- NHS England has published its new operating framework, which sets out the ways of working that will enable it to deliver its purpose as the ‘new NHS England,’ which from April 2023 will include Health Education England and NHS Digital. It reflects some feedback provided by the NHS Confederation and our members through various meetings and roundtables that we organised. We welcome the commitment to further iterate it through engagement and co-production with integrated care boards (ICBs) and providers.
- The document clarifies the behaviours underlying the new statutory duties on NHS England and system partners, without being too prescriptive about local arrangements.
- It is promising to see that the framework acknowledges the scale of change needed within NHS England and the national bodies in terms of culture, behaviours and ways of working to support system working and the establishment of statutory integrated care systems (ICSs). This will be vital if local systems are going to truly have the autonomy they need to lead on behalf of their communities.
- However, the lack of emphasis of the key role played by local government is an omission that should be addressed. Although NHS England does not have a formal oversight role with local government, not mentioning this key relationship and the important role played by integrated care partnerships is a missed opportunity to respect the significance of their key role within the new ICS structure.
- Although it is right that arrangements should be defined locally and the framework was focused on the relationship between NHS England and ICSs, it would have been a useful opportunity to emphasise some of Clare Fuller’s recommendations for integrating primary care.
- There is a risk that the way ICBs and their functions have been presented implies that they act as an additional layer of bureaucracy or management. ICS will not succeed if they are forced into this role. There is also some discord between the wording of ‘support’ and ‘partnership’ and the detail on who intervenes when things go wrong in providers and ICBs. More generally, NHS England needs to use this opportunity to move away from a top-down regulatory approach towards one of enabling and supporting improvement.
- This does not signal a reduction in the burden on systems or providers, just a shift of where the burden is managed from national to regional. There is a risk of stifling innovation if a more proportionate approach to regulation and oversight is not adopted. We hope to see this come through more strongly in NHS England’s new oversight framework.
The new NHS England operating framework outlines the ways of working that will be needed to remodel and improve care and put the health service on a more sustainable footing in line with the new Health and Care Act. It largely addresses five things: purpose, areas of value, leadership behaviours and accountabilities, and medium-term priorities and long-term aims.
The new NHS England operating framework outlines the ways of working that will be needed to remodel and improve care and put the health service on a more sustainable footing in line with the new Health and Care Act. It signals the direction NHS England is going as an organisation in order to streamline functions and support new ways of working, and as a larger organisation that will formally merge with Health Education England and NHS Digital in April 2023. The framework largely addresses five things: purpose, areas of value, leadership behaviours and accountabilities and medium-term priorities and long-term aims.
NHS England sets out its core purpose in the document as leading the NHS in England to deliver high-quality services for all. This purpose statement drives both ‘what’ it does (how it adds value and what its priorities are) as well as ‘how’ it operates (its values, behaviours and accountabilities, and structures). The purpose will be achieved by:
- enabling local systems and providers to improve the health of their people and patients and reduce health inequalities
- making the NHS a great place to work, where our people can make a difference and achieve their potential
- working collaboratively to ensure our healthcare workforce has the right knowledge, skills, values and behaviours to deliver accessible, compassionate care
- optimising the use of digital technology, research and innovation
- delivering value for money.
Where NHS England delivers value
- Setting direction – including developing and setting policy, strategy, guidance and priorities, managing the relationship with government and providing leadership on NHS contribution to reducing health inequalities.
- Allocating resources – including financial allocation and stewardship, working with partners to develop workforce planning and strategy, designing financial structures and incentives and contributing to the UK economy.
- Ensuring accountability – including defining accountability structures, regulation, monitoring and assurance.
- Supporting and developing people – including establishing a leadership culture, role modelling culture and behaviours, creating the conditions for a fully inclusive and diverse NHS, and delivering the workforce, training and education functions of Health Education England.
- Mobilising expert networks – in order to support service improvement. This includes managing relationships across national and professional bodies, enabling and supporting the development of systems and ICBs, benchmarking and looking at outcomes.
- Enabling improvement – including supporting the delivery of quality and operational performance improvement, deploying improvement resources and support and regulatory intervention.
- Delivering services – including driving digital, data and analytics, offering centralised commercial and procurement support and commissioning a number of services directly.
- Driving transformation – including supporting the delivery of medium-term priorities such as secondary prevention and earlier diagnosis, encouraging innovation and transformation including partnering with life sciences, and leading the NHS’s contribution to population health and prevention.
Further detail on the respective role of NHS England regional teams, national programmes and corporate functions in supporting ICSs and providers in their roles is outlined on pages 10-12 of the framework.
Leadership behaviours and accountabilities
NHS England sets out the following leadership behaviours:
- Driven by the people and communities we serve.
- Focused on clear outcomes.
- Inclusive and diverse.
- Collaborating, co-producing, co-owning, being a great partner.
- Accountability to role and team.
- Trusting and empowering each other.
- Working at pace when appropriate, with agility and courage.
- Being ambitious and can-do.
- Learning by doing, cycles of change.
- Data-driven and evidence-based.
- Hard on problems and supportive of people.
- Transparent, honest and authentic.
Details of how accountabilities and responsibilities will work are set out on pages 14-18. National accountabilities will be met in the following way through systems:
- ICBs are responsible for developing and overseeing the implementation of joint strategies and plans with their partners to meet national commitments, as well as any additional local priorities for health service, social care and public health improvement that are agreed within each ICS strategy and ICB/provider joint forward plan.
- Individual providers are responsible for delivering safe, effective, efficient, high-quality services in line with universal required standards and commitments, their statutory duties and their contracts and agreements with ICBs and NHS England, and for delivering any agreed wider contribution to implementing the integrated care partnership strategy and joint forward plan.
- NHS England is responsible for supporting ICBs, NHS providers and their local partners to deliver their plans and make their full contribution to the ICS strategy, and for intervening if the NHS’s national commitments are at risk or are not being met.
- NHS England is also responsible to parliament for NHS performance and has regulatory powers supporting this. Therefore, while it will not determine the day-to-day working relationships between leaders, it is important to be clear on the formal accountability lines between NHS organisations under the new arrangements.
- NHS Oversight Framework. The arrangements for applying this within each ICS area will be agreed and set out in a memorandum of understanding between each ICB and the relevant NHS England regional team, alongside other details of their agreed ways of working. This will provide clarity of oversight arrangements for each provider, avoiding duplication.
In practice, these new accountabilities and responsibilities will change the way NHS England works in the following ways (some examples are given on page 21 of the framework):
- Proportionate and streamlined: ICBs and NHS England will ensure oversight and performance management arrangements within their ICS area are proportionate and streamlined, and do not create duplication or unnecessary bureaucracy and reporting requirements for providers.
- Devolved: For both ICBs and their partner NHS providers the primary relationship with NHS England will be through the relevant regional team.
- No surprises: Relationships between NHS England, ICBs and providers will be mature, respectful and collegiate, underpinned with effective lines of communication and a ‘one team’ philosophy.
- ICB annual assessments: NHS England has a duty to annually assess ICBs across a number of domains. The first annual assessment of ICBs will be completed in Q1 23/24 and will use a variety of evidence, but a key part of the process will be ICB self-reflection and dialogue between the ICB and NHS England over the course of the year.
Medium-term priorities and long-term aims
NHS England’s objectives are:
- Stop avoidable illness and intervene early.
- Shift to digital and community.
- Share the best.
- Strengthen the hands of the people it serves.
- Support local partners.
It’s longer-term aims or required outcomes are:
- Longer healthy life expectancy.
- Excellent quality, safety and outcomes.
- Excellent access and experience.
- Equity of healthy life expectancy, quality, safety, outcomes, access and experience.
- Value for taxpayers’ money.
- Support to society, economy and environment.
There is much to welcome in the new operating framework. Overall, the scope and focus of the framework reflects the feedback provided by the NHS Confederation and our members through various meetings and roundtables.
Our ICS members believe the role of the framework is to set out a clear destination for ICSs to agree with their partners how they are going to get there. Generally, the framework meets this objective by setting out the national picture without being overly prescriptive about local arrangements, recognising that system leaders will need autonomy and space to be successful. We also welcome the commitment to further iterate the framework through engagement and co-production with ICBs and providers.
The framework touches on how NHS England will work with its partners across the health and care system. Considering the significant headcount reductions previously announced by NHS England, drawing on existing capacity and capability will be crucial to streamline functions and prevent duplication. For example, we at the NHS Confederation have already established an ICS leadership development programme and, in partnership with ICS leaders, have helped design the model for how systems contribute to local social and economic development on behalf of NHS England.
If the framework and its accompanying organisational development programme is implemented in full, it will mark a step change in the relationship between NHS England and the wider NHS
If the framework and its accompanying organisational development programme is implemented in full, it will mark a step change in the relationship between NHS England and the wider NHS. It is promising to see NHS England acknowledging the changes needed in terms of culture, behaviours and ways of working to support system working and the establishment of statutory ICSs, and examples provided in the framework are helpful. The approach NHS England colleagues have taken to developing this important programme of work has been open and candid, and we hope this will continue over the coming months and years as the changes are implemented.
However, the scale of change needed cannot be underestimated and this should be built on in the next stages of planning and engagement. We commissioned Sir Chris Ham to write a report on the relationship between the centre and healthcare leaders and strongly believe that successful implementation of the operating framework will require a more detailed examination of existing unhelpful practice and a move towards a relationship of trust and mutual respect.
We look forward to receiving more detail on the organisational development programme that will enable the different ways of working outlined in the document. We hope the future of national programmes will be clarified with a view to coordinate, streamline and prevent duplication.
There is a notable lack of mention of local government as well as the key role of the integrated care partnership. Although NHS England will not have formal oversight of these entities, not acknowledging their importance within the ICS is out of kilter with the emphasis our members place on cross-sectoral planning and delivery. Moreover, primary care is mentioned only once in the document. Although it is right that arrangements should be defined locally and the framework was focused on the relationship between NHS England and ICSs, it would have been a useful opportunity to emphasise some of Dr Clare Fuller’s recommendations for integrating primary care, which is widely supported and signed by all ICB chairs and CEOs.
It is useful to see some clarification around who is responsible for what in terms of regulatory functions. For example: ‘ICBs will lead on oversight of providers and work with NHS England regional teams if support is required at SOF 3. NHS England regional and national teams will lead on support and intervention at SOF 4.’ We welcome the stipulation that regional intervention in providers should only occur with knowledge of ICBs and their engagement. However, the language is focused on intervention, enforcement and who is accountable for what in challenged ICBs and providers, rather than on how improvement and transformation will be supported.
There is a risk of stifling innovation if a more proportionate approach to regulation and oversight is not adopted
This does not signal a reduction in the burden on systems or providers - just a shift of where the burden is managed from national to regional. There is a risk of stifling innovation if a more proportionate approach to regulation and oversight is not adopted. We hope to see this come through more strongly in NHS England’s new oversight framework.
There is also a risk in the way that integrated care boards and their functions have been presented, implying that they are an additional layer of bureaucracy or management when in fact their primary role is to support system working, support and enable transformation in the medium-to-long term and deliver progress against their four purposes.
While the wording of ‘support’ and ‘partnership’ is useful, NHS England will need to work with system leaders to clarify what this means in practice. It was disappointing not to see any mention of the role of ICB peer-to-peer support, sharing and challenge, which our members tell us will be crucial to moving away from a top-down regulatory intervention approach towards one of enabling and supporting improvement. We hope the emphasis put on NHS England’s role in collecting and sharing best practice is borne out in reality and that the starting point is that the most effective and sustainable quality improvement takes the form of local solutions that are scaled.
NHS England has made clear that this document is the core foundation of its new operating framework, which will be iterated based on engagements and co-production with system leaders. Accompanying the document will be a large organisational design programme to support changes to structural design and ways of working and will run beyond the merger date, recognising these changes will take time.
- We will continue to engage with NHS England as they look to iterate the framework and design and implement their organisational development programme through various channels with leaders from across the healthcare system.
- We would encourage system leaders to speak to their ICBs and NHS England regional directors about what they plan to do to adopt and tailor the framework locally.