1. To tackle the 8am rush and reduce the number of people struggling to contact their practice. Patients should no longer be asked to call back another day to book an appointment, and we will invest in general practice to enable this.

2. For patients to know on the day they contact their practice how their request will be managed.

a. If their need is clinically urgent it should be assessed on the same day by a telephone or face-to-face appointment. If the patient contacts their practice in the afternoon they may be assessed on the next day, where clinically appropriate.

b. If their need is not urgent, but it requires a telephone or face-to-face appointment, this should be scheduled within two weeks.

c. Where appropriate, patients will be signposted to self-care or other local services (eg community pharmacy or self-referral services).

1. Describe a single, shared NHS improvement approach. NHS England will set an expectation that all NHS providers, working in partnership with their integrated care boards, will embed a quality improvement method aligned with the improvement approach to support increased productivity and enable improved health outcomes. This will require a commitment from NHS England itself to work differently, in line with the improvement approach and the new Operating Framework.
2. Co-design with our health and care partners a leadership for improvement programme, commissioned and supported by NHS England, enrolling all providers and systems (including primary care) in it to support a whole-system focus on improving healthcare outcomes with our workforce, patients and communities.
3. Establish a national improvement board, to agree the small number of shared national priorities on which NHS England, with providers and systems, will focus our improvement-led delivery work, with national co-ordination and regional leadership. The new board will support more consistent, high-quality delivery of services to improve performance and reduce unwarranted variation. 

10 recommendations

1. NHS England’s Executive Group will agree a small number of more consistently executed priority improvement initiatives, offering national co-ordination and regional leadership to support delivery.
2. NHS England will consolidate capability and expertise into a national priority improvement function, whose role is to co-ordinate action on a small number of pan-national improvement priorities on a rolling basis.
3. NHS England will test the model for the new priority improvement function through delivery of a winter collaborative. Action co-ordinated through the winter collaborative will be codified into more standardised approaches to delivery and improvement to support the spread and scale of learning.
4. NHS England will set an expectation that all NHS providers, working in partnership with integrated care boards, will embed a quality improvement method aligned with the NHS improvement approach.
5. NHS England will collaborate with partners to co-develop leadership development products that support health and care boards, executives and the wider workforce to embed the NHS improvement approach in their organisations and systems.
6. NHS England will work with the CQC to align the revised CQC well-led with the improvement approach.
7. NHS England will critically review the NHS oversight framework, to incentivise providers and systems to embed improvement-led delivery.
8. NHS England's Support for Challenged Systems team will work with and through the regions to more consistently co-ordinate intensive support. This will include continued collaboration with other regulators and royal colleges to ensure consistent support and no duplication.
9. Further develop peer support between providers and systems, including through enhanced support for provider collaboratives programmes and pre-existing provider peer support networks.
10. NHS England will review the balance of national and regional resources between intensive support, pathway programmes and general capacity building. This will include an assessment of how national and regional teams more consistently support organisations in segment 3 and offer longer-term support to organisations exiting segment 4.

This letter outlines three essential measures:

1. Ensure measures are in place to enable all ambulances to handover patients no later than 15 minutes after arrival.
2. Free up maximum bed capacity by safely discharging patients, working closely with system partners, in advance of industrial action.
3. Confirm system-level operational plans for the days of ambulance industrial action with NHS England regional teams by 16:00 Monday 19 December to allow for any additional support to be considered and arranged. These plans must include how Emergency Departments will ensure the release of all ambulances within 15 minutes.

1. Invest in our workforce – with more people (for example, the additional roles in primary care, expansion of mental health and community services, and tackling substantive gaps in acute care) and new ways of working, and by strengthening the compassionate and inclusive culture needed to deliver outstanding care.
2. Respond to COVID-19 ever more effectively – delivering the NHS COVID-19 vaccination programme and meeting the needs of patients with COVID-19.
3. Deliver significantly more elective care to tackle the elective backlog, reduce long waits and improve performance against cancer waiting times standards.
4. Improve the responsiveness of urgent and emergency care (UEC) and build community care capacity– keeping patients safe and offering the right care, at the right time, in the right setting. This needs to be supported by creating the equivalent of 5,000 additional beds, in particular through expansion of virtual ward models, and includes eliminating 12-hour waits in emergency departments (EDs) and minimising ambulance handover delays.
5. Improve timely access to primary care – maximising the impact of the investment in primary medical care and primary care networks (PCNs) to expand capacity, increase the number of appointments available and drive integrated working at neighbourhood and place level.
6. Improve mental health services and services for people with a learning disability and/or autistic people – maintaining continued growth in mental health investment to transform and expand community health services and improve access.
7. Continue to develop our approach to population health management, prevent illhealth and address health inequalities – using data and analytics to redesign care pathways and measure outcomes with a focus on improving access and health equity for underserved communities.
8. Exploit the potential of digital technologies to transform the delivery of care and patient outcomes – achieving a core level of digitisation in every service across systems.
9. Make the most effective use of our resources – moving back to and beyond prepandemic levels of productivity when the context allows this.
10. Establish ICBs and collaborative system working – working together with local authorities and other partners across their ICS to develop a five-year strategic plan for their system and places. 

Review local chest drain clinical procedures/LocSSIP (or equivalent documents) to ensure they:

• Follow BTS guidelines for adults2 and/or children4 for controlled drainage of large pleural effusions.
• Include post-procedure management plans that align with BTS standards.
• Incorporate the good practice points outlined in the ARNS Good Practice Standards for adults.

Provide a bedside observation chart or monitoring document6 (electronic or paper) that embeds the key elements of the revised policy to ensure it includes:

• clear instruction on frequency of observation; including continuous direct observation for first 15 minutes
• red flag triggers for drain closure
• local escalation procedure for patient deterioration before, during and after chest drain insertion.

Their revitalised culture of support and collaboration will be underpinned by a new approach, including:

• a move away from relying solely on arm’s-length regulation and performance management to supporting service improvement and transformation across systems and within providers
• strong governance and accountability mechanisms in place for systems to ensure that the NHS as a whole can secure the best value from its combined resources
• a reinforcement of accountability at Board, Governing Body and local system ICS level for adopting standards of best practice and making their contribution to critical national improvement programmes, on a comply or explain basis
• making better use and improving the quality of the data and information that local systems and providers have access to improve patient services.

The five principles relate to different stages of a patient’s stay: some to the moment of admission, some to their time on a ward and some to the end of their stay.

1. Plan for discharge from the start
2. Involve patients and their families in discharge decisions
3. Establish systems and processes for frail people
4. Embed multidisciplinary team reviews
5. Encourage a supported ‘Home First’ approach

The 'Where Best Next?' website lists specific actions for each principle and provides links to useful resources.