Climate change is projected to alter river flows and the magnitude/frequency characteristics of floods and droughts. Ecosystem-based adaptation highlights the interdependence of human and natural systems, and the potential to buffer the impacts of climate change by maintaining functioning ecosystems that continue to provide multiple societal benefits. Natural flood management (NFM), emphasising the restoration of innate hydrological pathways, provides important regulating services in relation to both runoff rates and water quality and is heralded as a potentially important climate change adaptation strategy. This paper draws together 25 NFM schemes, providing a meta-analysis of hydrological performance along with a wider consideration of their net (dis) benefits. Increasing woodland coverage, whilst positively linked to peak flow reduction (more pronounced for low magnitude events), biodiversity and carbon storage, can adversely impact other provisioning service – especially food production. Similarly, reversing historical land drainage operations appears to have mixed impacts on flood alleviation, carbon sequestration and water quality depending on landscape setting and local catchment characteristics. Wetlands and floodplain restoration strategies typically have fewer disbenefits and provide improvements for regulating and supporting services. It is concluded that future NFM proposals should be framed as ecosystem-based assessments, with trade-offs considered on a case-by-case basis.