John Lister comments on the government’s 2025 mandate to NHS England and NHS England’s delayed 2025/26 Priorities and Operational Planning Guidelines
With local and national media headlines again and again flagging up the long delays of patients and ambulances at hospital emergency departments, delays endangering the lives of patients waiting too long for cancer care, and protests highlighting the scandalous under-provision of mental health care for children and adolescents as well as adults, we might have expected the delayed NHS England ‘Priorities and Planning Guidance’ to local health systems in England to focus hard on these key issues.
Health Secretary Wes Streeting is apparently seeking to bypass and sideline NHS England and effectively begin dividing control between the Department of Health and Social Care and local health systems. So, we might expect him to personally take responsibility for ensuring rapid progress in repairing the NHS, which he has insisted was ‘broken’ by the Tories—especially after Labour’s Manifesto promised to “Build an NHS Fit For The Future.”
Moreover, as the Health Service Journal has reminded us, before the July election,, Mr Streeting insisted that that a Labour government would meet all the targets in the NHS constitution within its first term.
But far from showing how the government takes all these issues seriously, and is putting them centre stage, it seems that the more the gaps and problems are highlighted, the further Labour is distancing itself from its promises to address them.
As the new year began, Keir Starmer began the retreat by personally launching the Elective Reform Plan. As the Lowdown has warned, this plan focuses more on investing in the private sector than the NHS.
But even if that aspect of the policy is set aside, a detailed Nuffield Trust critique has shown that it is, at best, “a partial plan,” with little if any detail on funding and staffing, no concrete commitment to tackling inequalities in access to health care, and no discussion of the implications for general practice. Like the Lowdown report, the Nuffield Trust analysis also highlights the fragmentation of the NHS workforce that inevitably follows from setting up separate diagnostic centres and surgical hubs.
The Royal College of Radiologists has also underlined the workforce issues that obstruct the government’s aspiration to run diagnostic centres 12 hours per day, seven days a week, which the RCR warns is unrealistic without immediate action to expand the number of NHS radiologists:
“The workforce is already stretched beyond capacity, struggling to report the growing number of scans being taken.”
The RCR also warns of the potential hidden implications of greater use of the private sector:
“In the short term, the only way to move closer to achieving these ambitions will be to outsource more scans to private providers, which will lead to NHS radiologists increasingly reporting for outsourcing companies.
“While this approach might temporarily ease demand, it comes at a high financial cost to the NHS, takes up NHS staff resource, and introduces inefficiencies, as private providers lack access to patients’ full medical histories, often requiring scans to be re-reported. This also represents a missed opportunity to use these scans for training, which is essential for developing a sustainable workforce.”
Hard on the heels of the Elective Reform Plan came Wes Streeting’s announcement that half of the New Hospitals Programme that Labour had promised to complete was to be postponed by at least 5-10 more years, with completion of some major schemes pushed back to the 2040s.
As Leeds Teaching Hospitals Trust has pointed out, the repeated postponements of the six schemes initially seen as priorities are constantly pushing up the eventual cost and making these projects increasingly out of reach. The added cost of postponing the Leeds building could be another £800m, while the latest plan would see it open 20 years after it was first promised funding.
In his Mandate to NHS England for 2025, published on January 30, Streeting confirmed fears that Labour’s ambition to deliver change in the NHS is far more limited than voters were told.
Gone is any promise to restore performance to previous targets on emergency care, cancer care or mental health. The Mandate does restate the commitment to deliver the NHS Constitutional maximum 18-week wait for elective care (albeit by 2029, the end of the 5-year span of the current government) – but sets no such specific targets for the other services that are the most visibly under pressure.
There are just three passing mentions of mental health in the whole 2,500 word Mandate, along with a few vague references to cancer – but both are only mentioned after discussion of the importance of the NHS App.
On cancer, NHS England is mandated in vague terms to:
- continue to support the NHS to maximise performance against the cancer waiting time standards and improve cancer outcomes
But as Dr Rachel Clarke pointed out on X/Twitter “Every 4 weeks of delay in cancer treatment increases the risk of death by up to 10%. For @wesstreeting & @NHSEngland to have scrapped the target to diagnose 75% of cancers at stage 1 or 2 is simply scandalous.”
A new Guardian report has highlighted the large-scale delays that put cancer patients’ lives at risk, with calculations showing 500,000 people had waited more than two months before commencing their treatment in the decade to November 2024. While all of this is clearly down to the policies of the previous Tory government, many voters would expect the first Mandate from a government pledging “change” to make a clear commitment to restore performance to previous targets.
On mental health the Mandate is even more vague and evasive:
- support the NHS to maximise performance on the waits patients experience for mental health services
It is likely many of the trusts currently struggling to deliver timely care are in fact already “maximising their performance,” given their problems with funding, staffing and lack of capital investment. Urgent mental health care is also mentioned, again only in general terms, and again with no performance targets or timescales set: NHS England is told to:
- improve patient flow through mental health crisis and acute pathways by providing new infrastructure for mental health crisis support …
Emergency care – which is probably the hottest topic for public and professional alarm at the state of the NHS – is not mentioned until half way through the Mandate, and the skimpy section also lacks any specific targets for performance, promising only to:
- support the NHS to reduce long wait times in urgent and emergency care settings …
There is a little more detail in the NHS England’s latest Priorities and Planning Guidance, which contains only the most timid promises on emergency services:
- improve A&E waiting times and ambulance response times compared to 2024/25, with a minimum of 78% of patients seen within four hours in March 2026
- and a higher proportion of patients admitted, discharged and transferred from ED within 12 hours across 2025/26 compared to 2024/25.
- Category 2 ambulance response times should average no more than 30 minutes across 2025/26
Royal College of Emergency Medicine President Dr Adrian Boyle expressed doctors’ disappointment at yet another missed opportunity to bring about real positive change:
“Today was a chance for the DHSC and NHSE to really give some guidance about how the national shame of corridor care and long A&E stays before admission will be tackled.
“We are glad to see acknowledgment of the fact that 12-hour waits are increasingly common as we know this is where the risk to patient safety lies – with almost 14,000 deaths associated with these stays in 2023.
“But apart from stating the ambition that ‘a higher proportion of patients admitted, discharged and transferred from ED within 12 hours’, there is little meaningful indication of how this is to be achieved. The focus remains on an unambitious four-hour target restricted to one month of the year. …
“Fundamentally corridor care and overcrowding are caused by lack of capacity in, and flow through, our hospitals and we are disappointed to see no meaningful commitments to tackle them. All the admission avoidance in the world won’t help an elderly patient waiting on a trolley in a corridor for hours.”
The lack of specific targets in the sections on mental health in NHS England’s Guidance has been strongly criticised by the Royal College of Psychiatrists:
“We’re also worried that targets which require services to provide essential care to those with severe mental illness, such as annual physical health checks, have been cut from the planning guidance. While the removal of excessive numbers of targets is necessary, they can help drive improvements in patient safety and quality of care, therefore it is crucial that the right targets are kept.
“The exclusion of targets to diagnose dementia, the leading cause of death in England and Wales, as well as the removal of mandates to roll out women’s health hubs is particularly concerning. It is crucial that some of these ambitions are retained and reinforced elsewhere, such as in the upcoming NHS 10-Year Health Plan.”
Funding Squeeze and productivity targets
However the omissions and evasions are not the only problems in the new Priorities and Guidance. The introduction from NHS England CEO Amanda Pritchard notes that, despite the extra funding in last October’s budget, the coming financial year is going to be another tight one:
“To balance operational priorities with the funding available, while continuing to lay foundations for future reforms, the NHS will need to reduce or stop spending on some services and functions and achieve unprecedented productivity growth in others. … We will back local leaders to take tough decisions, where they are clearly rooted in the needs of their populations and best use of available staff, and where all reasonable steps have been taken to maximise resources available for clinical services.”
The main document makes clear that despite the change of government, funding is yet again going to be a major problem: “2025/26 will be a challenging year and we must all live within our means.”
After the record £8 billion savings targets imposed on England’s 42 Integrated Care Systems in 2024/25, (with much of that burden falling on to trusts) NHS providers will once more face hefty savings targets:
“To deliver the goals set out above and live within budget, providers will need to reduce their cost base by at least 1% and achieve 4% overall improvement in productivity before taking account of any new local pressures or dealing with non-recurrent savings from 2024/25.”
Even the normally docile NHS Confederation, responding to the guidance has warned of the “eye-watering” target of 4 per cent efficiency savings and more tough times ahead:
“The finances remain very difficult and will be incredibly stretching. Despite a 4 per cent spending uplift at the budget, this will feel more like 2 per cent real-terms increase for most systems once particular cost pressures are accounted for. … Systems will have to make tough and unpopular decisions over service provision, closing some relatively lower value services to balance the books.”
Of course, NHS England guidance is just as reticent about what services are likely to be deemed “lower value” and axed as it is about targets for improvement. Previous Lowdown reports have highlighted the lack of detailed information on how ICBs and trusts have been seeking to make savings or what the impact of job cuts may be because these are being discussed (if at all) behind closed doors in secret sessions.
NHSE Guidance seeks to soften the blow of looming cuts after 14 years of austerity with promises of greater local control in a “more devolved system,” with more cash handouts and freedoms once again to be handed out to the systems and trusts that are already doing the best. Trusts are promised the chance to earn greater freedom and flexibility, with the most successful providers given a role in “leading the planning and transformation of local services”.
By contrast, there is nothing on offer for those who fail to balance the books other than more top-down bullying and intervention and hefty bills for (often questionable) advice from more management consultants.
However, there is one striking difference between the Elective Reform Plan and the subsequent Mandate and Priorities and Guidance: the repeated strong emphasis on use of private (“independent”) sector providers (along with the signing of a new “partnership agreement” between the NHS and the independent sector) is dramatically scaled back in the later documents, with just one fleeting mention in each.
Lowdown surveys of ICB Board Papers have previously reported that several ICBs have shown a marked reluctance to expand contracts with private sector providers, not least because of the costs and the loss of resources from the NHS. A few ICBs have even been seeking ways of repatriating work from private sector providers back to the NHS.
With so many priorities to address in 2025/26, with so little in the way of extra resources, it remains to be seen how many ICBs and trusts will seek ways to contract out more work to private hospitals and clinics: and how many may see the lack of emphasis on this as an excuse not make this a priority in the months ahead.
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NOTE TO READERS: As we have previously reported, the surveys of ICB Board papers have not revealed much tangible information on how substantial cash savings are being driven through and what services may be at risk. Local health unions and campaigners may see evidence of cutbacks in progress, or local news outlets may carry stories of cutbacks or job losses before they appear in Board papers.
We urge anyone with up-to-date evidence of how this works locally to send it to us so we can share it.
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