Towards Population Health Delivery Models: what you need to know

Summary

Purpose and scope of the blueprint

The blueprint provides guidance on the three population-based delivery models introduced in the government’s 10 Year Health Plan: single neighbourhood providers (SNPs), multi-neighbourhood providers (MNPs) and integrated health organisation (IHO) contracts. 

These new models aim to enable local leaders to align incentives, reduce the fragmentation of services across multiple contracts and organisations and rebalance where resources are directed. The document emphasises that to achieve these goals, leaders across sectors must ‘avoid organisational self-interest at all costs’. 

The blueprint is intentionally light touch and non-prescriptive, designed to be used to build on existing local contractual arrangements and service configurations where they are working well or to provide clear alternatives where they are not. Costly or disruptive reorganisation of the provider landscape is discouraged; instead ICBs are encouraged to empower capable providers to plan and deliver end-to-end pathways. 

The blueprint should be read alongside the Model ICB Blueprint, Strategic Commissioning Framework, the Neighbourhood Health Framework and the upcoming IHO blueprint. 

Three complementary population-based delivery models

The graph below shows how these contract types nest within one another so outcomes can be aligned from system level through to individual neighbourhoods.

Capabilities for commissioning the new delivery models

The blueprint sets a clear expectation that commissioning these new contracts will require effective use of data, insight and financial stewardship. Commissioners will need to: 

• have a robust understanding of population need, drivers of demand, how people use services, and the cost, quality and productivity of current provision, drawing on joined-up person-level data
• use detailed activity and cost data to guide medium-term planning, prioritise high-value interventions and shape workforce and skill mix design
• Apply national modern service frameworks to design evidence-based integrated neighbourhood care models and population health improvement plans
• Hold and manage the contract budget, commission and subcontract services across acute, mental health and neighbourhood care, coordinate integrated delivery of services, and broker savings and losses to direct resources where they deliver greatest value for patients.

Guiderails for local planning

The blueprint makes clear that there is no single prescribed route for implementing these delivery models. Local leaders are best placed to determine how and where they are commissioned. To support this flexibility, the blueprint sets out ‘guiderails’ that clarify local roles and responsibilities:

• The government expects ICBs to be able to explain how they have begun implementing some outcome-based contracts within the next three years. ICBs will always retain their role as the strategic commissioner, even where some responsibilities may transition to the IHO contract holder.
• Providers will continue to hold multiple contracts. A provider holding an IHO contract will continue to deliver services under the NHS Standard Contract for populations outside of the IHO scope and footprint.
• Delivery models will be assessed against locally agreed objectives, the Medium Term Planning Framework objectives, and performance against the NHS Oversight Framework.
• To increase investment in out-of-hospital care, commissioners are being asked to transition towards implementing new nationally developed financial flows, alongside locally tailored approaches. This may include risk/gain sharing arrangements, to incentivise and reward the shift of activity into community-based, preventative services.

End state

The blueprint sets out a future state in which providers are empowered to hold more responsibility for planning and delivering services, while ICBs as strategic commissioners work with local partners (including local authorities) to set the outcomes for the contracts. The government’s ambition is for IHO contracts to become the norm by 2035. Within the next three years ICBs are expected to evidence progress towards implementing some outcome-based contracts.

IHO contract holders will allocate resources and design care models for defined populations by subcontracting neighbourhood services (often through MNPs), managing the GMS contract locally, and either directly delivering or subcontracting other acute, mental health and community services from other providers.

What to expect next from the national team
 

• The upcoming strategic commissioning development programme will help ICBs and key partners, such as IHO designates, to develop the capabilities needed to commission the new contractual models.
• As 2026/27 is intended as a developmental year, the Department of Health and Social Care (DHSC) and NHSE will continue to consult and refine the new contracts, including testing with early adopters.
• Further guidance is expected that will set out further technical detail: an IHO blueprint will be published over the coming months, and a consultation will be launched alongside guidance on the implementation of SNP and MNP contracts.
• The first wave of providers eligible to hold an IHO contract will be designated in spring 2026, alongside publication of the updated advanced foundation trust (AFT) programme guide for applicants, following consultation.
• Support will be provided to IHO designates and their ICBs through a new IHO implementation programme, which will co-develop service scope, contract objectives and new financial flows, enabling an iterative approach while building a pipeline for wider rollout.
• The national team will consider routes to enable non-NHS organisations such as primary care providers to hold an IHO contract, including via partnering with NHS organisations, or forming a new NHS organisation themselves.
• Good practice guidance on effective provider group models will also be published later in the summer. 

Analysis

This document signals the government’s commitment to establishing a permissive and enabling framework that supports NHS leaders to integrate care and enhance services. NHS leaders will welcome this permissiveness and the ambition to empower them and will recognise the difficulties the models are intended to tackle. The blueprint is high level, providing an initial steer on the scope of new contractual models, without being too prescriptive on, for example, partnership structures and (sub)contracting arrangements 

At the same time, IHOs are a significant transformation that carries high levels of risk, meaning certain elements of the policy – such as the designation process – must remain appropriately structured and nationally led. It will be important to maintain a developmental and learning‑oriented approach as this policy area develops, ensuring progress is guided by evidence and shared objectives rather than external pressures. 

The blueprint provides some detail on how new contractual models relate to one another and sets an expectation that IHO contract holders – where they exist – will subcontract neighbourhood services, including through MNPs. This role will be conducted by ICBs in areas without an IHO contract. We agree on the need for clear mapping between SNP, MNP, and IHO contracts to enable the setting of consistent outcomes, coherent pathway planning and effective resource allocation. But we are concerned about how this will be achieved in practice. While it makes theoretical sense for the population covered by an IHO contract to align with one or more MNP footprints, practical considerations such as patient flow, service catchment areas and the ongoing reorganisation and realignment of ICB and local government boundaries may make this difficult to deliver. 

The blueprint also specifies that IHO models must involve a provider ‘working towards’ taking responsibility for resource allocation and service planning for a geographically defined population through a population health budget. This indicates that IHOs arrangements will be incremental, building up from collaborative arrangements such as lead provider models, to an end state whereby the host provider holds responsibility for the population health budget. 

The three-year timeframe for ICBs to begin implementing some outcomes-based contracts will likely be difficult to achieve. At the time of publication, planning for 2026/27 is already largely complete, meaning substantive implementation cannot begin until 2027/28. National guidance has also not yet been given on the new nationally developed financial flows, which will be essential to support outcomes-based contracts. It will be important for the pace of progress to be guided by organisational and system capability, ensuring changes are sustainable and not solely driven by external targets.

The roles of ICBs and providers

The blueprint clarifies the distinct roles of providers and ICBs in commissioning and delivering population-based delivery models. ICB leaders will welcome new contractual tools being developed to enable them to fulfil the enhanced responsibilities set out in the Strategic Commissioning Framework. 

The blueprint’s confirmation that ICBs will remain the strategic commissioner for each system is helpful. However, there are significant questions about whether ICBs currently have the capacity and capability to commission these contracts and to manage them effectively in the future. While the strategic commissioning development programme is intended to help build this over time, ongoing reorganisation, budget and staffing reductions, and the resulting disruption will make it difficult to develop and implement IHO contracts to the blueprint’s timescales.

Many trust leaders will welcome the opportunity to take on the greater role offered through holding an IHO contract. Those that do may continue to use lead provider arrangements for specific pathways. This will reassure providers, particularly mental health and learning disability providers, that their specialist expertise – already well-established through such models – will not be diluted under IHO arrangements.

There is some ambiguity around the intended role of primary care leaders. Many will welcome opportunities to take on new neighbourhood services through SNPs, and the strong emphasis on primary care clinical leadership in IHOs is similarly encouraging. But some also hope and expect to play a substantial role in leading MNPs – an ambition that is not strongly reflected in the blueprint. Leaders working within general practice, pharmacy, optometry and dentistry should be involved in the development of these contractual models.

IHO designation and oversight

There remain questions about the respective roles of NHSE and ICBs in designating eligible hosts and awarding IHO contracts. For instance, the current process to identify and support providers that are eligible to hold an IHO contract has been led by NHSE, with a lack of clarity about what happens if the ICB does not want to commission an IHO contract, or if an ICB sees an opportunity for an IHO contract but is blocked by the centre. Beyond the point of designation, the future role of DHSC/NHSE regional teams in overseeing IHO arrangements is unclear. There is therefore a risk that their provider oversight remit could overlap with ICBs’ contractual oversight responsibilities. ICBs must feel empowered and supported to make decisions based on their local population and service provision needs.

Widening eligibility for holding IHO contracts in future

IHO contracts are intended to improve allocative efficiency and financial performance. We therefore believe that limiting IHO contracts to only ‘high-performing’ foundation trusts (as they currently are) risks exacerbating performance variation and inequalities. We are therefore supportive of NHSE’s intention to consider widening eligibility to areas where an IHO contract might solve entrenched problems in a health system. This will help deepen their understanding of whether IHO contracts can address such challenges and, importantly, identify any additional mitigations need to manage risk. 

In areas which do have primary care at scale with robust formal governance, risk management and devolved decision-making, we believe these bodies should not be ruled out of becoming IHO host providers in the longer term, particularly as GP federations may in some places hold multi-neighbourhood contracts. We therefore welcome the commitment to explore routes for ‘mature neighbourhood providers’ (which include primary care at scale) to hold IHO contracts.

Incentivising partnership working

The blueprint’s emphasis on partners jointly using new contractual models to improve local services is welcome. However, the indication that partners should ‘avoid organisational self-interest at all costs’ is at odds with how the government currently holds NHS organisations to account, and with the duties placed upon boards. Firstly, FT boards have a statutory duty to promote the success of their organisations for the benefit of the public. Secondly, the metrics currently in the NHS Oversight Framework (NOF) and the Medium Term Planning Framework are too focused on the activity of individual organisations, rather than a set of shared outcomes focused on population health. While the criteria for AFT status and IHO designation appropriately incentivise partnership working, there is a risk that existing oversight frameworks and performance league tables reinforce organisational siloing and competitive behaviours, thereby reducing the incentive for the collaboration required to make these new models effective. Unless these conflicting policy agendas are resolved, they will continue to undermine progress towards delivering these new contractual models.

Next steps for NHS leaders

There are several encouraging references throughout the blueprint to co-production and an emphasis on an iterative approach to policy development, particularly with reference to IHO contracts. Given the structural changes and financial challenges that many providers and ICBs are experiencing, a pragmatic approach will be required to ensure a realistic pace of change. We therefore welcome the commitment from DHSC and NHSE to work closely with early adopters to gather learning and refine the model over time. To build the evidence base for IHO contracts, including considering widening eligibility to areas where this contract type may solve entrenched problems in a health system, we believe NHSE should co-produce the IHO blueprint and its IHO development programme with the first wave of IHO designates as well as leaders from more challenged systems who are interested in holding an IHO contract in the future. Our members will appreciate the opportunity to input on the contractual detail through the consultations in due course.