- Following the passing of the Health and Care Act 2022, integrated care systems (ICSs) became statutory bodies on 1 July, assuming a range of legal duties with regard to their local populations. Regulation has the potential to play a key role in supporting strong leadership behaviours, innovation, sharing of best practice and driving improvement.
- We have worked closely with regulators through various channels to inform their methodologies for system regulation and oversight. We worked jointly with NHS Providers to convene feedback sessions on the existing framework and to inform NHS England (NHSE)’s future plans for system oversight. We are pleased to see much of the feedback from our members included in the final framework.
- One of the most significant changes is a clearer explanation of the accountabilities and responsibilities for oversight of NHSE’s national and regional offices and integrated care boards (ICBs). The framework confirms that NHSE will discharge its oversight duties in collaboration with ICBs, asking ICBs to oversee and seek to resolve local issues before escalation.
- The focus on proportionate and effective oversight will be important to allow system leaders to get on with service improvements and address the big challenges they face.
- We are also pleased to see the framework attempting to ensure a balance between national and local priorities, clarity around the exit criteria for mandated support, and a commitment to consider the role of peer review as part of the oversight model in future. This should be built on in future iterations of the framework.
- However, it will remain to be seen if segmentation and exit criteria for mandated support improve clarity and regional consistency in practice.
- NHSE will work with system leaders over the coming year to develop a long-term model of proportionate and effective oversight of system-led care. We hope this will be underpinned by the structural, behavioral and cultural changes envisaged by the upcoming new NHSE operating model.
The NHS Oversight Framework describes NHS England’s approach to oversight of integrated care boards and trusts for 2022/23. It builds on the approach outlined in the NHS System Oversight Framework 2021/22. This briefing highlights the main changes to the framework for 2022/23 and our view on the implications for members.
In 2020 NHS England (NHSE) combined various existing oversight frameworks to form the System Oversight Framework. This framework provided a single, consistent NHS monitoring framework with the flexibility to support different system delivery and governance.
Given the impact of Omicron on the health and care system, and the delay to integrated care system (ICS) commencement, NHSE decided to carry forward the 2021/22 framework with some minor tweaks to account for the health and care bill and other developments, and focus on developing a long-term system oversight model for 2023/24.
To inform the new framework, we worked with NHS Providers to hold several engagement sessions with members across the Confederation and Iain Eaves, director of oversight and assessment at NHS England.
NHSE and the Care Quality Commission (CQC) will continue to work together to ensure synergy between the ICS reviews undertaken by CQC and the ICB assessments undertaken by NHSE.
What the framework says
The NHS Oversight Framework (‘framework’) has been updated to take account of changes enacted by the Health and Care Act 2022, including:
- the establishment of statutory ICBs with commensurate responsibilities and NHSE’s duty to undertake an annual performance assessment of these ICBs
- early learning from the implementation of the System Oversight Framework during 2021/22
- the priorities contained in the 2022/23 priorities and operational planning guidance.
The stated purpose of the framework is to ensure the alignment of priorities across the NHS and with wider system partners; identify where ICBs and/or NHS providers may benefit from, or require, support; and provide an objective basis for decisions about when and how NHSE will intervene.
The framework provides useful detail on lines of accountability for oversight.
NHSE will discharge its duties in collaboration with ICBs, asking ICBs to oversee and seek to resolve local issues before escalation. NHSE will intervene directly with providers only in exceptional circumstances, for example, where enforcement action is necessary, and with the full awareness of the relevant ICB.
ICBs will lead the oversight of NHS providers, assessing delivery against the domains listed below, working through provider collaboratives where appropriate:
- quality of care, access and outcomes
- preventing ill health and reducing inequalities
- finance and use of resources
- leadership and capability
- local strategic priorities.
The full set of oversight metrics can be found on the NHS England website. ICBs will consult with their NHSE regional team about areas of concern, specific support requirements and issues requiring formal intervention by NHSE.
Together, NHSE and ICBs will agree the specific arrangements for each system to ensure effective and proportionate oversight, reflecting local delivery and governance arrangements.
Approach to oversight
The memoranda of understanding (MoU) developed jointly between NHSE regional teams and ICBs in 2021/22 forms the basis of these arrangements. NHSE has developed an outline MoU and supporting guidance to support ICBs and regional teams to update individual MoUs to reflect the new statutory arrangements and the updated framework.
Notably, MoUs will now be expected to set out more detailed arrangements for proportionate and robust oversight mechanisms and structures across the ICB and its partner organisations, which reflect the local delivery and governance arrangements and the respective roles of the ICB and NHSE, as clarified in the framework.
Bespoke oversight arrangements will be required in certain instances: for example, where ICBs commission services under a delegated agreement; providers operate across multiple ICBs; or a nominated ICB acts as a lead commissioner on behalf of the region. In such cases, regional teams will work with ICBs and service providers to ensure there are appropriate oversight arrangements.
Performance will be measured according to the themes of the framework (see Figure 1 on page 6 of the document). NHSE will collect and review both quantitative and qualitative data:
- quantitative data, including the published NHS oversight metrics
- qualitative information, derived from oversight, quality, improvement and performance conversations with ICBs and their formal reporting documents, as well as other routine information, including from relevant third parties.
If implemented successfully, the framework will facilitate the early identification of emerging issues and concerns to prevent material impact or deteriorating performance. NHSE’s expectation is that ICBs and trusts will maintain relationships with NHSE so that actual or prospective changes in performance are shared in a timely manner. Where quality risks are material to the delivery of safe and sustainable services, these should be managed and escalated in line with the National Quality Board quality risk response and escalation guidance.
NHSE regional teams will work with ICBs to ensure that oversight arrangements at ICB, place (including delegated commissioning arrangements) and organisation level incorporate regular review meetings as appropriate. See Table 1 (page 11 of the framework) for further details on the scope, format regularity of these meetings.
Criteria for segmentation decisions
The framework provides further detail on the criteria used to determine the scale and nature of support needs, ranging on a scale of segment 1 (no specific needs) to requirement for mandated intensive support (segment 4).
Primary care providers and primary care networks (PCNs) will not be allocated to segments. However, notably, the overall quality of primary care will inform ICB segmentation decisions.
Segmentation decisions continue to be determined by assessing the level of support required based on a combination of objective criteria and judgement. They will be regularly reviewed to ensure they remain an accurate reflection of the level of support required. For individual trusts, NHSE and the relevant ICB will together discuss segmentation and any support required. NHSE will be responsible for making the final segmentation decision and taking any necessary formal enforcement action.
See Tables 2 and 3 on pages 13-15 of the oversight framework for an explanation of segments and decision-making criteria. The main additions for the 2022/23 framework are further criteria within segments 3 and 4 regarding quality and safety risk management (see page 14 and 15).
Autonomy will be the default position within the framework, with the expectation that ICBs and trusts will be allocated to segment 2 unless specific mandated support is required. The principle of earned autonomy still applies to those ICBs and trusts allocated to segment 1, who will benefit from the lightest oversight arrangements, and may be encouraged to provide peer-to-peer support and spread good practice to other systems and providers.
NHSE has committed to working with ICBs in 2022/23 to explore the role peer review could play in the oversight model in future.
Recovery Support Programme
The framework elaborates on how the Recovery Support Programme (RSP) – which applies to providers and ICBs in segment 4 – will operate. In addition to the detail outlined in the 2021/22 framework, the RSP is:
- available to support ICBs and trusts with increasing, complex challenges, helping to embed improvement upstream to prevent further deterioration and enable stabilisation
- focused on building resilience within trusts and systems with knowledge and skills transfer providing sustainable capability within the system, such that they exit the programme with the knowledge and skills they need to achieve sustainable improvement
- designed to place an expectation on systems to build the capacity required to maintain improvement.
Moreover, where a trust is in the RSP, an improvement director, reporting to the director of national intensive support, will support the trust and its system partners to develop an improvement plan which will include a target timeline for exit from the RSP and segment 4.
NHSE must sign off the improvement plan for both ICBs and trusts placed in segment 4.
The new framework also elaborates on the exit criteria used to leave segment 4. NHSE will make a decision on exit from the RSP on the basis that the agreed exit criteria have been met in a sustainable way and any required transitional intensive support is in place as an ICB or trust moves to segment 3.
As support is also mandated in segment 3, the improvement plan should remain in place and will continue to be reviewed at a regional level to ensure improvement is being achieved. Where the objective eligibility criteria for entry into the RSP included a recommendation from the CQC, the decision to exit segment 4 will consider the evidence underpinning the CQC recommendation.
In addition to the process described above, further RSP review meetings may be held between the NHS England board and the trust and its system or the ICB. (See Annex A and page 26).
Under the Health and Care Act 2022, NHSE now has a legal duty to annually assess the performance of each ICB in each financial year and publish a summary of its findings.
In conducting this performance assessment, NHSE will consult each relevant health and wellbeing board as to its views on the ICB’s implementation of any joint local health and wellbeing strategy.
The NHSE regional team will conduct the annual assessment, drawing on national expertise as required and having regard to relevant guidance. It will, in particular, consider how successfully the ICB has:
- contributed to the wider local strategic priorities of the ICS
- performed its statutory functions, including in particular how it has discharged its legal duties under the National Health Service Act 2006 (as amended by the Health and Care Act 2022) and the Local Government and Public Involvement in Health Act 2007, in relation to:
- improving the quality of services
- reducing inequalities
- obtaining appropriate advice
- the effect of decisions (the “triple aim”)
- public involvement and consultation
- financial duties
- having regard to local assessments and strategies
- promoting and using evidence from research.
- delivered on any guidance set out by NHS England or the Secretary of State regarding the functions of the ICB
For 2022/23 the assessment will be in narrative form and will identify areas of good and/or outstanding performance, areas for improvement and any areas that are particularly challenged.
As this will be the first year in which ICBs operate, NHSE will work with them during the first half of the year to develop further detailed guidance to support annual assessments for 2022/23. NHSE will review and develop this approach for future years.
We support NHSE’s logic in making small adjustments to the framework and pursuing a larger evolution for 2023/24 once there is further certainty about how the various layers of governance and accountability will work in practice.
The framework offers some welcome clarity on the delineation of roles and responsibilities between NHSE’s national and regional teams, ICBs and wider ICSs. This description of lines of accountability for oversight, particularly relating to provider collaboratives and place-based partnerships, will need to evolve in sophistication over the coming months and years as relationships develop, and the role and added value of system regulation and system working more generally becomes crystallised.
We look forward to working with NHSE to ensure an open dialogue between national/regional teams and providers/systems
There is some attempt within the framework to ensure a more consistent application of the framework across regions, including the behaviours of regional teams and their relationships with systems and providers. However, much of this will depend on practice on the ground and we look forward to working with NHSE to ensure an open dialogue between national/regional teams and providers/systems.
Consistency is a particular concern for ambulance trusts which span several ICSs. We are therefore pleased to see that bespoke arrangements will be negotiated between regional teams, ICBs and service providers in such instances.
We are also pleased that NHSE has reaffirmed its commitment to work with ICB leaders over the coming year to explore the role of peer review within the framework.
NHSE should look to maintain proportionality in its setting of national objectives
As we emphasised in a recent report, proportionality will need to be an important guiding principle for regulators as they start to regulate and oversee systems. We are pleased to see this wording reflected several times within the framework and a clearer explanation and exit criteria for the Recovery Support Programme. NHSE should look to maintain proportionality in its setting of national objectives within the upcoming refresh of NHS Long Term Plan priorities as well as other key documents, such as the planning guidance and NHS Mandate.
The NHSE operating model was not explicitly mentioned within the framework but will be a key instrument for ensuring the cultural and behaviour change needed to support integration. There will need to be some behaviours underpinning both the operating model and oversight framework, namely:
- an adult-to-adult relationship
- a move away from a blame culture
- better communication, coordination and cohesion across NHSE’s internal structure.
We welcome further engagement with our members working across ICSs on the new operating model to this end.
The next framework should support a move away from easily measurable processes and towards outcomes such as reduced health inequalities
We look forward to working with NHSE on the next iteration of the framework. System leaders tell us that the next framework should be a bigger evolution and will need to grapple with the complexity they are operating within – particularly in relation to accountabilities, the role and expectations of provider collaboratives and the added complexity of bigger ICSs and places within them.
The next framework should clearly support a move away from easily measurable processes and towards outcomes such as reduced health inequalities, which will make a real difference to populations. It should build on insights from primary care, including Claire Fuller’s recommendations on integrating primary care, to ensure the 2023/24 oversight framework appropriately incorporates primary given its key role in supporting integrated care pathways. It would be useful to include some worked examples of what the framework is aiming to achieve – this would bring the framework to life.
How we will be supporting members
2022/23 will be a year of transition as ICBs are formally established and new collaborative arrangements are developed at system level. NHSE will take the opportunity in 2022/23 to consult with system leaders to develop a long-term model of proportionate and effective oversight of system-led care. It will work with system leaders during the first half of the year to develop guidance on annual ICB assessments for 2022/23.
We will support and convene such co-design processes wherever possible. We will continue to work with our members across the system to develop oversight models that are proportionate and enable system leaders to improve population health, reduce inequalities, enhance productivity and efficiency and help the NHS support broader social and economic development. We will continue to drive conversations around the role of peer review as a robust improvement methodology within NHSE’s framework, ICS assessments and the wider regulatory landscape.