding how resources are allocated, how pathways are configured and which services should be commissioned at local, system or wider scale, rather than simply rolling forward historic provider plans and funding. NHS England reinforced this direction in April, asking ICBs to set out how their commissioning approach would develop over the next three years and support priorities such as neighbourhood health. 

That is likely to bring greater challenge to historic resource allocations and a stronger focus on population need, outcomes and value. Providers may therefore need to make a clearer case for where services should sit, while also planning for the double-running and stranded-cost risks that can arise when activity and funding move between settings. 

The scope of ICB commissioning will also widen materially. Subject to parliamentary approval, most remaining NHS England direct commissioning functions are expected to transfer to ICBs from April 2027, with offices for pan-ICB commissioning being established where services need to be commissioned at a larger scale. For more detail, see NHS England’s guidance on how commissioning is changing. 

Providers that rely heavily on nationally commissioned activity should not assume that historic flows and funding arrangements simply roll forward. As commissioning responsibility moves, they will need to understand the new commissioning footprint, how contracts and payment will work, and whether strategic commissioning decisions could alter referral patterns or service configuration. 

NHS England has also said that formal ICB capability assessments are expected to form part of the 2027/28 annual assessment, including the ICB’s role as a strategic commissioner and its approach to neighbourhood health. 

5. Neighbourhood health now has a specific 2027/28 planning requirement 

Neighbourhood health has also become much more concrete since the 2026/27 to 2028/29 Medium Term Planning Framework was published. NHS England’s March 2026 guidance on neighbourhood health and new delivery models set out preparatory work for 2026/27 and confirms that ICBs and local government will be asked to develop local neighbourhood health plans from 2027/28. 

Those plans will need to set out how national objectives will be delivered locally, how neighbourhood health will support outcomes and health inequalities, the geographies involved and which organisations are responsible for delivery. The guidance also asks local areas to establish integrated neighbourhood teams around priority cohorts and develop the data and governance needed to support them. 

More specifically, current guidance points towards neighbourhood plans being expected to show how this will work in practice. Systems have already been asked to agree neighbourhood footprints, establish integrated neighbourhood teams around priority cohorts, consider pooled or devolved funding and put the necessary data-sharing arrangements in place. NHS England has also been explicit that neighbourhood health should reduce non-elective admissions and bed-days for groups such as people living with frailty, care-home residents and people who are housebound, something 2027/28 plans may need to make explicit in their assumptions. 

This should make the hospital-to-community shift harder to keep separate from the main operational plan. If neighbourhood services are expected to prevent admissions, reduce bed-days or change outpatient demand, those effects should eventually be visible in acute activity assumptions as well as in community capacity and workforce. 

The 2027/28 planning framework may also provide greater clarity on the delivery architecture for neighbourhood health. NHS England has consulted on new Single and Multi-Neighbourhood Provider contracts, while ICBs are already developing pipelines for neighbourhood health centres. We would expect the next framework to say more about how these models should be reflected in local plans, including provider responsibility, contracting and payment, and the relationship between neighbourhood service change, estates and capital investment. NHS England has briefed finance leaders that it has developed three illustrative blended-payment models covering GP-led services and integrated neighbourhood teams, alongside a population-based year-of-care payment model still in development. We would expect the 2027/28 planning and payment framework to provide more clarity on whether and how these approaches should be used. 

6. Digital should increasingly be treated as part of the operating model 

Digital remains one of the three national shifts, but many of the commitments in the current Medium Term Planning Framework now have delivery dates attached - that the 2027/28 framework will likely reaffirm. Acute, community and mental health providers are expected to implement all core national products and services in the national product adoption dashboard by the end of 2027/28, including the Electronic Prescription Service, e-Referral Service APIs, the national collaboration service and existing NHS App capabilities. 

A second group of commitments runs through to 2028/29. These include making at least 95% of appointments available through the NHS App after appropriate triage, migrating direct-to-patient communications to NHS Notify, onboarding acute, community and mental health providers to the Federated Data Platform and achieving full EPR coverage as soon as possible. ICBs are also expected to use the FDP’s population-health tools to support strategic commissioning. 

The 2027/28 framework may therefore give much more detail on the delivery trajectory behind these commitments. We would expect it to say more about what organisations should have implemented during 2027/28, rather than simply restating the 2028/29 destination, particularly given that the core national-product deadline falls at the end of the year. 

There is also likely to be a stronger focus on digital as a source of operational productivity. NHS England’s April 2026 update highlighted ambient voice technology alongside digital tools supporting theatre utilisation, discharge, RTT validation, community waiting lists, Advice and Guidance and electronic prescribing. We would expect future plans to focus increasingly on the capacity, productivity or financial benefit these technologies deliver, rather than implementation alone. 

2027/28 will also coincide with the planned launch of NHS Online, which is expected to begin treating patients from 2027. The next planning framework may therefore clarify how NHS Online should be reflected in local referral, activity and workforce assumptions, particularly for planned-care providers. 

What we will be looking for when the guidance arrives 

We do not expect the basic planning architecture to change significantly in 2027/28. What matters is how NHS England translates the developments set out above into practical requirements for trusts and ICBs. Even within a stable framework, the performance trajectories, the withdrawal of deficit support and price rebasing could have significant consequences for individual organisations' plans – potentially more than many are currently expecting. 

We will be looking closely at the 2027/28 performance trajectories, but also at what NHS England expects in 2029/30 as the numerical planning horizon rolls forward. For some measures that may simply mean maintaining standards restored by 2028/29; for others, particularly A&E and potentially cancer, the new framework may need to set a further stage of improvement. We will also be looking at what organisations are asked to do on neighbourhood health and strategic commissioning, and any changes to payment, finance and digital delivery. 

Once the guidance is published, we will review it and publish a follow-up blog setting out the changes and implications for trusts and ICBs. We will link that analysis from this article and share it through The PSC on LinkedIn, so follow us there if you would like to see it when it is released.