2025/26 NHS Oversight Framework: what you need to know

Overview

The new NHS Oversight Framework sets out a revised approach to assessing integrated care boards (ICBs), NHS trusts and foundation trusts for 2025/26. Its goals are to enhance public accountability for performance and improve the identification of providers that require support to improve.

The NHS Oversight Framework 2025/26 replaces the version published in June 2022, which was operational for three years and emphasised system working. 

Over the last 18 months, NHSE has iteratively updated and consulted on a new framework in response to a new government and a corresponding set of changes to the wider NHS operating model. Notable developments include a commitment to greater public accountability, major cuts to ICB and provider budgets, the transfer of provider oversight from ICBs to regions to facilitate a greater focus on strategic commissioning for ICBs, and the integration of NHSE into the Department of Health and Social Care (DHSC). 

Throughout the development of the new framework, NHS leadership and staff, representative bodies and think tanks were engaged, including through two public consultations in 2024 and 2025. There was a clear request for greater simplicity, clarity and consistency in the assessment approach. 

There remains considerable uncertainty across the system, with the ten-year health plan due shortly. To ensure the oversight of ICBs and providers is designed to support the delivery of the plan and the government’s three shifts, NHSE has committed to reviewing its approach to performance assessment again ahead of 2026/27. 

Approach to segmentation

Integrated care boards

ICBs will not be allocated segments in 2025/26, recognising that this is a year of significant change and disruption as they deliver major running cost reductions and transition into their new role as strategic commissioners. 

ICB performance against the full suite of oversight metrics will still be published to aid planning and improvement and NHSE will continue to review how well each ICB is performing its statutory duties as part of statutory annual assessments. 

Providers

There will be no pause to segmentation for providers in 2025/26, with initial segments expected in July. Providers that are part of a provider collaborative or group model will be measured as individual trusts, not as a wider group.

The segmentation of providers will involve four steps: 

1. Organisational delivery score: Each provider will receive an organisation delivery score between 1 (high performing) and 4 (low performing). This will be calculated based on its performance across six domains (see Annex A in the framework for a full list of metrics and the methodology manual for more details on scoring). For this transitional year, the delivery metrics reflect short-term NHS priorities and the 2025/26 operational planning guidance. Unlike in the 2024 consultation, ‘system considerations’ will not influence a provider’s segment.
2. Financial override: The organisational delivery score will be considered alongside each organisation’s financial position to produce an initial segment. Provider organisations in deficit or receiving deficit support will be limited to a segment of no greater than 3. 
3. Identification of the most challenged providers: An additional segment (segment 5) has been introduced for the most challenged providers. These providers will be considered for the PIP (Provider Improvement Programme), which replaces the RSP (Recovery Support Programme). Placement in segment 5 is based on the provider’s segment and its provider capability rating (see below). In exceptional cases, providers in higher segments may enter PIP if NHSE identifies serious concerns about a provider’s capability. 
4. Finalisation of segments: Once NHSE approves the final segmentation, it will be communicated to each organisation and published on NHSE’s website. Segmentation data will be reviewed at least quarterly. 

NHSE’s improvement support offer

Integrated care boards

In 2025/26, NHSE’s improvement support to ICBs will focus on the safe implementation of plans to cut running and programme costs. ICBs currently in the RSP will continue in this programme and will be assessed against their current improvement trajectory to agree a transition plan.

Providers

NHSE regions will coordinate the oversight response with NHSE national teams and wider system partners. This will be based on an organisation’s segment but also its provider capability rating to ensure capacity and resources are prioritised for those with the lowest performance and least capability to improve independently. 

NHSE’s approach to provider capability assessments is not yet finalised. New guidance is expected to be issued in Q2 of 2025/26, working closely with the CQC to ensure alignment with their own assessment practices. The extent to which providers collaborate and support system working will be part of the provider capability rating. 

The framework outlines varying degrees of intervention across the three aspects of NHSE’s improvement support:  

• Oversight of performance improvement: the frequency of review meetings with ICBs will depend on the region’s confidence in the ICB’s ability to deliver required improvements. Escalation will be considered when necessary, including requiring providers to attend review meetings. 
• Improvement support: NHSE’s improvement offer will be aligned with organisational delivery scores. Providers that score poorly on areas within priority areas (finance, urgent and emergency care, elective and mental health sub-domains) will receive improvement support from NHSE, either on- or off-site depending on the severity. 
• Performance management: Where required, NHSE regional teams will undertake performance management activities for providers with low scores in priority areas. Some providers will receive more scrutiny and may be entered into national programmes, such as the PIP.  

Incentives and consequences

The framework reiterates the commitment to rewarding high-performing systems in 2025/26, including a partial release of revenue surpluses for capital expenditure in high-performing providers and ICBs. At the same time, very senior managers of organisations in segment 5 (or ICBs in the RSP/PIP) will not be eligible for the annual pay award, unless exempt. Performance incentives for 2026/27 will be reviewed following publication of the ten-year health plan. 

The framework also describes the regulatory powers NHSE possesses to step in and secure improvement when performance falls below an acceptable standard and/or there are serious governance issues. More details are set out in the NHS enforcement guidance.

Public transparency and accountability

Integrated care boards

While ICBs will not be placed in segments, their performance against the full suite of oversight metrics will still be published on a new NHSE dashboard. These will be reported as contextual information to be used in strategic planning and improvement conversations. The metrics and system considerations reflect the NHS priorities and operational planning guidance, system performance and longer-term strategic priorities.

Providers

NHSE will publish a dashboard that shows a breakdown of each provider’s domain scores, organisational delivery score, final segmentation and capability rating. A longer list of ‘contextual’ metrics will also be shown, covering measures of population health, primary prevention and health inequalities.

Analysis

Overall, we support this framework, which clearly recognises the context in which it is being introduced as ICBs undergo significant reorganisation and with details of the new operating framework still emerging. While the framework will need to be updated following publication of the ten-year health plan – which will inevitably create some disruption – the framework provides useful clarity in the short-term, encourages a focus on the immediate challenges facing the system and lays the foundation for the plan’s delivery.  

"we particularly welcome the decision not to place ICBs into segments this financial year"

Noting the considerable uncertainty across the health and care system right now, we particularly welcome the decision not to place ICBs into segments this financial year and instead to focus on supporting them to implement their cost-reduction plans. The decision will help rebuild trust with ICS leaders by illustrating that the centre understands the pressures they are under, giving them vital breathing room during this difficult and disruptive change process. 

"members ... will continue to have concerns about whether the current framework strikes the right balance between recovery and reform"

There is also welcome alignment between the framework and the government’s broader ambitions to address the health service’s operational and financial challenges. In particular, ICS and trust leaders will appreciate the increased simplicity and enhanced local autonomy that a reduced set of metrics tied to this year’s planning guidance will bring. Our members told us during recent engagement exercises that this would lessen the bureaucratic burden associated with the previous performance regime. 

However, while members generally understand the desire to focus on short-term operational priorities, they will continue to have concerns about whether the current framework strikes the right balance between recovery and reform. This relates both to the metrics chosen and the decision for system considerations not to influence provider segmentation. There are worries that basing segmentation on activity, rather than outcome-based metrics, could undermine progress towards the government’s three shifts and the ambitions of the upcoming ten-year health plan. 

"we remain concerned that it will be difficult in practice to fully divorce contract management (held by ICBs) from formal oversight of providers (held by regions)"

We welcome attempts made by NHSE to clarify the respective performance management roles of ICBs and regional teams, including a case study that ICB and provider members will find helpful. However, we remain concerned that it will be difficult in practice to fully divorce contract management (held by ICBs) from formal oversight of providers (held by regions). Without more clarity on how contract management and NHSE’s oversight role will interact, there is risk that providers are subject to performance management by two separate bodies. This is further complicated by ICBs and regions each potentially holding providers to account for a different set of metrics, with the oversight framework focused on a list of short-term operational metrics and ICBs instructed to commission based on longer-term population health outcomes. 

Members will also have concerns about variation in how the framework is applied across regions, which has undermined objectivity in the past. This concern is heightened by uncertainty about the future role of the region, potentially affecting regional directors’ ability to engage meaningfully and consistently with the new framework. It is important in the upcoming months that time is taken to build strong relationships between NHSE national and regional teams, ICBs and providers, especially given an inevitable change in personnel in some areas. 

We appreciate that some of the challenges described are a feature of the ongoing transition period. We therefore welcome the commitment to revisit this framework once the ten-year plan is published, when we will have greater clarity on the future system operating model and the mechanisms to deliver a more preventative approach, closer to people’s homes. 

In 2026/27, we would like to see a more fundamental reset to oversight, addressing the concerns described and placing greater emphasis on system working and outcomes over activity. 

We will be working closely with our members and colleagues in DHSC and NHSE to achieve this.