NHS England has released its national priorities for 2025/26 alongside its planning guidance. A reduced number of targets but still with the ambition of reducing waiting times for planned care, waits in A&E/ambulance handovers, improving timely access for diagnostics, and, of course, ensuring finances are balanced.

But are we setting targets that are challenging enough? What happens if targets are missed and, given the narrative coming from ‘on high,’ some targets seem to be a higher priority than others? We also have to be honest and acknowledge that many staff, in both senior and junior roles, clinical and managerial, within the NHS, have not operated in a ‘performance target driven’ environment. Questions also remain about the performance management of organisations against these targets and the implications of not reaching them. The Health Minister has made firm commitments to ‘root out’ underperformers. This enforcement is one thing, but who is accountable when it goes wrong?

As an ex-COO and Trust Board member, it was always understood that all the targets needed to be achieved and the finances balanced, whilst maintaining quality. It was, in truth, what your success and that of your executive colleagues was judged on. Targets require a shift in thinking, a shift in priorities, and, most importantly, the knowledge and buy-in from staff that hitting the targets will make a difference for patients and, indeed, staff themselves. Also, targets require close monitoring of other measurable patient outcomes to ensure quality and clinical outcomes aren’t adversely affected. Targets without improved patient outcomes defeat the objective. It is a collaboration of managerial, clinical, and change management skills that brings about this form of change.

My worry on whether the targets are challenging enough stems from the level of change a lower target will drive. Could the level of improvement needed in pure percentage points be gained by counting more people in the denominator or simply validating lists? I would hazard a guess that it could, but what good is that for patients? Yes, we need the correct numbers for planning purposes, but without looking at the metrics below the headlines, it will be hard to see what true progress is being made.

On the RTT target, the majority of the ‘waiting list’ sits in the non-admitted pathways, but there needs to be clarity over who still needs to be on the outpatient lists. Having this will help Trusts maximise outpatient capacity and avoid inefficiencies. If the majority of this can be done in one-stop clinics, then it should be implemented sooner rather than later.

Likewise in planned care, we need to ensure there is as much capacity as possible via ring-fenced/elective care centres so emergency pressure does not interfere with planned activity. It goes without saying that theatre productivity/day case activity needs to be optimal, and that includes capacity planning. As outpatient activity increases, a percentage of patients will move to procedures and therefore become part of an inpatient waiting list, potentially exacerbating the problem here.

Avoiding unnecessary face-to-face follow-ups will also help to circumvent over-treating patients and reduce the outpatient list. Implementing patient-initiated follow-ups (PIFU) will also help to release time and resources to dedicate to more complex patients and those waiting for their initial appointments, as well as allow the clinician and patient to jointly develop the patient’s clinical plan. Alternatively, there should be a clear post-consultation plan that can be followed in primary care.

Within urgent care, ignore the 4-hour performance at your peril. I believe the 78% target isn’t challenging enough, even though many systems are a long way from the 78% standard set, and when type 3 activity is stripped out, the gulf is even wider. Type 1 activity provides a far better standard and correlates more with mortality figures and ambulance waits to name two key outcomes.

Even though the government is highlighting long waiting lists, not having a robust system to handle urgent care patients will lead to huge hours lost in handling pressures, and, no matter what the directive is, emergency demand will trump other demand and for good reason. The 4-hour standard was initiated on clinical grounds, and we can’t ignore that. Hospitals simply become less productive when emergency pressures exist continuously, and improving productivity is being named as a key measure of success.

Emergency demand needs to be supported by work with primary, community, and local authority care colleagues, and the time lag for the impact of this needs to be recognised. Systems need to understand the demand and where patients can be seen in a timely manner. In the immediacy, Acute Trusts need to stream patients to the appropriate area and maximise same-day emergency care (SDEC) by resourcing this appropriately and ensuring the operating models are clear and able to meet demand.

It will be interesting to see how the roles of the Integrated Care Boards and NHS England in holding people to account for delivering the priorities develop. It has been unclear in the recent past who held what responsibility. Targets without a clear accountability framework will just lead to confusion and failure. Getting the right balance between monitoring and support is also key. Freedom to make changes should not be hampered by red tape; otherwise, excuses for non-action are easy to make.

At the heart of the NHS is its highly skilled, hard-working, and devoted-to-the-cause staff. Harnessing that potential and pointing everyone in the same direction, whilst ensuring the necessary skills are created and maintained, will be the most productive way to solve many issues. Technology, of course, has a major role to play also, but without supporting the staff to use it to its maximum, gains will be minimal.

Nothing in the above is new; there are many people and agencies who can give the same advice, but action is the key here. As a Chief Operating Officer, I would be thinking, “Do I have the right skill set in my workforce to enable me to get the right information to formulate a meaningful plan and, above all, enact it?” The solutions exist within the workforce, but capacity and capability must be invested in to elicit the desired outcomes.