1. Introduction

1. The NHS England operating framework published in October 2022 sets out how our ways of working has evolved to reflect the development of integrated care systems (ICSs). It describes how we work with integrated care boards (ICBs), providers, and wider system partners to improve local health and care outcomes, maximise value for taxpayer money and deliver better services for our patients.

2. Our approach to NHS oversight and assessment is critical to the implementation of our operating framework, fostering a culture of continuous improvement, and in ensuring we support ICBs in achieving full maturity. Following the merger of NHS England and NHS Improvement, the first joint oversight framework was published in September 2021. This was replaced by a revised NHS Oversight Framework published in July 2022 to coincide with ICB establishment. Two years after the last update, we have developed proposals for updating the current framework.

3. The updated NHS Oversight and Assessment Framework has been developed with input from a range of stakeholders, including through a dedicated four-week engagement period in April, 2024. Seven regional events were held to discuss the proposed framework with ICBs and providers, and we have worked closely with NHS Confederation and NHS Providers to gather broader views from NHS leaders. In addition, we have established a clinical advisory group to provide input into the oversight metrics and have engaged with key stakeholders to inform the approach we are consulting on.

4. We have worked closely with the Care Quality Commission (CQC) to ensure our ICB annual assessment approach is aligned with the approach it will take to assess integrated care systems and to avoid duplication with their approach. We will continue our collaboration with CQC to ensure our approaches are mutually beneficial and complementary.

5. We have also engaged with a variety of think tanks and stakeholders, including the Local Government Association (LGA), in recognition of local councils’ significant role in integrating care systems, as well as bodies representing patients and professional groups. During 2024/25, we will continue to work with NHS partners and key stakeholders to develop and implement a comprehensive oversight and assessment approach.

6. The draft framework contains details of our revised approach, and we would like your feedback regarding these proposals. Below we have summarised the key changes for ease of reference. However, feedback should be provided on the draft NHS Oversight and Assessment Framework, not the summary provided in this document. Please find the draft framework here. Please refer to Section 3 of this document for instructions on responding to the consultation.

2. Scope of framework

7. The framework sets out the processes by which ICBs and providers are held to account for delivering high-quality care for patients and how we ensure problems are quickly identified and diagnosed, and necessary support or intervention is provided to address challenges. It serves four core purposes

• to align priorities across the NHS and with wider system partners to drive shared ownership of improvement
• to enable the sharing of good practices to support mutual improvement
• to identify where ICBs and/or providers may benefit from or require support or intervention, and
• to provide an objective basis for decisions about when and how NHS England intervenes using our regulatory powers should this be necessary.

Summary of proposed changes

8. We are updating and systematising our approach to oversight and assessment of ICB and provider delivery. All ICBs and providers will be assigned a segment on a scale of 1 to 4 that considers how well the organisation is performing against the delivery objectives NHS England has set. The segmentation process will consider the following elements:

• a set of objective, measurable criteria based on metrics associated with the 6 domains of the oversight framework
• a set of ‘additional considerations’, including the aggregated NHS system performance on key national priorities such as Urgent and Emergency Care, Elective Care, Mental Health care, Primary Care, and finance
• the capability of the organisation to improve without additional support or intervention
• a consideration of the organisation’s improvement trajectory along with the role it is playing in supporting its NHS system partners in meeting shared priorities. We also consider whether challenges are long-standing and how the organisation is working to address them

9. We are also, based on experience and feedback, evolving our approach to ICB annual performance assessments to meet our statutory responsibility. The performance assessments will consider both the ICBs’ capability and delivery. Capability will be assessed based on the ICBs’ delivery against 6 core functional areas and will result in a descriptive rating, determined by the ratings given to each functional area. Once finalised, we will publish these ratings as part of each ICB’s annual assessment alongside a description of how the rating was reached and highlighting areas of good practice and areas where further improvement may be required.

10. Furthermore, we are systematising our approach to provider capability by introducing quarterly self-certifications linked to our expectations regarding good governance and publishing provider capability ratings.

11. Our view of how well an ICB is discharging its functions informs its role in the oversight of NHS providers. The proposed provider oversight model is that we will work either with or through the relevant ICB (i.e. asking it to oversee providers in the first instance) based on the level of risk (determined by provider segmentation) and ICB capability. 

Segmentation (section 4.3 of Oversight and Assessment Framework)

12. Every ICB and provider will be assigned a ‘segment’ on a scale of 1 to 4 which broadly represents the level of intervention we are taking with organisations, as well as indicates whether oversight of providers should take place with or through its relevant ICB. The segment will be initially driven by a range of metrics which are structured to align with the four core purposes of an ICS to ensure an even approach across all areas through a balanced scorecard.

13. The metrics will reflect organisations’ responsibilities aligned to the four core purposes of an Integrated Care System of improving outcomes in population health and healthcare; tackling inequalities in outcomes, experience, and access; enhancing productivity and value for money; and helping the NHS support broader social economic development and reflect their specific role, in achieving those.

14. Performance against organisational metrics will generate an indicative delivery score that will be moderated through consideration of ‘additional criteria’ comprised of aggregate system performance measures. This means that an ICB or provider that is delivering well on its own specific metrics can be moderated by its wider system performance. For 2024/25, the additional criteria will be based on key national priorities UEC, elective and cancer waits, financial performance, mental health and primary care performance. This is to ensure that all system partners are invested in collaborating to resolve system issues and meet shared priorities.

15. The segment will be determined by taking the delivery score of an ICB or provider after the moderation for additional considerations and then considering our confidence in the organisation’s capability through their capability ratings. This will then undergo a process of calibration to ensure consistency in decision-making.

16. Where it is determined that an organisation has a final segment of 4 it will enter the Recovery Support Programme (RSP) and enforcement action. Organisations with delivery segments of 2 or 3 may receive specific interventions and support from NHS England, depending on their level of challenge. Organisations with a delivery segment of 1 do not receive support or intervention and are encouraged to provide peer support and share best practices.

Integrated care board (ICB) annual performance assessment (section 5.2 of Oversight and Assessment Framework)

17. We have a legal duty to assess the performance of each ICB annually and publish a summary of our findings. The annual performance assessment of an ICB will include consideration of:

• its capability rating looking at how effectively the ICB has delivered against 6 core functional areas to meet its legal functions; that is improving the quality of services, reducing inequality of access and outcome, public consultation, financial management and contribution to wider system priorities. This will be conducted annually but could be revised in-year if required
• an delivery segment looking at how effectively the ICB has delivered against the objectives set by NHS England. This is reviewed and updated dynamically throughout the year to build up to an annual reflection

18. The capability assessment will be informed by an ICB’s self-assessment of performance against the 6 functional areas and by comprehensive feedback from key system partners including health and wellbeing boards, Healthwatch, local authorities, provider partners, and the CQC. Through a process that will include regional consultation, the ICB will be required to evidence its self-assessment, and to identify and agree areas of best practice and areas where further development or support is required, to support its continuing improvement. Capability ratings for each ICB will be assigned on the following scale: excelling, achieving, progressing, and insufficient progress.

19. Regional directors will send a letter to the ICB chair and chief executive setting out its annual performance for the preceding year, including a summary of its capability rating and delivery segment and identifying key next steps for improvement. The individual capability ratings and delivery segments will be published on our website and we will publish a summary of all assessments in line with our statutory obligations. ICB boards will be asked to publish their annual assessments alongside their annual report and accounts as part of a public meeting.

Provider capability assessment  (section 5.3 of Oversight and Assessment  Framework)

20. NHS England will also publish the capability of providers on a scale of ‘no material concerns’, ‘some concerns (provider under review)’, and ‘major concerns’. We will consider this rating during delivery segment process for their organisation. We will base this on:

• the provider’s CQC well-led rating
• findings from information from third parties that indicate a possible issue with the provider’s governance
• outputs of quarterly self-certification aligned with our expectations of good governance

21. Where providers are unable to prospectively self-certify against the requirement, or retrospectively fail to comply with an actual certification, we may consider support or intervention

Oversight of providers (section 3.1 Oversight and Assessment Framework

22. ICBs and NHS England both have responsibilities to oversee providers under the NHS Act 2006. NHS England also has statutory powers to take enforcement action against a provider if there is a suspected or actual breach of its licence.

23. In line with our operating framework, we aim to discharge our responsibility for overseeing providers through the relevant ICB (asking the ICB to oversee providers in the first instance) where the ICB’s capability rating is ‘Excelling’ or ‘Achieving’.

24. In some circumstances, however, we may need to take a more direct role and oversee providers with the ICB as partners, such as when a provider requires intensive support or intervention, has a delivery segment of 3 or 4, or the relevant ICB’s capability rating is Progressing or Insufficient progress.

25. Oversight of the performance of primary care contractors will depend on the contractual relationship between the commissioner and the provider. As legally independent contractors each with different legal underpinnings, we will not include individual delivery segments for each primary care provider. However, the assessment of that performance is critical to understanding the performance of the ICB. Therefore, metrics for primary care will be included in the quarterly ICB delivery segment. The ability of the ICB to properly commission and support primary care is also critical and will be measured under the ICB annual capability assessment.

26. Oversight of other non-statutory partners is key and through the capability assessment of ICBs, NHS England will test the commissioning arrangements for other providers (e.g. independent sector providers and VSCE).

Role of integrated care partnerships and local priorities

27. We understand the importance of local priorities and ICBs having the capacity to work with system partners in the ICS to deliver on the priorities set through the ICP. These relationships are critical to deliver effective public health and prevention interventions as well as improving the wider determinants of health.

28. As part of our annual assessment of ICB performance we will assess how ICBs, as NHS organisations, are working with their system partners and promoting integration, this will include seeking the views of the ICP and local Health and Wellbeing Boards as to how effectively the ICB is supporting the delivery of wider local health and care strategies.

Publication of information

29. To support transparency NHS England plans to publish ICB & Provider capability scores, segmentation, and underlying metrics on a quarterly basis

3. Responding to the consultation

30. Those interested in participating in the NHS Oversight and Assessment Framework consultation are encouraged to respond to the questions set out in this document by completing the online survey here: NHS Oversight and Assessment Framework consultation – NHS England – Citizen Space

Following consultation, the updated NHS Oversight and Assessment Framework will be published and implemented later in 2024. This consultation is open from 23 May 2024 to 13 June 2024.

Consultation questions

1. Are you responding as an individual or as part of an organisation?
2. Describe the organisation or group you belong to?     
3. What is the name of your organisation?
4. To what extent do you agree or disagree with the proposed approach to oversight set out in this document meets the purposes and principles set out in para 6?
5. What changes would you make to the framework, Please share details.
6. Does the updated framework provide a clear explanation of the role that ICBs and providers play in NHS oversight?
7. Do you think any further clarification is required? Please provide suggestions.
8. To what extent do you agree or disagree with the approach to ICB assessment which considers their capability and delivery? (See section 5.1 of the draft framework for further information).
9. To what extent do you agree or disagree that the ‘additional considerations’ (comprising aggregated system performance) alongside organisational delivery metrics will encourage greater collaboration between NHS system partners to resolve system-wide issues? (see section 4.3 of the draft framework for further information).
10. Do you have any other comments?

Publication reference: PRN00351_ii