Redefining roles across the NHS

The Medium-Term Planning Framework (MTPF) for 2026/27–2028/29 marks a deliberate move away from short-term cycles towards multi-year, integrated planning across finance, quality, activity, and workforce. Coupled with the Neighbourhood Health Service direction, it empowers local systems to assume wider responsibilities for specialised commissioning, service redesign, and performance delivery while retaining national consistency through trajectories and oversight. This paper sets out what boards and system leaders must do now to translate the framework into credible, paced change.

A birds-eye view of a group of NHS professionals in uniforms (doctors, nurses) gathered in a circle,focused on a document one of them is holding.

From central oversight to local ambition: redefining roles across the NHS

Annual planning has constrained strategic focus and forced local services into reactive modes. The MTPF introduces a three-to-five-year horizon with clear expectations for plan triangulation, productivity and reduction of unnecessary bureaucracy, creating space to reset foundations (workforce, estates, digital) and deliver immediate improvements.

Shifting roles and responsibilities 

Delegation of specialised services to ICBs expands local accountability. System leaders will need operating models that balance local autonomy with national frameworks: transparent decision rights, shared risk, and alignment to trajectories in elective care, urgent and emergency care, primary and community services.

Multi-year planning is not a spreadsheet exercise; it is how we rebuild confidence, capacity and care pathways.

Finance and planning discipline 

Multi-year discipline demands credible phasing of investments and benefits. Plans should connect medium-term affordability to service change, demonstrating how savings from administrative simplification are reinvested in frontline capacity and quality.

Risks and mitigations 

Fragmentation risk as responsibilities devolve: mitigate through common assurance standards, league-table style transparency and peer review. Capacity gaps in planning and governance: mitigate via shared-services across clustered ICBs, analytics uplift, and phased delegation with gateways.

Delegation without discipline invites variation; discipline without delegation stifles innovation. The art is the balance.

Practical actions for boards?

  • Establish a Medium-Term Plan Office to coordinate submissions and maintain a single source of truth. 
  • Publish a system accountability framework mapping national trajectory to board KPIs.  
  • Run quarterly performance clinics to test triangulation and corrective actions.  
  • Stand up cross-system design councils for specialised services transfer, with clinical and VCSE participation.