Purpose
In October 2024, the NHS Confederation’s ICS Network gathered the views of integrated care board (ICB) leaders on the future of provider oversight. Through this exercise, we sought to clarify the position of different members and the degree of consensus that exists across ICBs in relation to the oversight framework and wider operating model. ICB chairs and chief executives of all 42 systems were consulted on three potential models of provider oversight, one of which was based on NHS England’s draft oversight framework, published in June:
- Model 1: The proposed NHS oversight framework is implemented in its current form, i.e. only ICBs with higher capability ratings will have delegated oversight of NHS trusts and foundation trusts.
- Model 2: Changes are made to the proposed oversight framework to remove the link between capability ratings and provider oversight, i.e. meaning that all ICBs would be responsible for provider oversight, not just those with higher capability ratings.
- Model 3: The oversight framework is changed to remove a provider oversight role from ICBs.
We shared the findings of our engagement exercise with senior leaders at NHS England in October and at the Department of Health and Social Care in early November, to inform their thinking about the future approach to system oversight and the views of ICB leaders.
Response
We received detailed responses from 41 individuals including 24 ICB chief executives and 17 ICB chairs. Two-thirds of ICBs (28 out of 42), across all seven regions, are represented in our analysis. 13 ICBs provided a joint response on behalf of both the chair and chief executive.
Summary
There was a clear consensus view among 86 per cent of ICBs that they should have a role in provider oversight. There was also strong alignment on how this should be carried out, with almost 70 per cent of ICBs favouring a fixed model (model 2) over one based on capability ratings (model 1).
Many systems had concerns that removing oversight responsibilities (model 3) would disempower ICBs, impeding system working and delivery of the left shift.
This was largely because system leaders felt that model 3 would make it harder to effectively hold providers to account for their contribution to system aims. Particular concerns were raised about the deliverability of commitments to improve population health and reduce health inequalities under model 3. ICBs were also concerned they would lose key intelligence and levers for system leadership, including financial management. They felt this could lead providers to disengage with system working and increase competition. Removing ICBs from provider oversight would also inhibit a more granular knowledge of local circumstances and relationships.
There was a recognition across responses that we need a tailored approach to account for the variation in size, maturity and capabilities of different ICBs and the providers in their system. However, almost every ICB felt that removing their role in oversight altogether was not the solution. Instead, the majority felt that where providers and/or an ICB are less mature, NHS England should provide additional support, with the goal of helping them become self-managing and self-improving.
There was also a clear appreciation among responses that the current oversight arrangement is making the lives of some providers more difficult due to unclear and duplicative processes. ICB leaders felt a sustainable solution could be found by setting clearer boundaries around the respective roles and responsibilities of NHSE and ICBs. Approximately half of respondents felt that NHS England’s draft oversight framework (published in June) did not provide sufficient clarity. Alongside greater clarity, multiple ICB leaders described the importance of strengthening working relationships between ICBs and regional teams, including joint regional oversight relationships.
Findings
Almost every system voted for ICBs to have a role in provider oversight
We asked ICB leaders to vote for the model of provider oversight they felt would work best. As illustrated in Figure 1, there was a clear consensus with 24 (86 per cent) of surveyed systems believing that ICBs should have a role in provider oversight. By comparison, only one system (4 per cent) categorically told us that ICBs should have no role in provider oversight (model 3). The remaining three systems (11 per cent) were categorised as inconclusive.
Figure 2 provides a full breakdown of votes across the three models. The 24 systems (86 per cent) that were supportive of ICBs having a role in provider oversight include:
- 3 systems (11 per cent) who voted for model 1, i.e. that ICBs should be responsible for provider oversight, but that it should be dependent on ICB capability assessments.
- 19 systems (68 per cent) of systems that voted for model 2, i.e. to give every system a role in provider oversight.
- 2 systems (7 per cen) – categorised as ‘other’ in figure 2 – that voted for a combination of model 1 and model 2.
Impact of the three models on ICBs and providers
Our survey asked each ICB leader to explain their choice of model, and to describe the impact each would have, particularly on their relationship with the NHS Trusts / Foundation Trusts in their system. We analysed that feedback, with our findings organised under three main themes.
1. If oversight was solely conducted by NHS England, this would disempower ICBs, impeding their ability to deliver against their four purposes
Nearly half of surveyed ICBs expressed significant concern that transferring full oversight responsibilities to NHSE could undermine and disempower ICBs. For almost 40 per cent of those in favour of model 2, oversight is a critical lever that ICBs need if they are to achieve their four purposes and unlock their full potential in strategic commissioning. In particular, numerous respondents felt that model 3 would make it harder to effectively hold providers to account on their contribution to improving population health, make the left shift to prevention, and address health inequalities. The loss of accountability for system finances would inhibit the movement of financial resource into prevention and care closer to home.
The most cited impact of NHSE retaining all oversight of providers was that it would threaten partnership working. ICB leaders are concerned that under model 3 they would lose key intelligence and levers, making it harder for the ICB to understand the challenges that Trusts are facing and undermining their ability to engage the wider system in solutions.
ICB leaders shared concerns that providers could disengage with system working prioritise their relationship with NHSE and return to a sovereign organisation mindset.
ICB leaders also told us that if NHSE is given sole responsibility for oversight, it could lead to a reduced focus on longer-term issues, resulting in a return to competition.
While there was a clear consensus among respondents that ICBs should have a role in provider oversight, there was nuance among responses about precisely what oversight should look like, with systems sensitive to the experience of providers. Overall, systems were broadly in agreement that for model 2 to work there needs to be greater clarity on accountabilities. For instance, one respondent said there needs to be “clear guidance on how the region and the ICB will work together with clearly defined boundaries and responsibilities.”
2. Systems recognised that ICBs are at different stages of maturity with additional support required
Three systems voted for model 1. Their reasons included the need to consider the variation in ICBs’ size, maturity and capabilities, with some not deemed to be ready to hold an oversight role. One ICB leader was worried that the latter risked undermining the principles of the ICB provider oversight role moving forward. Another felt that model 1 provides an incentive for ICBs with lower capability ratings to improve.
However, based on analysis of written responses, a high proportion of ICB leaders were opposed to model 1, with just over 20 per cent of those in favour of model 2 doing so on the basis that they did not agree with the capability assessments model proposed in the draft oversight framework. Two main concerns were raised:
- Model 1 would further disempower struggling ICBs who need greater support.
- The potentially variable function of an ICB would introduce uncertainty and instability, straining ICB-provider relations.
Many ICB leaders are sympathetic to the challenge that model 1 aims to address, i.e. that not all systems are at the same stage of maturity or capability. However, most members felt that using capability assessments to determine oversight is not the right approach. Instead of removing all responsibility from those with lower ratings, many felt that NHSE should work with and support those systems to get to the stage they can deliver that role independently.
3. A few ICBs felt that provider oversight sitting with NHSE could free up ICBs to focus on system priorities and lead to clearer lines of responsibility
As discussed, the majority of ICB leaders strongly opposed model 3. However, one respondent voted for model 3, with a few other leaders slightly warmer to it:
- One system felt that giving ICBs a role in oversight could introduce challenges for providers, potentially confusing the role of the ICB and further complicating oversight arrangements. By contrast, they felt a “linear arrangement” could provide greater clarity.
- One ICB leader felt that giving ICBs a role in oversight would challenge the ability of ICBs to remain focused on relationship building and system improvement.
- Linked to this, two ICB leaders felt that removing oversight altogether from ICBs would free up capacity to focus on delivering their integrated care strategies. As described above, however, the opposite view was held by a much higher number of ICB leaders.
Additional considerations
Approximately half of systems said they did not feel the current operating model provides sufficient clarity
Several respondents highlighted the impact this lack of clarity can have on providers in terms of duplication, parallel conversations and relationships. Issues raised included variation across NHSE regions and the lack of levers afforded to ICBs. One member suggested it would be helpful to have a roles and responsibilities matrix across national, regional and ICBs. Those who felt they had clarity indicated that they had established a positive relationship with their NHSE regional team with clearly articulated roles. Three systems highlighted the effectiveness of North-East and Yorkshire’s ‘4+1’ model, which they said has provided greater clarity, improved support, built trust and reduced duplication, something which was explored in a recent report by Sir Chris Ham.
There was a clear acknowledgement in ICB leaders’ responses about the experience of providers, namely around duplication of oversight. For instance, one system commented that “Greater clarity is needed to avoid duplication of efforts and causing confusion for Providers.” However, from their perspective, a lot of this relates to the clarity of the framework. There was a feeling, based on examples of good practice, that these concerns could be remedied through increased clarity in the framework about the respective roles and responsibilities of ICBs and NHSE (national and regional) combined with strong working relationships between ICBs and regional teams, including joint regional oversight relationships. One system told us:
“Finally, we would like to add that we all work as part of a system, NHSE and region included and that does mean that whilst more clarity than currently exists is needed, collaboration and joint working to resolve who does what on some occasions is also needed (e.g. clarity needs to be collaboratively reached not just provided in a top down way).”
Mixed views of ICB leaders about whether they have sufficient clarity and support from NHSE national and regional teams to effectively discharge a provider oversight function
In our qualitative analysis, less than 30% surveyed systems felt they had sufficient clarity and support from NHSE national and regional teams to effectively discharge a provider oversight function. By comparison, 25% felt they do not. The remaining responses were coded as ‘other’ due to them being more ambiguous.
The most common challenge described, which was cited by six systems, was the insufficient availability and access that ICBs have to data. One system told us:
“ICBs cannot always see the data that NHSE teams have access to even though it comes from ICS providers. The sort of support that would really make a difference is if NHSE shared their performance reports/unvalidated data so that ICBs are in the best place possible to address issues with providers at the outset…”
Five responses also highlighted challenges relating to insufficient resource and capacity to discharge a provider oversight role, with one system citing the recent 30% cut to ICB running costs. Multiple leaders also described an imbalance between the capacity of NHSE regional teams and ICBs. There were also repeated concerns about a general lack of clarity around the framework, including how it is administered and about the roles and responsibilities held respectively by NHSE and ICBs, with concern raised about duplication and the damage this does to relationships with providers.
A number of ICBs described positive working relationships between NHSE regional teams and the ICB, and this corresponded with levels of confidence within the ICB in how they discharge their oversight role. ICB leaders cited the value of strong relationships with NHSE regional teams, involving and/or leading to effective intel sharing. Many described co-producing a regional oversight model that clearly sets out roles and responsibilities, plays to respective strengths and is formalised through a memorandum of understanding (MOU).
