Organisation objective

• NHS Mandate from Government

Working with people and communities

What approaches have been used to ensure people and communities have informed this programme of work?

• consultation/engagement
• quantitative data and insight, for example national surveys. 
• statutory Item
• governance

Action required

The Board is asked to comment and reflect on the proposals for a new approach to NHS oversight and assessment as we undertake formal consultation.

Background 

1. NHS England’s role is to lead the NHS in England to deliver high quality services for all. NHS England has a responsibility to ensure the NHS is achieving for patients and delivering against our constitutional and legal duties (for example the NHS Constitution and the Government’s Mandate to the NHS) in the context of the resources allocated to it.

2. To do this, there should be clarity about the responsibilities of and between NHS organisations, what success looks like, how performance is measured and what actions need to be taken accordingly.

3. NHS England has a duty to undertake oversight transparently so that the public, staff, Government and ultimately Parliament understand how performance is measured, where accountability sits, the reasons behind both challenges and successes, and how the NHS plans to improve.

4. The NHS England Operating Framework was published in October 2022 to set out how we work with each other. The framework for example sets out NHS England’s role to lead the NHS to deliver high quality services for all, and the 8 areas that NHS England focuses on to achieve this.

5. NHS England also has an NHS Oversight and Assessment Framework which sets out how we determine success. This document was updated in 2022 and has been used to inform support requirements for improvement and regulatory action.

6. Two years on from the last update to the Oversight and Assessment Framework, NHS England has proposed updates to the framework and undertaken engagement sessions with NHS leaders to get feedback on the proposed changes. This has shown strong support and a shared desire for greater clarity of roles and responsibilities, use of a broader range of short and medium-term outcome measures, less subjectivity in measuring success, and adoption of mature relationships in supporting organisations to improve.

7. In response, 3 pillars of work are being taken forward:

i. Oversight and accountability: with a new Oversight and Assessment Framework that rewards improvement, clarifies the role of all parts of the NHS system and focuses on the immediate and future priorities facing our communities.

ii. Developing our leadership: by giving leaders tools that help them lead their organisations and systems locally and equipping them with skills and leadership competencies to drive forward the changes needed.

iii. Delivering Improvement: to ensure that NHS England’s approach to improvement and support underpins this work through NHS Impact.

8. This paper focuses on the proposed updated NHS Oversight and Assessment Framework within pillar one. As part of this, NHS England’s work will update the process of assessment of integrated care boards (ICBs), clarify their role and set out how success will be measured as well as update the arrangements that are in place for the assessment of NHS providers to achieve:

a. a clear understanding of the roles and responsibilities of the different NHS organisations

b. the right balance between the focus on immediate and medium-term priorities so that we look at how ICBs arrange services which can meet the needs of their populations and improve access and outcomes at the same time as a focus on the immediate national priorities

c. robust processes that clearly set out how organisations will be overseen

d. a clear expectation of how we will determine the support segmentation of providers and assess ICBs

e. an ICB assessment approach which is supportive, rewards strong performance, drives the development of mature systems

f. transparency in our approach.

9. ICBs are still relatively young organisations and integrated care systems are still developing so it is important that we continue to assess, develop, and adapt both the NHS England Operating Framework and the Oversight and Assessment Framework on a regular basis. Therefore, we expect it to evolve as our system architecture matures and we will ensure that the annual planning process is aligned to changes on a year-by-year basis.

Engagement

10. The updated NHS Oversight and Assessment Framework was developed with input from a range of stakeholders. Recently we have also undertaken a four-week period of wider engagement. The proposed framework has been discussed with integrated care board and providers through seven regional events, and we have worked closely with NHS Confederation and NHS Providers to get broader views from our leadership community. 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 which we now plan to formally consult upon.

11. We have worked closely with the Care Quality Commission to ensure our assessment framework is aligned and not duplicative of their approach to review the performance of integrated care systems. We have also met with several think tanks and different professional bodies including the Local Government Association, recognising the important role of local councils in integrated care systems.

12. We plan to launch a short period of public consultation from 20 May – see the next steps section for details.

Roles and responsibilities of NHS organisations

13. The NHS England Operating Framework defines each organisation’s roles and responsibilities in oversight. All parts of the system, NHS England, integrated care boards (ICBs) and providers are collectively responsible for delivering the NHS Mandate, integrating NHS services and integrating health and care services. Under the National Health Service Act 2006 (‘the NHS Act 2006’) and the Health and Social Care Act 2012 (‘the 2012 Act’), as amended by the new Health and Care Act 2022 (‘the 2022 Act’), NHS England has statutory accountability for oversight of both ICBs and providers of NHS services.

14. Role and responsibilities of the ICB: ICBs are responsible for strategically commissioning and arranging for the provision of healthcare services to meet the health needs of its local population, alongside other statutory duties. The ICB is the leader of the NHS system within its ICS and is responsible for the delivery of joint system plans and strategies requiring mutual accountability. The ICB also has a responsibility to work in a statutory committee with its local authorities to form the integrated care partnership which is a broad alliance of organisational have a role in improving local health, care and wellbeing. A key role of the ICB is to ensure that the service-delivery models in its NHS system are working effectively via place-based partnerships, provider collaboratives, the primary-secondary care interface and integrated neighbourhood teams.

15. The Oversight and Assessment Framework sets out 6 key capabilities ICBs should demonstrate to fulfil their statutory role. They are shown in Annex A.

16. Roles and responsibilities of NHS providers (trusts and foundation trusts): NHS providers are responsible for providing safe, effective, efficient, and high-quality services. Providers must work effectively with their NHS and wider health and care system partners to deliver their contributions to shared objectives, plans, and priorities, including financial and operational performance and to identify and reduce unwarranted variation. They must comply with the NHS provider licence and standards set by regulators. All providers have a duty to collaborate, and the duty to consider the wider effect of their decisions on population health (including inequalities), the quality of services provided by themselves and others, and the sustainable and efficient use of resources by themselves and other bodes. They should also ensure that they have robust partnership arrangements in place to support the development on integrated neighbourhood teams.

17. The Oversight and Assessment Framework sets out the key capabilities NHS providers require to fulfil their role which are shown in Annex B.

18. Roles and responsibilities of other NHS providers: Primary care providers are crucial to the success of the NHS and ICBs, as is the voluntary, community and social enterprise sector. Primary care includes general practice, community pharmacy, dental and optometry services. Roles and responsibilities for these providers are defined by the contractual arrangements under which they deliver healthcare and the regulations which underpin them. They are overseen through the delegated commissioning arrangements from NHS England to ICBs. The performance of primary care is critical to that of the wider health and care system.

Proposed approach to NHS oversight and assessment 

Integrated care boards

19. NHS England has a legal duty to assess the performance of each integrated care board (ICB) annually in respect of the previous financial year and publish a summary of our findings. We propose the assessment of ICBs will include consideration of:

i. Annual capability assessment: an annual capability rating on a 4-point scale, based on how well an ICB has performed against the 6 core capabilities and discharged key activities with input from ICB’s own self-assessment, key stakeholders, NHS England regional and national teams. The capability assessment will be informed by the ICB’s self-assessment of performance against the key functional areas and by comprehensive feedback from key system partners including health and wellbeing boards, Healthwatch, local authorities, and the Care Quality Commission (CQC). It will be supported by an evidence-based understanding of achievement against what good looks like and will operate within a national framework to ensure consistency. It will incorporate a 360 review, including review by an ICB chair or CEO from another region. 

ii. Quarterly delivery score: quarterly delivery segment (1-4 scale) based on how well the ICB has uniquely contributed to and delivered against system priorities and targets. The ICB delivery segment will be based on performance against a balanced scorecard of metrics across 4 domains (improving access and outcomes, reducing health inequalities, enhancing productivity and value for money, and supporting wider social and economic development) which reflects their specific role in achieving those aims.

20. The combination of an annual capability assessment and quarterly delivery scores will be combined to give an overall rating which gives NHS England, ICBs themselves and their system partners the information needed to understand how ICBs are performing, and to what extent they can deliver against their priorities and responsibilities.

NHS providers (trusts and foundation trusts)

21. NHS providers will also receive a quarterly delivery segmentation (1-4 scale). As with ICBs, the metrics for providers will reflect their contribution to delivery across the same 4 domains and will reflect their specific role in achieving those aims.

22. Capability assessments for NHS providers will be based on its most recent CQC well-led rating, the provider board’s self-certification on the provider’s capability and any relevant information from third parties relating to the provider’s governance and capability. The self-certification will also require the provider to set out plans it has in place to address known capability challenges. These will be undertaken quarterly.

23. As with ICBs, these 2 assessments will be combined to give an overall rating which gives NHS England, providers themselves and their system partners the information needed to understand how they are performing, and to what extent they can deliver against their responsibilities.

Non-Statutory NHS providers

24. 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 are not including 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 is measured under the ICB annual capability assessment.

25. 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 (eg independent sector providers and voluntary, community and social enterprise sector).

Relationship between integrated care boards and NHS providers performance

26. We want to ensure all NHS providers and ICBs work together and take collective accountability for the overall experience of their populations and use their collective resources to improve against in-year high priorities and to reduce unwarranted variation. Whilst ICBs and providers are assessed on their delivery segments separately, we will consider the aggregate system performance on urgent and emergency care, elective and cancer waits, financial performance, and mental health through a “double lock” which moderates an individual organisation’s rating. We are considering the addition of a metric in primary care to ensure that the focus is retained across the whole care pathway.

27. Our assessment of how well an ICB is discharging its functions will inform its role in the oversight of NHS providers. The proposed NHS provider oversight model is that we will work ‘with’ or ‘through’ ICBs, asking them to oversee providers in the first instance, based on the level of risk (determined by provider segmentation) and ICBs’ capability. This will include working with ICBs on how they oversee, support and drive transformation of primary care in their area.

28. ICBs and NHS trusts that are situated in a high-functioning NHS system and have no specific needs or challenges are likely to be assigned a delivery segment of 1 or 2. ICBs and providers that are assigned a delivery segment of 1 are expected to offer peer-to-peer support and share best practices with other organisations to support collective improvement.

29. We are exploring additional recognition and reward options for the highest performing ICBs and providers.

30. NHS trusts and ICBs that have complex and/or serious challenges and support or intervention needs, or those operating within challenged NHS systems requiring a coordinated system-wide response are likely to be assigned delivery segments of 3 or 4, depending on the scale and nature of the challenges. They may be subject to enforcement action, enhanced oversight and, depending on the nature of the problem(s) identified, additional reporting requirements and financial controls may be introduced.

31. Given the breadth of metrics that are included in the proposed Oversight and Assessment Framework, an ICB or a provider in a higher segment may still have challenges in some specific areas. Hence, the provision of support through topic specific expert ‘tiering’ programmes will remain part of NHS England’s intervention and support offer. In addition, NHS England retains the right to intervene and take action in respect of any significant governance concerns that it has, in areas covered by the Oversight and Assessment Framework and those outside of it.

The role of integrated care partnerships and local priorities

32. NHS England understands 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 integrated care partnership (ICP). These relationships are critical to deliver effective public health and prevention interventions as well as improving the wider determinants of health. ICSs are not NHS systems, they are health and care systems, and assessing their performance as a whole not the role of NHS England. How well ICSs are delivering on local ICP priorities and the assessment of ICPs is more suited to the CQC assessment of systems. However, NHS England will assess how ICBs, as NHS organisations, are working with their system partners and will seek the views of the ICP and local authorities in assessment as set out previously.

Considerations

33. The engagement to date has indicated support for the overall approach. People have welcomed clarity on the respective responsibilities of integrated care boards and providers in the new NHS reflecting their specific capabilities, and how NHS England will oversee the service. Areas that have been mentioned for further consideration include:

i. ensuring the right balance between oversight (particularly access and finance metrics) and focus on improving population health

ii. being mindful of the potential burden and complexity of the approach

iii. ensuring alignment with the Care Quality Commission’s approach to integrated care system assessment

iv. considering how improvement in challenging circumstances can be recognised.

Next steps

34. We plan to run a short period of public consultation from week commencing 20 May based on a draft version of the updated NHS Oversight and Assessment Framework. Following evaluation of the consultation responses, the Board will be asked to approve the final framework before it is launched in July 2024.

35. The Oversight and Assessment Framework includes a selection of metrics to inform an overall rating for an integrated care board (ICB) and provider. In support of the framework, NHS England will also publish an Insightful Board series which will set out a larger range of metrics that well governed Boards should be considering through their governance arrangements. One will focus on provider trusts, one on ICBs and one on NHS England. We expect to publish these during quarter 2.

36. Alignment of our approach to ICB annual assessment with the approach the Care Quality Commission (CQC) will take to its assessment of the wider integrated care systems is important and we will continue working with CQC to ensure that our approaches are mutually beneficial and reinforcing.

37. Through the engagement period NHS England sought views on what incentives and recognition of strong performance would reinforce the Oversight and Assessment We are considering that feedback and undertaking further work on this. 

38. For an individual organisation the application of the Oversight and Assessment Framework, will mean that different interventions and mechanisms of support will be required. This can range from peer review and support through to regulatory enforcement action, either in one specific area or across a whole organisation and system. NHS England is in the process of reviewing the current landscape of intervention and support (including undertakings, tiering and Recovery Support Programme) to align with the new Oversight and Assessment Framework. To support this work NHS England is also considering how it continues to implement its operating model to achieve these aims.

Publication reference:  Public Board paper (BM/24/24(Pu)