nhs business plan 2023

NHS England releases its 2023/24 business plan

New plan focuses on cutting waiting lists, recovering core service performance, delivering on the NHS Long Term Plan and supporting digital transformation.

NHS England has released its business plan for 2023/24, setting out its priorities and commitments for the coming year. The plan identifies “three key tasks” for the NHS, namely; recovering core services and productivity; delivering the key ambitions of the NHS Long Term Plan ; and continuing to transform the NHS for the future.

Also included are measures to support the NHS workforce through increased training, retention and modernisation of working practices, in line with the recently published NHS Long Term Workforce Plan, and to support the transition of staff to integrated care systems.

The document also includes a breakdown of the NHS’ commissioning budget for the year (see Figure 1), which stands at £168.8bn, up from £153bn in 2022/23, as well as that of the central admin and programme revenue funding (Figure 2). The majority of this fund – £114.3bn – will be allocated to integrated care boards (ICBs) to commission local services, while £32.3bn will be used to directly commission a range of primary care and public health services.

A further £4.9bn will be spent on workforce education and training via an annual investment planning process – the Multi-Professional Education and Training Investment Plan (METIP).

The full NHS business plan 2023/24 can be accessed here .

Below is a selection the NHS’s key commitments for the year 2023/24, as stated in the business plan, along with a some of the provisions included to deliver on these objectives:

Improving ambulance response and A&E waiting times

Increasing capacity: Dedicated funding for £1bn to pay for additional capacity, including 5,000 new beds; working with the ambulance service and wider systems to increase capacity supported by dedicated additional funding of £200m; the provision of £150m to build 150 new facilities to support mental health urgent and emergency care services.

Growing the workforce: The launch of a new targeted campaign to encourage retired clinicians, and those nearing retirement, to work in 111 rather than leaving the NHS altogether; making recruitment easier by reviewing the training and NHS Pathways licence requirements.

Reducing elective long waits and cancer backlogs, improving performance against the core diagnostic standards

Elective: Developing and implementing a new outpatient productivity programme that focuses on freeing up capacity; targeting improvement/transformation support to the most challenged providers, and clinical specialty pathways.

Cancer: The provision of more than £390m in cancer service development funding to cancer alliances to support delivery of early diagnosis and key operational priorities; a continuation of the rollout of non-specific symptoms pathways; supporting the rollout of targeted lung health check sites.

Diagnostics: Providing funding to support the development of pathology and imaging networks and the development and rollout of community diagnostic centres (CDCs) (£2.3bn of capital funding to 2025 has also been allocated to support diagnostic service transformation, including to implement CDCs, endoscopy, imaging equipment and digital diagnostics).

Improving access to primary care services, particularly general practice

Empowering patients: Transforming the NHS App to support the ambition for 75 per cent of all adults in England to be registered on the NHS App by March 2024; launching Pharmacy First (subject to a DHSC led consultation with Pharmaceutical Services Negotiating Committee) enabling pharmacists to supply prescription-only medicines to treat common health conditions where clinically appropriate.

Implementing modern general practice access: Supporting the transition to digital telephony; making high quality online consultation, messaging and booking tools available to general practice; investing in a new National Care Navigation Training Programme for up to 6,500 staff.

Improving maternity and neonatal services

Equity and personalised care: Piloting and evaluating new service models designed to reduce inequalities, including enhanced midwifery continuity of carer; acting on findings from the evaluation of independent senior advocate pilots as set out in the interim Ockenden report.

Retaining, growing and investing in the workforce: Funding a retention midwife in every maternity unit during 2023/24; strengthening neonatal clinical leadership with a national clinical director for neonatal and national neonatal nurse lead; working with the Royal College of Obstetricians and Gynaecologists to develop leadership role descriptors for obstetricians to support job planning, leadership and development.

Preventing ill health and narrowing health inequalities in access, outcomes, and experience

Major conditions and public health: Developing cardiac and pulmonary rehabilitation resources to support local decision making and improve access; delivering national services to support improvements in Type 2 diabetes prevention and remission services and national digital structured education support for Type 1 and Type 2 diabetes.

Screening and vaccinations: Developing and publishing a vaccination strategy and starting implementation in partnership with regional teams and ICSs; developing strategies for NHS screening and Child Health Information Services (CHIS).

Health inequalities: Publishing a healthcare inequalities strategy, with supporting resources including a new system accountability framework and framework for NHS action on inclusion health.

Building and developing the workforce for now and the future

Growing the workforce: Supporting expansion of the workforce and development of new roles aligned to key service development priorities; implementing the global health workforce strategy; delivering the 2023/24 METIP plan for medics, and clinical professions and develop the Clinical Placement Management System.

Culture: Co-producing management, talent and leadership development products, taking account of the Messenger review; developing and supporting implementation of interventions to deliver on the People Promise, improving staff experience and retention.

Digitisation

Ensuring that 90 per cent of trusts have an electronic patient record (EPR) ; developing and deploying a support offer to trusts undertaking EPR-related transformation and publish Minimum Digital Foundations guidance; providing practices with the digital tools to support Modern General Practice Access, and fund transition cover (for those that commit to adopt this approach before March 2025).

Developing the NHS App as the digital front door of the NHS ; delivering new functionality for the NHS App, to help people take greater control over their health and their interactions with the NHS.

Procuring a Federated Data Platform , available to all ICSs, with nationally developed functionality including tools to help maximise capacity, reduce waiting lists, and coordinate care.

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NHS England sets out 23/24 business plan

Home > News > NHS England sets out 23/24 business plan

NHS England has set out its 23/24 business plan with a foreward by Chairman Richard Meddings below:

"We are creating a new organisation following the legal merger of NHS England with NHS Digital on 1 February 2023, and Health Education England on 1 April 2023. This new NHS England will be smaller, more efficient and joined up, and speak with one voice to systems.

NHS England operates under a mandate from government and has a duty to seek to achieve the objectives set out within it, which are under four headings:

Cut NHS waiting lists and recover performance.

Support the workforce through training, retention and modernising the way staff work.

Deliver recovery through the use of data and technology.

Continue work to deliver the NHS Long Term Plan to transform services and improve outcomes.

This business plan incorporates the actions we will take to meet the 2023 mandate objectives and deliver on our purpose to lead the NHS in England to deliver high-quality services for all. The NHS England Board will oversee its implementation to ensure we make real progress for the patients and populations we serve.

The NHS resource budget for 2023/24 is £168.8 billion and the Government expects NHS England to ensure that overall financial balance is delivered for the NHS each and every year. We will continue to support the NHS in making the most effective use of this public money.

This is an ambitious programme made possible through the extraordinary efforts of NHS staff across England and I wish to place on record my appreciation for their engagement."

Read full business plan

Date: 14 September

Posted in News on Sep 14, 2023

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NHS 2023/24 Business Plan

NHS England has published its business plan for 2023/24 which includes main objectives under four headings: Cut NHS waiting lists and recover performance, Support the workforce through training, retention and modernising the way staff work, deliver recovery through the use of data and technology and continue work to deliver the NHS Long Term Plan to transform services and improve outcomes. To read the Business Plan in full, click here .

NHS England 2023/24 business plan

NHS England have published a 2023/24 business plan which sets out NHS England’s work in leading and supporting the NHS to respond to three key tasks including: the recovery of core services and productivity, progress in delivering key ambitions in the NHS Long Term Plan and transformation of the NHS for the future.

You can view the 2023/24 business plan publication here: NHSE 2023/24 business plan

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NHS England publishes 2023-2024 business plan with focus on digital

NHS England has published its business plan for 2023-2024, setting out plans to address challenges including health inequalities, access to primary care services, elective long waits and ambulance response, as well as highlighting the intention to “transform care through harnessing data, information and technology”.

The new business plan incorporates actions that will be taken to meet the 2023 mandate objectives across four headings: cutting NHS waiting lists and recovering performance; supporting the workforce through training, retention and modernising the way staff work; delivering recovery through the use of data and technology; and continuing work to deliver the NHS Long Term Plan to transform services and improve outcomes.

Digital is said to play a role in reducing elective long waits and cancer backlogs, particularly in the area of diagnostics, with the plan mentioning specifically £2.3 billion in capital funding allocated to 2025 for supporting diagnostic service transformation, including digital diagnostics and digital diagnostic infrastructure. The ambition is that 95% of patients receive a diagnostic test within six weeks by March 2025. The plan also highlights the development of a Patient Initiated Digital Mutual Aid System (PIDMAS), which “will offer patients the ability to opt-in to move provider when they have been waiting over 40 weeks for care”.

In access to primary care, the role of digital will focus on helping to implement modern general practice access, with practices transitioning to digital telephony, ambitions for 75% of all adults in England to be registered on the NHS App by March 2024, and a commitment to improving “the digital infrastructure between general practice and community pharmacy to streamline referrals”.

Under “improving mental health services and services for people with a learning disability and autistic people”, the plan highlights the need to “create a strategy for integrating digital health technologies in mental health settings and pathways”, in order to support the delivery of mental health improvements.

Digital is again a key factor set out by the new plan in preventing ill health and tackling health inequalities, with a focus on the potential to develop a “national digital structured education support for Type 1 and Type 2 diabetes”, as well as a digital tobacco dependency service. To strengthen screening and vaccinations, the plan notes the need to “enhance the vaccinations digital platform, developing a national vaccination record, extending the use of the NHS App and establishing the foundations for a lower cost base”, and to “implement the digital transformation of screening, to deliver new digital products for the invitation of, and communication with, eligible members of the public for the breast and diabetic eye programmes”.

On developing the workforce, digital technology will be used to “help increase the time to care and respond to changing population needs”, whilst the plan identifies the development and roll-out of digital solutions such as a staff app or digital staff passport, as helping to “support flexible working practices and flexible deployment of staff across organisational boundaries”.

Finally, under the header “transform care through harnessing data, information and technology”, the plan sets out the opportunities to “accelerate the digitally enabled transformation of the NHS, adopting effective technologies and building on insights from data and cutting-edge research”. According to the plan, NHS England “will continue to work with systems to level up digital infrastructure, drive greater connectivity and support the development of a digital first option for the public, helping patients identify their needs, manage their health, and get the right care in the right setting”. Here, the plan states, will involve a focus on three areas: ensuring digital foundations “are in place everywhere”; “helping the different parts of the NHS to work together through improved use-ability, connectivity and interoperability”; and “using digital products and leveraging innovation and research to transform health and care”.

Priorities under the same header include ensuring that 90% of trusts have an electronic patient record (EPR), delivering “technology upgrades across primary care”, developing a “portfolio of core digital products and services” to improve outcomes and “address legacy technology constraints”, and accelerating “the uptake of the most promising Artificial Intelligence (AI) technologies”.

Specific actions to help deliver on these priorities include developing a “support offer to trusts undertaking EPR-related transformation and publish Minimum Digital Foundations guidance”; procuring a Federated Data Platform, available to all ICSs, with nationally developed functionality including tools to help maximise capacity, reduce waiting lists, and coordinate care; and piloting an “Artificial Intelligence deployment platform”.

Last year, we explored the role of digital in NHS England’s business plan for 2022-2023 , which focused on responding to pandemic challenges, transforming delivery of health and care through collaborative system working, and using data and digital technologies.

Just last month, we also considered the importance of digital technologies in supporting NHS England’s winter resilient system roles and responsibilities plan , which highlighted the role for digital in supporting primary care access, and in achieving an 80 percent occupancy rate target for virtual wards over the winter period.

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Business plan 2023-2024

Foreword by matt westmore, chief executive.

The Health Research Authority (HRA) plays a pivotal role in making possible high-quality, and trustworthy health and social care research that is done with and for everyone.

Our strategy is focused on two guiding principles: include and accelerate. These underpin the HRA's commitment to earning and maintaining the public's trust in research, which in turn is essential for the success of the research community. If we do this right, we will continue to be one of the best places in the world to do research with outstanding science, globally successful companies, thriving national health and social services and strong public support.

The HRA cannot achieve its vision alone; we work in partnership with various stakeholders, including the devolved administrations, other regulators and agencies, the NHS, the research community, charities, industry, and the public. I would particularly like to acknowledge and say thank you to our dedicated staff who work tirelessly to support the research community and promote the interests of the public, and the HRA Community who generously give their time to make a difference in the UK's research landscape.

This business plan for 2023-2024 will make it easier to do research that people can trust. This will be achieved by focusing on the issues that matter to people, involving people in our work, making use of digital technology and constantly improving processes. We will continue to simplify and join up research set-up processes across the UK, reducing the time it takes to start good research. We will ensure more diverse groups of people with lived experience are involved in all stages of research and are able to take part. We will make sure the findings are shared publicly so that they can be used to improve care. We will support action to make sure precious NHS resources are focussed on research that will help improve care, and we will work with research teams to explore new ways to do research.

The work we set out in this business plan supports other government priorities, including the work of Recovery, Resilience and Growth Programme partners, the review of clinical trials led by Lord O’Shaughnessy and work being undertaken with Sir Patrick Vallance on the life sciences regulatory environment.

Our plan is challenging and exciting. By speeding up how health and social care research is set-up and working with the Medicines and Healthcare products Regulatory Agency (MHRA) on new clinical trial regulations, we aim to make the UK an even more attractive environment for life sciences investment. By putting people at the centre of research and supporting people from across the UK to be involved and participate, we will contribute to the government’s ambitions for levelling up. Most importantly, we will embark on the next phase of the development of the Integrated Research Application System (IRAS), which will benefit not only the HRA but also the other agencies and researchers who rely on it to set up research in the NHS or social care.

In short, our business plan demonstrates the HRA’s commitment to making it easy to do research that people can trust. I am confident that it will enable us to continue to play a vital role in making possible high-quality, trustworthy health and social care research in the UK.

Chief Executive, Health Research Authority

Introduction

Our strategy, how we will make change happen, our plans for 2023-24, include: health and social care research is done with and for everyone, accelerate: research findings improve care faster because the uk is the easiest place in the world to do research that people can trust, digital: use digital technology well to do our work, improve: ensuring we have the right culture and capability to deliver our strategy, financial plan, capital funding, research systems transformation, financial plan 2023-2024.

Our vision is for high quality health and social care research today, which improves everyone’s health and wellbeing tomorrow.

We help realise this by making it easy to do research that people can trust. Established in 2011, we have transformed UK research regulation and governance by simplifying processes, removing duplication and reducing timelines. We have better supported the research community by putting people first.

The Health Research Authority is an independent arm’s length body of the Department of Health and Social Care (DHSC) . We have more than 260 staff in England who work at home and in our offices in Bristol, London, Manchester, Newcastle and Nottingham. Our staff are supported by a community of 850 people who volunteer their time generously to help us deliver our services, alongside NHS staff and members of the public who advise us on our work.

The HRA is led by a Board chaired by Professor Sir Terence Stephenson which includes our Chief Executive, Matt Westmore, two executive directors and four non-executive directors. Two further directors also attend. The Board has strategic oversight, agreeing high-level policy and ensuring that the HRA is run effectively and efficiently. Find out more about our leadership .

We are one of many organisations that work together in the UK to regulate different aspects of health and social care research. Most of our services apply to research undertaken in England, but we also work closely with the other countries in the UK to provide a UK-wide system.

To make it easy to do research that people can trust, we:

• work with people to understand what you want research to look like and act on this so that you can trust research
• make sure that people taking part in research are treated ethically and fairly, by reviewing and approving health and social care research studies that involve people, their tissue or their data
• work with other organisations across the UK to make sure that, wherever you are, research studies can be set up smoothly and are always subject to the same scrutiny before they start
• work with others to co-ordinate and standardise the way research is set up and managed
• encourage and support transparency about research, so that you can find out what research is taking place, and what it found
• are one of the gatekeepers of patient data, making sure that your information is protected if it is used for research
• put in place and support the digital platforms to help research get set-up and managed in the UK

You can find out more about our work and what we do on this website, in our monthly newsletter HRA Latest and via social media .

This is our second year of delivering our three-year strategy.

Our enabling pillars will help us achieve our strategy. They set our culture, making sure our people can do their best work and that our technology meets the needs of the people who use and benefit from our services.

These enabling pillars are:

We will design, create, and support simple to use, accessible systems that make it easier for researchers to do trusted research and for patients and the public to find out about that research.

Improving ourselves: Always look for ways to do things better

Our people are key to our strategy. We will build a diverse and inclusive organisation giving our people the tools and support that they need.

There are three key aspects to our approach to change. We will be:

• user-centred, with people at the heart of everything we do
• iterative and agile, trying new things and learning from them
• collaborative, working with others to make progress more quickly

We will split the year into three monthly time periods and co-ordinate our change work to provide predictability for people using our services, our stakeholders and our staff. Where things will take more than three months, we will look for ways to break down the longer-term goal into smaller pieces of work to manage performance and to make sure there is effective governance of our work.

In 2022-23 we worked together to define the culture we needed to enable innovation and change to deliver our strategy. This model sets out six core elements to nurture this culture. In 2023-24 we aim to further develop this model to support our strategy.

Everything we do helps us to achieve our vision. Our strategy runs through our planning, performance, innovation and change, people and risk management processes. These processes make sure we successfully deliver on our priorities and that our people understand their role in achieving our strategy.

We are committed to delivering on government priorities as part of our strategy and business plan development. This includes the Life Sciences Vision , Build Back Better: our plan for growth , and NHS Long-Term Plan

2023-24 business plan by strategic objectives

Include everyone in research.

Meaningfully involving people in all stages of research and sharing its findings is crucial to earn people’s trust. It helps us do better research that can improve care.

What success will look like: More diverse groups of people with relevant lived experience are involved in all stages of research and are able to take part, with the findings shared publicly so that they can be used to improve care.

Ask you what you want research to look like and act on this

Research must address the issues that matter to you to earn your trust.

What success will look like: People taking part in research have a better experience because researchers know how to put them first and do things in a way that earns their trust. Over time, more people will feel confident and able to take part in research, helping us to improve care for everyone.

Involve you in the HRA

Increase public involvement in how we make decisions.

What success will look like: We make better decisions, informed by a diverse group of people with relevant lived experience.

Save money and time so that you can focus on doing good research

To earn people’s trust, research projects involving people, their tissue or their data need several approvals before they can go ahead.

What success will look like: It is easier for researchers to find out what they need to do and earn the approvals for their research to go ahead.

Create a new online system to help you make research happen

The approvals that each research project needs come from different organisations depending on the research. We aim to connect the steps that are part of doing research and make them easy to follow.

What success will look like: A new online system is helping researchers take the steps needed to make their research happen.

Support new ways to do research

We will make it possible to do new types of research here in the UK so that we can get better, quicker answers and put people first.

What success will look like: The UK is a destination to do new types of research that people can trust.

We will design, create and support simple to use, accessible systems that make it easier for researchers to do trusted research and for patients and the public to find out about that research.

Design digital systems in a human-centred way

Process automation and integration improves our work

Our people deliver our strategy. We will enable a diverse and inclusive organisation giving our people the tools and support that they need.

Continuously learn, improve and innovate

Overall progress will be measured by:

• our staff survey question: ‘I have the learning and development I need to do my job effectively’ (68% in 2022, benchmark 65%)
• celebrating and making more transparent a growing number of improvement activities each quarter (three each quarter)

Be a great place to get involved and work

• maintain our staff engagement score in our annual survey (82% in 2022, benchmark 67%)
• improving the annual survey score for ‘I am satisfied with what the staff forum is achieving for staff and it is meeting my expectations’ (40% in 2022)

Be committed to environmental sustainability and achieving net zero

In 2023-24 we will embed environmentally sustainable practices into our daily business, making sustainability the norm.

• reducing our carbon usage and waste each year measured quarterly

Our total funding anticipated for this year is £25.2 million (£24.3 million in 2022-23). We receive most of this directly from the Department of Health and Social Care.

In 2023-24 this funding, known as grant-in-aid (GIA), will be £18.5 million (£18.9 million in 2022-23) to fund revenue activities, £2.8 million (£2.6million in 2022-23) to fund capital investment and £3.2 million (£1.7 million in 2022-23) to fund non-cash revenue (for example, depreciation).

The rest of our revenue comes from two other sources:

• £0.2 million from NHSE to fund regulatory work supporting data driven technologies (£0.7 million in 2022-23)
• £0.4 million from the devolved administrations as part of cost sharing arrangements for ethics review and UK wide research governance (£0.4 million in 2022-23)

The HRA is committed to providing value to the public purse.

We achieve this in two ways:

• streamlining the research set-up process, driving economies and efficiencies to the research sector
• achieving ‘more for less’ in our services and policy work, by continuously improving our processes, reducing duplication and using technology to add value and reduce costs

We have planned for a balanced income and expenditure position for 2023-24 on our core services and activities. The financial plan table sets out our sources of revenue funds for 2023-24. It also shows how these compare with our 2022-23 financial plan.

Our plans suggest a capital funding requirement of £2.8 million (£2.6 million in 2022-23). This funding supports our essential research systems transformation programme as well as core infrastructure (estates and technology). Capital funding has been confirmed by DHSC. The following table shows how capital funding will be invested.

The HRA research systems transformation programme is in the process of gaining approval from DHSC Investment Committee.

Estimated funding and activity related to this programme are included within this business plan for 2023-24 with comparatives from 2022-23 based on our proposed business case adjusted for DHSC funding parameters.

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Our Breakdown of the NHS Business Plan 2023/24

The NHS England 2023/24 business plan is a comprehensive strategy that outlines the organisation's objectives for the upcoming year. This ambitious plan aims to enhance various aspects of healthcare services, including ambulance response times, primary care access, mental health services, and more. In this article, we'll explore the key priorities and strategies outlined in the plan to achieve these goals.

Improving Ambulance Response and A&E Waiting Times

One of the foremost challenges faced by the NHS is the mounting pressure on urgent and emergency care services. To address this issue, the 2023/24 business plan focuses on two main priorities:

Increasing Capacity : The plan allocates dedicated funding of £1 billion to create an additional 5,000 hospital beds. This investment aims to help hospitals manage growing pressures and ensure timely care for patients.

Growing the Workforce : To meet rising demand, efforts will be made to recruit and retain healthcare professionals, including retired clinicians and those nearing retirement. This step is essential to maintain a sufficient workforce for delivering high-quality care.

To further alleviate the burden on A&E departments and improve patient outcomes, the plan includes initiatives to streamline discharge processes and strengthen community-based healthcare services.

Reducing Elective Long Waits and Cancer Backlogs

The COVID-19 pandemic has led to extended waiting times for elective treatments and backlogs in cancer care. The 2023/24 business plan prioritises addressing these issues through the following objectives:

Increasing Capacity and Transforming Elective Care: A targeted investment fund will protect and expand elective activity, enabling more patients to receive timely treatment. Additionally, an outpatient productivity program will focus on freeing up capacity for those facing long waits.

Improving Patient Information and Support: Enhancing patient-facing information on waiting times and providing tools for managing conditions will empower patients to make informed decisions. Expanding community pharmacy services will also enhance accessibility to health services.

Streamlining Cancer Pathways and Case-finding : Strategies will be implemented to simplify cancer pathways and implement targeted case-finding programs, ensuring early diagnosis and treatment.

Maximising Diagnostic Capacity: Investments in pathology and imaging networks, along with community diagnostic centres, will support necessary diagnostic activity levels and address both elective and cancer backlogs.

Enhancing Access to Primary Care Services, Especially General Practice

Access to primary care, particularly general practice, has been a concern for many patients. The 2023/24 business plan aims to improve access and patient experience through these priorities:

Empowering Patients: Enhancing the NHS App and providing reliable health information will empower patients to manage their health effectively. Expanding community pharmacy services will offer a broader range of health services.

Modernising General Practice Access: Transitioning practices to digital telephony and simplifying online requests will improve patient experiences. The plan aims to make it easier for patients to contact their practice and receive same-day responses.

Building Capacity: Support for larger multidisciplinary teams in general practice will increase capacity and meet patient demands. Recruitment and retention efforts will focus on doctors and emergency medical technicians.

Improving Digital Infrastructure: Integrating digital platforms like the NHS App and NHS 111 online will streamline access to care, offering comprehensive advice and services to patients. Extensive trials of the 111 First initiative will be conducted to enhance 111 services.

Improving Mental Health Services and Services for People with Learning Disabilities and Autism

The COVID-19 pandemic has significantly affected mental health, especially among individuals with learning disabilities and autism. The plan aims to improve mental health services and cater to the specific needs of these populations through the following objectives:

Expanding Access to Mental Health Services: Promoting access to NHS Talking Therapies and increasing services for children, young people, and perinatal mental health.

Enhancing Service Quality: Developing new care models will improve the quality of mental health services and ensure better integration with primary care. A digital strategy for mental health settings will also be developed.

Supporting Recovery in Urgent and Emergency Care: Recognising the impact of mental health on urgent and emergency care, strategies will ensure timely and appropriate care for mental health-related emergencies.

Improving Physical and Mental Health for Learning Disabilities and Autism: The plan focuses on enhancing the quality and accessibility of healthcare for individuals with learning disabilities and autism through toolkits and guidance.

Improving Maternity and Neonatal Services

The 2023/24 business plan for maternity and neonatal services aims to achieve the following priorities:

Equity and Personalised Care : Reduce inequalities in maternity and neonatal care and provide personalised care to meet the unique needs of mothers and babies.

Workforce Support : Support the workforce through initiatives like funding retention midwives and strengthening neonatal clinical leadership.

Safety, Learning, and Support : Emphasise safety, learning, and support in maternity and neonatal services, with resources and programs developed to enhance the culture of safety.

Best Practices and Data Use : Implement best practices and data utilisation in maternity and neonatal care, including recommendations for early warning systems.

Preventing Ill Health and Tackling Health Inequalities

Prevention is vital for improving population health and reducing health inequalities. The plan focuses on the following priorities:

Improved Clinical Management: Prevent avoidable ill-health by enhancing clinical management of conditions like cardiovascular disease, respiratory disease, and diabetes, with a focus on evidence-based prevention programs.

Optimising Healthcare Impact : Reduce smoking, obesity, and alcohol intake while promoting healthy lifestyle choices to enable longer, healthier lives.

Increasing Vaccination and Screening Uptake: Implement strategies to reduce variation and disparities in vaccination and screening programs, addressing health inequalities and improving detection rates for cancers.

Supporting NHS Strategic Priorities: Align with the NHS's strategic priorities, including restoring services inclusively, mitigating digital exclusion, ensuring complete and timely datasets, accelerating preventative programs, and strengthening leadership and accountability.

Recovering Productivity, Increasing Efficiency, and Delivering a Balanced Financial Position

To provide high-quality care for all, NHS England focuses on the following priorities:

Supporting Integrated Care Systems (ICSs): Collaboration and continuous improvement in ICSs to address unwarranted variation across clinical pathways and support the GIRFT program.

Reducing Agency Staff Bills: Strategies to reduce reliance on agency staff and encourage stable workforce arrangements.

Efficient Medicine Investments: Initiatives to maximise the value of NHS investments in medicines, including the VPAS framework for branded medicines pricing and access.

Commercial Excellence in Procurement: Improve commercial excellence in NHS procurement and reduce costs through strengthened practices.

NHS Estates Productivity and Efficiency: Focus on improving productivity and efficiency in NHS estates, including long-term planning, and reducing non-clinical space.

Building and Developing the Workforce for Now and the Future

The NHS recognises the importance of its workforce in delivering high-quality patient care. The plan prioritises the following initiatives:

Growing the Workforce: Recruitment efforts, domestically and internationally, to reduce vacancy rates and increase the number of qualified healthcare professionals.

Reforming Education and Training: Review and reform of education and training to better meet patient and student needs, including flexible training routes like apprenticeships.

Supporting Digital Technology and Workforce Transformation: Supporting digital tools, innovation, and flexible working practices to respond to changing population needs.

Improving Leadership and Staff Retention: Enhancing leadership, talent management practices, staff retention, and promoting equality, diversity, and inclusion, along with support for health and well-being.

The NHS England 2023/24 business plan lays out a comprehensive road map for enhancing healthcare services in the coming year. By addressing key priorities and implementing ambitious initiatives, the NHS aims to continue providing excellent healthcare services for the people of England.

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Our 2024 – 2025 Business Plan

We are creating one connected and efficient supply chain that delivers for the NHS.

The NHS is facing challenges but remains committed to providing outstanding patient care. NHS Supply Chain plays a crucial role in supporting the NHS to evolve, deliver on its priorities and continue to put patients first. Together with our partners, we are not just focused on reducing prices; we are working to bring more value to the entire healthcare system while ensuring supply chain resilience and sustainability.

Looking ahead to 2024 – 2025, we are excited to continue enhancing our capabilities and services. This includes upgrading our technology, improving customer experiences, and expanding our inventory management solutions to offer digital transparency across the NHS.

Our goal remains clear: to leverage our talented team and expertise to prioritise patient care. Collaboration is key and by working together, we are dedicated to delivering even greater value to the NHS and its patients.

Our strategy

We are pleased to share our Business Plan with you. It helps us deliver on our ongoing commitment to supporting the NHS to deliver safe and excellent patient care.

One NHS Supply Chain We are one organisation in the eyes of our teams and stakeholders, operating efficiently as a single organisation within the NHS family.

Strengthen Resilience We ensure availability of critical products, supporting the NHS to deliver excellent patient care.

£1 Billion of Value We will create £1 billion of recurrent value to return to the NHS from 2030.

See our Downloads ▼ section to read our full business plan for this year.

Working together for the NHS

As part of the NHS family, our Strategy and Business Plan are firmly rooted in the principle of working together with our NHS partners to deliver patient-led care. We are firmly committed to the NHS value of working together for patients and we will do this through five focus areas:

Organisational Development Developing our clinical capabilities through clinical practice, evidence-based decision-making and effective collaboration; and strengthening clinical leadership across our organisation.

A Sustainable NHS Delivering our Sustainability Strategy in alignment with the NHS Greener Plan and the Chief Nursing Officer Nursing and Midwifery Strategy.

Quality-Led Resilience Building supply chain resilience to strengthen patient safety, patient experience and clinical effectiveness, to ensure we are procuring using the best available clinical evidence.

Products and Category Management Facilitating patient engagement in what we buy and how we buy it; and embedding clinical leadership at each stage of our category development and contract management processes.

NHS Clinical Engagement Collaborating with national healthcare organisations such as GIRFT along with National Clinical Directors, to deliver once for the NHS; supporting local and regional priorities; communicating effectively with all our clinical stakeholders; and utilising clinical feedback to improve how we work.

Commercial transformation Transforming our commercial capabilities

We are here to provide the NHS with superior procurement services that meet all of the latest regulations. Our goal is to streamline processes and strengthen our ability to handle any supply challenges that may come our way.

Here is what you can expect from us in the coming months:

• Implementing higher standards for clinical quality across all procurement activities.
• Identify opportunities to bring new products to market that will enable trusts to lower the total cost of care delivered (for example through reduced length of stay) – known as value-based procurement.
• Collaborating across different categories to strengthen supplier relationships.
• Introduce an eSourcing solution and Supplier Collaboration platform for smoother transactions.

Resilience and sustainability Embed an optimised, resilient and sustainable supply chain

As we move through 2024, supply chains around the world are expected to face various challenges, from shortages of raw materials to disruptions in manufacturing and transportation.

In response, we are taking steps to make our supply chain more flexible, capable, and resilient while also minimising our environmental footprint.

Here is what we have planned for the year ahead:

• Designing a Logistics and Operational IT Strategy to enhance our operations.
• Finalising the procurement of a logistics provider to ensure smooth delivery.
• Getting ready for UKCA marking compliance.
• Making improvements in packaging and promoting a circular economy.
• Through these initiatives, we’re committed to ensuring that our supply chain remains robust.

Integrated Care Systems Connect across Integrated Care Systems and regions

We are dedicated to improving patient care and clinical outcomes by working closely with partners across the NHS. This means enhancing how we communicate and engage with healthcare providers to better meet their needs.

Here is how we are making strides in this direction:

• Building strategic relationships with Integrated Care Systems to improve coordination.
• Collaborating with healthcare providers to create smoother patient pathways.
• Hosting customer panels and working groups to gather feedback and shape our strategies.
• Piloting a new eCommerce platform for select healthcare providers to streamline transactions.
• Rolling out our new inventory management system to improve efficiency in 20 healthcare providers.

Through these efforts, we’re committed to making it easier for healthcare providers to focus on what they do best: caring for patients.

Improving capabilities Develop, empower and engaging our workforce

In the upcoming year, we are committed to embedding the changes introduced via our Target Operating Model throughout the organisation.

Here’s what is in store for the year ahead:

• Welcoming 28 graduates into our graduate scheme to nurture new talent.
• Establishing a Leadership Academy to develop leadership skills within our team.
• Evolving and implementing our People Strategy to better support our team members.

Efficiency improvements Operate a well-run organisation

Our Business Plan will help us deliver our goals for 2030, which are closely tied to the priorities laid out in the NHS Long Term Plan.

Here is where our focus lies:

• Implementing new ways of working that align with our Target Operating Model.
• Sharing best practices across the organisation through our academies.
• Procuring IT providers to support our operations.

Downloads ▼

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Corporate reports and publications

Our current publications.

Annual report and accounts 2023/24

Publication date: 23rd July 2024

NHS Resolution’s Annual report and accounts for 2023/24 demonstrates that our continued innovation in dispute resolution, and a collaborative approach, have continued to deliver benefits and enhance opportunities to learn and improve safety.

In line with our strategy to keep patients and healthcare staff out of court, a record 81% of claims in England were resolved in 2023/24 without resorting to legal proceedings, continuing a trend seen over the last seven years.

This means that over 10,800 claims were resolved for patients and their families through our various dispute resolution processes rather than formal legal processes.

The report also describes how the continued development of ‘upstream’ approaches such as our Early Notification (EN) scheme have helped families to access compensation for immediate needs more rapidly.

NOTE: Unfortunately we have identified an error in Figure 22, details are available in this correction note .

Business plan 2024/25

Publication date: 22nd July 2024

NHS Resolution’s Business plan 2024/25 outlines our financial and service delivery goals for the third and final year of our strategic plan, Advise, Resolve and Learn: Our Strategy to 2025 .

The business plan reflects NHS Resolution’s four strategic priorities to resolve issues in a fair and timely manner; use data to improve healthcare; improve maternity outcomes; and invest in staff and systems.

Our strategy to 2025

Publication date: 19th May 2022

Our three-year strategy, Advise, Resolve and Learn: Our Strategy to 2025 is now available.

It builds on our work since 2017, and provides our direction of travel in the coming three years under our four key strategic aims: delivering fair resolution; sharing data and insights as a catalyst for improvement; collaborating to improve maternity outcomes and investing in our people and systems to transform our business.

Previous publications

• Annual report and accounts 2022/23
• Annual report and accounts 2021/22
• Annual report and accounts 2021/22 – Summary
• Annual report and accounts 2020/21
• Annual report and accounts 2020/21 – a summary
• Annual report and accounts 2019/20
• Business plan 2023/24
• Business plan 2022/23
• Business plan 2021/22
• Business plan 2020/21
• Our refreshed 2019-2022 strategic plan

If you cannot find the document you are looking for please get in touch with us by emailing us at nhsr.press@nhs.net .

As per our document retention policy we keep three years’ worth of documents online and older documents can be found on the National Archive where you can access our old NHS Litigation Authority (link opens in new window) and National Clinical Assessment Service (link opens in new window) websites.

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NHSCFA Strategy 2023-26 and Business Plan 2023-24 launch

Our new strategy and business plan sets out our key priorities to counter fraud in the nhs over the next three years..

Published: 8 June 2023

Today, the NHSCFA launches a new Strategy 2023-26 and Business Plan 2023-24 , which sets out our key priorities for the coming years and how we intend to work collaboratively with the health sector to understand, find, and prevent fraud in the NHS.

Since our last Strategy was launched back in 2020, the changes we have seen in the wider world have been unprecedented. As a result, the NHS is under more pressure than ever to treat patients, save lives, and save money. Healthcare expenditure in 2021 was estimated at £277 billion and remains a target for fraudsters. The NHSCFA has assessed that, in the context of a 2021 to 2022 NHS budget in England of almost £150.614 billion, the NHS is vulnerable to fraud, bribery, and corruption to an estimated £1.198bn. A complex system like the NHS, therefore, needs a shared strategy and a shared understanding of fraud risk. This is precisely why the NHSCFA exists – to fight fraud and save money – and will need to work in partnership with you to understand, find, and prevent fraud in the NHS.

Following an extensive program of collaboration, feedback, and input from a wide range of key partners across the health sector, our focus will be on four key pillars of activity, supported by our people and our resources. These describe our current and future approach to drive vulnerability down and increase the amount of fraud we detect, prevent, and recover. These pillars of activity - Understand, Prevent, Respond, and Assure - will form the basis of everything we do. At the heart of this new approach is our new vision which will build upon our partnership working: Working together to understand, find, and prevent fraud, bribery, and corruption in the NHS.

For more information and resources see our fraud awareness toolkit .

In launching the plan, NHSCFA’s CEO, Alex Rothwell, said:

“I’m delighted to launch our new strategy today which will develop and evolve during its lifetime. I am committed to strengthening our collaboration and engagement with key partners and that is why the NHSCFA has undergone a significant transformation programme to ensure we have the right operating model to strengthen our counter fraud response across the health sector. Data analytics and insight will be at the heart of our approach. The creation of a new Fraud Hub will also herald a new approach to support and enable alignment between the national and local counter fraud response and cuts across all four pillars of the strategy, generating a joined-up approach to tackling fraud bribery and corruption within the NHS”.

Director of Performance and Improvement Tricia Morrison said today:

“During the development of our new strategy we have taken the opportunity to listen, re-measure, analyse and refocus every aspect of our operating model. This includes the systems that drive our performance, planning and measurement processes. Collaboration with our key partners remains our focus - setting out a clear delivery plan driven by our strategic intelligence assessment, targeting improved reporting of outcomes and giving health bodies the information they need to focus on impact, our strategy reflects our ambition to continually develop how we work with our partners in the wider counter fraud community – as it’s only by working together that we can make a difference in the fight against fraud”.

The Chair of NHSCFA’s Board, Tom Taylor adds:

“The primary aim for the NHSCFA is ultimately to provide value for money for the public, and this Strategy clearly and concisely sets out how we intend to achieve this over the next three years. I would like to thank all our colleagues and stakeholders for their considerable efforts in creating this Strategy, and it will form the basis of all our work over the next three years”.

Sean Byrne, Deputy Director, Head of Counter Fraud, Department of Health & Social Care

“The NHSCFA provides an essential function as part of the wider health family in the fight against fraud, ensuring tax-payer funds are used to deliver better patient care and not diverted into the pockets of fraudsters. This new three-year strategy will ensure that the NHSCFA understands and keeps pace with new and emerging threats and has the capability to deal with them”.

Mark Cheeseman OBE - Interim CEO, Public Sector Fraud Authority

“Fraud is an often unseen and underestimated problem, and it takes money away from critical services on which the public rely. I welcome the new strategy from the NHSCFA - which recognises the extent of the challenge faced, and makes a commitment to real, meaningful and measurable action”.

4 Nations Partners across England, Scotland, Wales and Northern Ireland - Graham Dainty ( Counter Fraud Wales), Donna Scott ( Health & Social Care Northern Ireland), Gordon Young (NHS Scotland), Tricia Morrison, NHS Counter Fraud Authority

“We have a collective determination to work together to find, report and stop NHS fraud across the UK. Understanding how each territory operates we can continue to develop and deliver the most effective counter fraud measure across England, Scotland, Wales, and Northern Ireland, ensuring that NHS funds go to patient care and not into the hands of fraudsters”.

Michael Brodie OBE – CEO, NHS Business Services Authority

“The NHS Business Services Authority has a lot of high-volume transactional work, and we are responsible for over £39bn in NHS spend. We take tackling fraud and loss very seriously and our inhouse fraud team work closely with a range of counter fraud stakeholders including DHSC Anti-Fraud Unit, NHS England Counter Fraud Team and NHSCFA. Working in partnership with the NHSCFA helps us both maximise our potential”.

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Our 2022/23 business plan

This business plan sets out our work in leading and supporting the NHS to respond to the challenges of the last two years as well as the opportunities to transform the delivery of care and health outcomes through collaborative system working, and the use of data and digital technologies.

You can find the web accessible version of our 2022/23 business plan here .

Our 2022/23 Business plan

The state of integrated care systems 2023/24: tackling today while building for tomorrow

26 September 2024

Integrated care systems (ICSs) play an instrumental role in tackling the issues facing the health and care system today while building for tomorrow. This report examines progress made by local systems over the past year. Leaders of integrated care boards (ICBs) and integrated care partnerships (ICPs) reflect on their ambition for the future, the barriers and enablers that stand in the way and how the government and other national partners can better support them to succeed.   

Most ICS leaders are positive about the progress their local systems are making against their four purposes and will play a key role in delivering the government’s reform agenda, including improving productivity and maximising available resources, enhancing devolution, supporting the development of a neighbourhood health service and shifting resources into prevention and closer to people’s homes. 

However, they are struggling to marry their collaborative ambition with today’s fiscal realities. Delivering against short- and longer-term priorities is a careful balancing act, and performance management conversations focused almost entirely on finances are crowding out the longer-term transformation ICSs were established to deliver.

Over 90 per cent of ICS leaders surveyed are committed to shifting resource to allow more people to access more care closer to home. But they are struggling to match this ambition due to financial constraints. 

Over three-quarters of ICS leaders surveyed are concerned that financial challenges in the NHS and local government will impact their ability to deliver on their ambitions and negatively impact partnership working. In order to balance budgets today, they are being forced to cut back, delay or defer the programmes that will lead to tomorrow’s financial sustainability as well as improved outcomes. 

Only 40 per cent of ICS leaders surveyed believe accountabilities are well defined between ICBs and NHS England’s national team and there is clear variation in experiences of working with NHS England regional teams. 

But as the Darzi report highlighted, ICS leaders are held back by a lack of investment in capital as well as primary, community and social care services, performance standards focused on hospitals, unclear accountability arrangements, single-year budgets and politically driven short-term funding decisions. They need greater support from national government and arm’s-length bodies to deliver transformation.

ICS leaders welcome the opportunity to shape the future of the health and care system through active involvement in development of the government’s ten-year health plan, which they are pleased to see will take a more expansive ‘health’ (not solely NHS) focus.

On behalf of ICS leaders, this report makes several recommendations to national government and national bodies for consideration as part of the development of the ten-year health plan, including moving to multi-year funding settlements; changing to the payment scheme to support a focus on integration and prevention; evolving and embedding the new operating framework; ensuring oversight incentivises a balance between today and tomorrow; and giving ICBs levers to devolve decisions to place and neighbourhoods. 

Introduction

The establishment of integrated care systems (ICSs) is ushering in a new era of collaboration and partnership to better support the health and wellbeing of people across England. Based on a strong understanding of their local communities and working closely with their partners, ICS leaders are focused on building the health of the nation and delivering their four core purposes: 

• improving population health and healthcare outcomes
• enhancing productivity and value for money
• tacking inequalities in outcomes, experience and access
• helping the NHS to support broader social and economic development.

But as they enter their third year as formal partnerships, ICS leaders continue to face a challenging operating context, with high and growing levels of demand for care, a depleted workforce, stark health inequalities and the ongoing legacy of austerity. The recent Darzi investigation of the NHS in England explored in some detail the impact of decisions outside the NHS’s control that have impacted NHS performance, including austerity and deteriorating population health.

This third publication in the ICS Network’s flagship annual report series, reflects the views of ICS leaders on the development and impact of ICSs. It aims to provide insight on their successes, challenges and what they might need from national partners to deliver for the local populations they serve.  

The research is primarily based on a national survey of ICS leaders (ICB chairs and chief executives and ICP chairs), undertaken before the general election and was followed up with several interviews over summer 2024.   

We would like to extend thanks on behalf of the ICS Network to everyone who participated, for their helpful insights and contributions. We are particularly grateful to the ICS Network Board for their feedback and guidance throughout the project. 

A new political landscape

The election of a new government signifies a shift in the policy landscape with new opportunities to tackle longstanding challenges. Labour’s manifesto outlined its plans for a health mission, which envisages three shifts towards care closer to home, prevention and digitisation.

ICSs play a key role in addressing some of the issues that matter the most to the public, such as primary care access, elective recovery and urgent and emergency care. At the same time they are committed to delivering the transformation needed to guarantee the sustainability of the health and care system. This includes more people accessing more care closer to home, a focus on prevention, embedding new models of care, driving social and economic development, devolving decision-making and harnessing the power of digital and data.

ICSs will therefore be instrumental in delivering the government’s missions for health and growth and are uniquely placed to accelerate integration and address the wider determinants of health. ICS leaders also welcome the opportunity to shape the future of the health and care system through active involvement in development of the government’s ten-year health plan, which they are pleased to see takes a more expansive ‘health’ focus, not solely an NHS focus.

A note on language

An integrated care system (ICS) brings together the health and care organisations in a particular local area to deliver joined-up health and care services. Each ICS is responsible for planning health and care services in the area it covers. There are 42 ICSs across England. Each one is made up of an integrated care board (ICB) and an integrated care partnership (ICP), along with NHS and social care providers and other partners, which will work in tandem to meet their four purposes.

ICBs are statutory NHS organisations responsible for developing a joint forward plan in collaboration with system partners to meet the health needs of their population, managing the NHS budget and arranging for the provision of health services in their defined area. All ICBs include board members from local authorities, NHS trusts and/or foundation trusts and primary care.

ICPs are responsible for producing an integrated care strategy on how to meet the health and wellbeing needs of the population. It operates as a statutory committee formed between the NHS ICB and all upper-tier local authorities that fall within the area, with membership of other partner organisations determined locally.

We refer to ICB and ICP leaders collectively as ‘ICS leaders’ and to all the bodies working together within the ICS geography as ‘system partners’ or ‘the system’ when talking about the entire range of activity that the ICS is working towards. At other times, we refer to the views of ICB and ICS leaders when we are writing more specifically about those entities.

At times we use the term ‘the centre’ to refer to national government and national bodies collectively, predominantly meaning the Department of Health and Social Care (DHSC) and NHS England’s national and regional teams. However, this may also encompass other departments such as the Ministry of Housing, Communities and Local Government and national bodies such as the Care Quality Commission (CQC).

Methodology

The report is based on data collected through desktop research and quantitative and qualitative methods. 

We invited leaders of the 42 ICSs in England to share their views on ICS development through a national survey, which was open to chief executives and chairs of ICBs and chairs of ICPs. The survey was open from 8 May to 13 June 2024. We received 62 responses overall, representing 36 out of 42 systems: over 85 per cent of systems.

Responses were split across 16 ICB chairs, 23 ICB chief executives, 13 ICP chairs and ten joint ICB/ICP chairs. All respondents were asked the same questions.

At times we have compared responses to last year’s survey, but comparison is limited by different wording of questions and the individuals completing the survey. Qualitative responses were analysed using inductive thematic analysis to identify emerging themes. We also undertook individual interviews with nine leaders from various roles across ICBs, ICPs and place to discuss the findings and the wider context in greater depth.

Progress against ICSs’ four core purposes

Confidence is still high among ics leaders.

Overall, ICS leaders feel confident their system is able to fulfil each of the four core purposes. When compared to last year’s survey , the proportion of respondents who were 'very confident' has grown slightly across three of the purposes, from 6 per cent to at least 11 per cent. The proportion of those ‘not very confident’ has also seen a small increase.

The reality of system working is making clear successes and areas for improvement. Each system has had a different starting point in terms of history of collaboration, size, level of deprivation, workforce challenge and waiting list backlog. Many are also tackling complex legacy issues as well as recovering from the significant impact of the COVID-19 pandemic on staff, patients and populations. ICS leaders’ confidence is likely also linked to the scope they are given to focus on particular issues.

ICS leaders are most confident about enhancing productivity and value for money. This has been an enduring area of focus for the government and NHS England due to the current fiscal environment and lower productivity levels. It also reflects that many ICS leaders see opportunities to enhance productivity, although current NHS financial flows mean that at times these opportunities can be hard to realise.

Over three-quarters (77 per cent) of respondents were also confident their systems are improving population health and healthcare outcomes, which is the core and expected business of NHS leaders and many of their partners. ICS leaders feel they are making progress towards delivering their plans, although financial constraints mean they can struggle to reserve headspace to focus on innovation, digital transformation and shifting towards a preventative approach.

They described their work taking population health approaches, working closely with their partners and particularly public health teams, using data to inform decision-making and focusing on specific clinical areas such as cardiovascular disease, cancer, or children and young people’s health. A number of respondents described work which focuses on the social determinants of health. One ICB chief executive said they had “downgraded our ability to impact because of external factors affecting our population: poverty, cost of living etc.”

Improving population health and health outcomes

Case study: an integrated oral health service is improving access and outcomes for disadvantaged communities in suffolk and north east essex.

Residents in Suffolk and North East Essex (SNEE) were struggling to get a dental appointment, which was particularly impacting the system’s most vulnerable groups. This had a knock-on impact in the acute sector, with a 45 per cent increase in 111 calls and an 100 per cent increase in GP contacts for urgent dental support.

SNEE ICB became responsible for the commissioning of NHS dental services in April 2023. To address these issues, it decided to think differently and develop an oral health service specifically for the most vulnerable people in the community. The Dental Priority Access and Stabilisation Service specification (DPASS) was developed with extensive expert input from the dentistry sector and the contract was awarded to 18 current high street dental practices and a new provider, the University of Suffolk Dental CIC. All are additionally contracted to provide more routine NHS dental appointments for the general public. The DPASS is a pilot and an evaluation in 2025 will inform future commissioning plans.

DPASS combines urgent and emergency care, and preventative care and treatment, while retaining units of dental activity (UDAs) and a range of metrics for measuring outcomes. The model seeks to improve access and outcomes from an equity lens by prioritising groups most at risk of poor oral health.

The University of Suffolk Dental CIC delivers an innovative contract comprising 100 per cent NHS care, with 80 appointments each week ringfenced for the unscheduled care of patients referred under DPASS. Other KPIs for the CIC focus on workforce recruitment and retention, quality and patient experience.

As part of the NHS dental recovery plan, the ICB has also invested in a mobile dental surgery which will serve deprived areas within Suffolk.

Tackling health inequalities

Tackling health inequalities continues to be a challenging area, with much variation across systems. After last year’s survey, where it was the only area with no ‘very confident’ systems, the NHS Confederation undertook research into ICSs’ approaches to tackling inequalities and produced a practical toolkit to support and scale successful approaches. Compared to last year’s survey the proportion of respondents who are both ‘very confident’ and ‘not confident’ has increased. This may be explained in part by the large impact of the wider determinants of health on inequalities. It is promising in this context that Lord Darzi recommended this be an area of focus in the government’s upcoming ten-year health plan.

One leader shared that they have strong strategies for tackling health inequalities and increased maturity in their relationships to deliver them, but that ‘progress to deliver results gets stuck, for example in long commissioning processes, or other discussions about money flows and sustainability. While there are many successes, the overall picture is one of slow progress.’

Some of the successes shared by respondents include elective and dental recovery plans targeted towards inequalities, and delivering chronic obstructive pulmonary disease (COPD) support through local area partnerships.

Tackling inequalities in outcomes, experience and access

Case study: the bedford borough warm homes project.

This project is funded by Bedfordshire, Luton and Milton Keynes Integrated Care Board, commissioned by Bedford Borough Council and run by the National Energy Foundation’s warmth and wellbeing service Better Housing Better Health, to reduce health inequalities in the borough.

Over 1,600 patients were invited to take part, because GP records showed that they could be at risk of fuel poverty and they had a chronic health condition that could be made worse by living in a cold or damp home. An additional intended benefit of the scheme was a reduction in carbon emissions.

Fifty-three households with residents who have a chronic health condition in Bedford borough benefited. They were offered home improvements that could make their homes warmer and/or less damp, with an average cost of £2,500. The main products installed were replacement gas boilers, thermostatic heating controls and loft insulation. A further 320 households also received expert, impartial advice to help improve the energy efficiency of their homes and save them money.

The evaluation of the scheme is ongoing but it is expected the NHS will make savings of £358,000 against the total project cost, through reduced attendances at general practice and A&E. For example, residents whose chronic asthma was exacerbated by their cold or damp home are expected to see improvements in their health and need fewer appointments as a result.

ICS leaders feel least confident to deliver their fourth purpose of helping the NHS support wider social and economic development. This is an area of work that has often been led by local government and the voluntary, community and social enterprise (VCSE) sector, which NHS bodies should support and build on. For example, through economic development approaches such as regeneration and affordable housing programmes. This may be new territory for some NHS leaders, who are shifting mindset from being providers of services to providers of employment and economic activity as part of a wider partnership.

One ICB chair shared that “the ICB is a relatively small direct player – the challenge is to make this high on every delivery organisation’s agenda.” Although ICS leaders feel they are not making as much progress as they would like, they emphasised work around anchor institutions and a focus on employment and education as areas of progress. This includes “working with partners in the education sector to train, employ and retain local people.”

In particular, the awarding of £64 million WorkWell funding across 15 pilot ICSs has raised health and work up the agenda – an issue which is largely seen through ICSs’ fourth purpose. This is a very positive development. The ICP was cited as a key vehicle for delivery across this purpose in general, given its breadth of connections and scope.

“Our ICP has been established with representation from local authorities, voluntary sector organisations, education, police and fire services. We are focused on working across all organisations to improve workforce recruitment and retention and target local communities for job opportunities; to improve mental health, give children and young people greater opportunities and also improve social care provision and support.” ICB/ICP chair

The NHS Confederation is continuing to provide expertise and support for systems to unlock social and economic development and is working with government to help formulate their approach. For example, in partnership with the IPPR Commission on Health and Prosperity , we have recently published some key principles for achieving this, based on engagement with five local areas. Upcoming work with the Local Government Association will explore how the government can help strengthen the role of ICPs within systems, which would bolster this important agenda.

The health and work agenda was mentioned in the Darzi report , which highlighted the potentially huge contribution the NHS could make towards national prosperity by improving access to care. Recent research conducted by the NHS Confederation and Boston Consulting Group highlighted the need for a whole-of-government approach to tackling the causes of long-term sickness and economic inactivity.

ICS leaders are also interested in leveraging the potential of devolution, which will be important for improving the health and prosperity of the nation. Under the previous government’s plans , every area of England would have a devolution deal by 2030. This is likely to accelerate under the new government, which has already written to local government leaders committing to ‘expand devolution further and faster’.

Based on promising early findings from several areas in England where ICSs and combined authorities are working closely, our report Prevention, Population Health and Prosperity: A New Era in Devolution urged the new government ‘to place health at the heart of any future devolution deals, leveraging the growing ICS – combined authority relationship’. On top of their close partnerships with county councils, in areas with devolution deals ICSs are partnering with combined authorities and metro mayors to co-develop and deliver programmes of work that benefit local communities, in particularly by contributing to wider social and economic development.

Helping the NHS to support broader social and economic development

Case study: partnership between west yorkshire icb and combined authority to address the wider determinants of health.

West Yorkshire ICB (WYICB), the West Yorkshire Mayor and West Yorkshire Combined Authority (WYCA) have a strong partnership built over a number of years, working together on health, socio-economic development, equity and inclusion. A memorandum of understanding has been in place since 2023 to formalise the partnership, linked to West Yorkshire’s integrated care partnership with the aim of an inclusive approach on improving the physical, mental, economic and social wellbeing of people in West Yorkshire. The partnership aims to embed a ‘health in all policies’ approach with the combined authority and links to ICSs’ fourth purpose. Strong partnership working is embedded in reciprocal governance arrangements between both organisations and joint initiatives such as Creative Health, Housing for Health and the Warm Homes scheme.

WYICB and WYCA have jointly appointed some senior roles, including an associate director of public health and West Yorkshire’s inclusivity champion, which have supported influencing the strategic policy on areas beyond health and care including crime and policing, housing, transport, skills and local growth. Further, the mayor and WYCA chief executive are members of the ICP with local authority leaders, and ICB leaders sit on WYCA committees such as on climate change and place, regeneration and housing. This allows both bodies to mutually support and influence each other’s decision-making and strategic planning and delivery. 

Work is now underway on practical and more in-depth delivery. For example, a West Yorkshire Work and Health Partnership Group has been developed, which brings together local authority and combined authority leads from skills and public health alongside colleagues from the ICB, Department for Work and Pensions/local JobCentre Plus, and the VCSE sector. WYICB and local authorities with WYCA have signed up to the West Yorkshire Fair Work Charter, which was based on co-design with local communities and research into how workplace charters can reduce health inequalities for employees and create inclusive workplaces. Over 173 businesses have signed up to the Charter from across various sectors including the VCSE sector, manufacturing and food, police and public transport. A one-year review will be conducted to evaluate impact and support future implementation. Other projects underway include an apprenticeship levy, influencing inclusive growth and aligning infrastructure policy.

Barriers and opportunities

In their role as system conveners, ICS leaders are uniquely placed to understand the specific challenges facing their local population. This will include issues relating to the quality and safety of services, operational demand and acuity of the population and finances and workforce challenges. An ICB chief executive warned that “the scale of the challenge over the next one to two years cannot be underestimated.”

In the context of these challenges, ICS leaders think that the current financial positions of the NHS and local government, as well as lack of funding for social care, are the biggest barriers to ICSs over the next two years. They also continue to sound the alarm on the capacity of their workforce across health and care, particularly in the context of rising operational demand.

This assessment is shared by national bodies. In July, the National Audit Office raised concerns that ‘the NHS may be working at the limits of a system which might break before it is again able to provide patients with care that meets standards for timeliness and accessibility.’ It highlighted that policymakers needed to address the ‘potential growing mismatch between demand for NHS services and the funding the NHS will receive.’

The delivery of the NHS Long Term Workforce Plan encapsulates a number of these issues. In the words of one ICB chief people officer we interviewed: “100 per cent we cannot deliver the ambitions in that plan with the resources we have.”

ICSs are expected to achieve a difficult balancing act: simultaneously cutting costs while tackling workforce shortages and working much more closely with their local authority partners while meeting NHS imperatives from the centre that can challenge partnership working.

Workforce capacity is a barrier to integrated working not simply because of the overall number of health and care staff, but also in terms of having the right mix of roles, skills and experience in the right places. This can be challenging in areas of care that are seeing high shortages despite more activity and higher demand. For example, the number of GPs has fallen and there is a clear need for additional mental health staff. To tackle key issues in adult social care, ICS leaders are supportive of Skills for Care’s adult social care workforce strategy.

At the same time, these areas of pressure are also where ICS leaders believe there is most opportunity for collaboration between NHS and local government. These five priorities remain the same compared to last year’s survey: tackling health inequalities, children and young people’s services, adult social care.

Making an impact

We asked ICS leaders what one thing their system had achieved in the last 12 months that they are most proud of. Responses covered a broad range of areas, but some specific sectors stood out. For example, 20 per cent of respondents cited urgent and emergency care improvement due to partnership working as their proudest achievement, and 14 per cent cited activity in primary care. Using data capabilities to drive evidence-based decisions was cited by some as a key enabler of these successes.

Improving population health and healthcare outcomes

Case study: data-informed decision making in nottingham and nottinghamshire ics.

Nottingham and Nottinghamshire ICS faced significant challenges when trying to make financial efficiencies alongside a surge in emergency demand and prevailing and chronic inequalities among their population. These competing demands highlighted issues between organisations due to a lack of join-up data. 

In response to these issues, the ICB established the System Analytics and Intelligence Unit (SAIU). The unit’s purpose is to support data-informed decision-making for ICS leaders and work alongside the ICS’s Shared Care Record, which had already integrated and joined up GP data. This was enabled by a Section 251 order by the Secretary of State for Health and Social Care, which allowed pseudonymised data analysis and secure data sharing across NHS organisations, local authorities and VCSE partners.

The ICB has leveraged this new data capability in various ways to support its local population. For example, data insights contributed significantly to the reduction of discharge delays across the ICS, with one acute hospital gaining two wards’ worth of space by speeding up patient discharges. Insights from the SAIU also informed cost-of-living interventions by mapping local authority data on fuel poverty against the prevalence of diabetes, frailty, and chronic obstructive pulmonary disease (COPD). Working alongside primary care networks, VCSEs and local authorities, the ICB could enable targeted initiatives such as warm spaces and food banks in the communities that needed them most and to provide effective signposting and offer vaccinations.

The SAIU has seen transformational results and plans are underway to roll the work out across all three acute hospital sites in the ICS and properly integrate VCSE partner data through collaborative efforts with the local VCSE alliance. The project has been recognised as national best practice by NHS England and DHSC.

Balancing today’s challenges and building for tomorrow

ICSs play an important role in addressing both short- and longer-term issues. Many see the ICS focus on the four core purposes and system perspective as the only way to shift the dial on integration and move care upstream into primary and community care, which is essential to overcoming the operational issues facing the health and care system.

ICSs’ competing demands

Building and maintaining relationships in a complex adaptive system takes time and sustained commitment. When we asked ICS leaders what they hoped to achieve over the next 12 months, over a quarter focused on building relationships and leadership capability to better deliver on their plans:

“Improved partnership working, contributions and relationships with local authority partner and across partners. […] I would hope that if achieved, we can really make progress on improving urgent and emergency care. Without it I don’t think we will.” ICB chair

ICS leaders are also focused on delivering on their financial plans, productivity targets and productivity and prevention ambitions, as well as specific areas of work such as children and young people’s services, service reconfigurations and delivery of integrated neighbourhood teams. These changes will depend on strong relationships and balancing the interests of many different partners who are committed to making progress against their short- and longer-term goals. One ICB chair would like to “demonstrate people and place at the heart of all we do, with even more evidence of the advantages of a place-based approach.”

In their qualitative reflections on accountabilities, around half of ICS leaders we surveyed shared concerns about the levels of NHS England top-down performance management of ICBs, focused on acute issues, without much support or focus on longer-term transformation. ICS leaders understand the need for accountability, but consider that this can be detrimental when it is overly cumbersome or drives focus towards a narrow set of issues.

“We are not clearly held to account against our four objectives by the national team… And the things we need the centre to do – eg set out what good looks like, do detailed bottom-up modelling of what things should cost, build commissioning capabilities – don’t happen.” Joint ICB and ICP chair

ICB leaders are rarely asked about delivery against their four purposes at quarterly performance meetings and are regularly sent new directives on national priorities which tend to focus on short-term operational issues and finances. While these issues are important, system leaders want to simultaneously be held accountable for longer-term goals such as shifting towards prevention and care closer to home. These longer-term goals are not a ‘nice to have’, but essential to the sustainability of the healthcare system. 

Responses from ICP chairs who are also local councillors reveal how performance management focused solely on NHS issues can impact partnership working, which is best summarised as ‘challenges, bad feeling and disengagement’. One ICP chair bemoaned the “very short notice NHS England gives the ICB to get bids, reports, strategies, etc back to NHS England,” suggesting that longer lead-in times would bolster partnership working.

Another reflected: 

“I am accountable to a 1.2 million electorate and the NHS is accountable to Amanda Pritchard. They are very different.” ICP chair 

An ICB chief financial officer explains how a relentless focus on NHS finances ‘today’ can inhibit ‘building for tomorrow’: 

“Finance absolutely dominates the agenda. We have more financial conversations internally and with NHS England than anything else at the moment. How do we get the balance back going forward? We need to deliver this year and look towards the future.”

ICB leaders are clear on their duty to manage the money effectively but are concerned that micro-management from the centre and a short-term approach to financial planning does not effectively support financial sustainability. For example, NHS England’s planning guidance for 2024/25 was published two working days before the start of the financial year. ICB leaders had to deal with a high level of uncertainty and made plans based on assumptions that then shifted. Revisiting and reworking financial plans in the same year as they are meant to be delivered has consumed a vast amount of ICB capacity, time and headspace, which is taken away from delivering service improvement and making best use of available funds.

The Hewitt review reiterated that the proliferation of ‘penny packets’ and ‘nonrecurrent’ money that in practice becomes recurrent, makes it impossible to plan effectively. In reference to the planning process, an ICB chief financial officer reflected:

“The earlier we can understand the information the better. Next year we’re going to have to make some quite radical tough decisions. So can we have the information to make it?”

This is particularly important as ICBs are setting medium- and long-term financial strategies, working closely with NHS, local authority and voluntary sector partners to fund and deliver effective services for their populations. While some adaptation is needed, uncertainty over funding streams damages relationships and slows down delivery and the transformation needed.

A constrained environment

There is a clear consensus that finances are a risk to the success of ICSs over the next year. More than three-quarters of respondents (over 85 per cent) are concerned that the financial position of their ICB and local authorities will affect the delivery of their ICS’s ambitions. ICS leaders also chose the current financial position of the NHS and of local government as the two biggest barriers to their system’s progress over the next two years. Some of these financial pressures are within their gift to tackle (eg total system agency spend), while others may be driven by wider decision-making and the external environment (eg pay awards and energy costs) and so less within their control.

Leaders’ concern in last year’s survey that reductions to ICBs’ running cost allowance would hinder system delivery has come to fruition. The requirement for ICBs to reduce their running costs by 30 per cent by 2025/26 continues to put pressure on their staff and makes it more difficult to balance attention given to progressing other priorities that are essential to delivering reform and achieving longer-term financial sustainability. This impact is felt by some ICBs more than others, often reflecting system size and legacy of whether predecessor clinical commissioning groups had merged or not.

The challenging financial environment for the NHS more widely is illustrated by financial planning for 2024/25, where nearly three-quarters of ICBs have submitted deficit plans to NHS England with a total overspend of £2.2 billion.

Our survey of NHS leaders in April 2024, demonstrated the pressure the sector is under to deliver efficiency savings. More than six-in-ten NHS leaders said they would need top-up funding from the government within the year to be able to hit their efficiency targets. Cutting spend on agency, locum and/or bank staff as well as freezing vacancies was the main way NHS leaders said they would achieve these savings. Given high levels of demand for care and pressures on staff, these decisions were not made lightly.

“We’ve figured out how much we need to deliver, not even what we would like to deliver but what we think we should be delivering. And it’s not the settlements that the NHS is offering us. And that’s all over the country.” ICB chair

Local government is also struggling, with a rise in local authorities issuing section 114 notices or ‘declaring bankruptcy’ over the past year. The Local Government Association has warned that councils face a funding gap of more than £6 billion over the next two years, in the context of a reduction in their real-terms spending power since 2010/11.

NHS spend is being driven by a range of factors , with variation across the country. Some are outside ICS leaders’ control, such as higher inflation, energy and construction costs. Others are more within their grasp, such as driving medicines optimisation and addressing staff costs. The longstanding maintenance backlog has continued to increase, which is both a drain on productivity and a risk to patient safety. The expected pay award for NHS staff to settle industrial action was either not planned or cost much more than was budgeted for at the start of the year.

For local authorities, key cost drivers include an increased demand in SEND services and children’s and adult social care . An ageing population and increased comorbidities also mean demand for health and care services will continue to rise . A number of regulatory decisions may also be driving up costs in particular areas such as staffing. For example, one chair shared an example of a CQC decision leading to an increase in midwives despite the birthrate in their system decreasing. This is one of the areas Dr Penny Dash, chair of North West London ICB, will be exploring in her review of the operational effectiveness of the CQC.

Tough decisions are testing partnerships

These financial constraints are testing relationships and partnership working within systems. Leaders across the country are making difficult decisions about what to prioritise. They are grappling with addressing current pressures and planning within their budgets while limiting the fallout from reducing services and programmes on staff and patients.

One ICB chief executive shared that they are “already cutting back, delaying or deferring the very things that will be the route to medium-term financial sustainability (and better health and healthcare), sacrificed on the altar of break-even today.” This aptly demonstrates how a lack of funding and tightening of fiscal rules can undo efforts at reform, undercutting the new government’s agenda.

Investment in health inequalities can be one of the first areas affected. NHS Confederation research into how systems used additional funding for health inequalities demonstrated that leadership, governance and relationships were the key enablers in maintaining this investment. 

The overall financial context can lead to retrenchment within organisations. For example, in one place-based partnership, an NHS trust can no longer commit to splitting funding of a public health team equally with the council as previously agreed. Its place leader reflected that "if you don’t stick to what you’d committed to, all you’re doing is transferring that financial problem onto a partner. That’s not partnership." 

For some, this is also an opportunity to make some radical choices and bold decisions:

“The depth of the challenge is really making partners come together, face up to the structural deficit, and get on with making changes that have been ducked for the last decade or more. I’d much rather we weren’t in this situation, but I suspect that without it we’d still be stuck in many of our old ways.” ICB chair

Stepping up to the financial challenge

Despite financial constraints, system leaders are stepping up to the financial challenge and are creating value.

A system approach to maximising value for money

Each ICS faces its own history and context, including the local economy and labour market, provider history and levels of deprivation. For the most challenged systems, the road to financial sustainability will be incremental. Data also suggests that overall NHS productivity has fallen since 2019, despite an increase in staff and funding, with some areas seeing improvements. As the Darzi report highlighted, this does not mean that staff are not working hard, but rather that operational processes are not supporting staff to work efficiently, which is then impacting on their motivation and enjoyment of work.

Reflecting on this challenge, a third of respondents believe there are more opportunities to maximise available resources and improve productivity. In fact, nearly 80 per cent of respondents are confident that their system is currently able to enhance productivity and value for money. An ICB chief executive shared that "this is a prime focus in our system (as in many). The key will be consistent measures and getting behind the data in a way that helps staff engage." An ICP chair highlighted the need to take a targeted approach by focusing on "population need and a system approach to improving outcomes". 

ICBs and ICPs have a vital role as convenors and catalysts for change. Together, they can identify areas of increased efficiencies and productivity, bring together partners and set a shared vision for the future. ICS leaders shared examples of system-wide, medium- and long-term financial planning and of working as one finance team across providers. For example, a joint ICB/ICP chair shared that they “have a detailed financial improvement plan that all providers support and have signed up to, with a system improvement director and project management office to drive delivery of the identified improvements.” One ICB chief finance officer made clear that the ICB had not set the plan but rather it was “agreed as a system, with all partners from the outset,” which had brought them closer together. 

Investing time to improve relationships by having honest conversations and creating a culture of financial transparency can support real improvement, as demonstrated by the experience of North West London ICS.

Enhancing productivity and value for money

Case study: addressing acute productivity and a longstanding deficit in north west london.

North West London ICS faced a longstanding deficit, difficult relationships in the system with productivity challenges across the system. 

To tackle it, they undertook a needs analysis across the ICS in acute, community, mental health, primary care and Continuing Healthcare compared it with their areas of spend. This enabled them to identify gaps between resourcing and needs and where they were spending more than they needed to.

The system also analysed productivity levels, including cost-weighted activity across different sectors. One of the root causes of excess expenditure in the acute sector was low theatre productivity. To address this, the ICS focused on increasing grip and control and ensuring basic processes (such as scheduling) were as effective as possible improving productivity and financial planning.

This was enabled by improving ways of working, transparent reporting, operational challenge and decision-making. Being open and transparent about resources, financial plans and performance data and ensuring that all the directors of finance worked together is key. In addition to this, it ensures that all system financial decisions are made collectively, and that no organisation should be “left in distress” as a result of those decisions. 

Overall system theatre utilisation moved from 70 per cent to 83 per cent and the system has consistently achieved over 80 per cent for 12 months. North West London ICB has also submitted a breakeven plan for 2024/25.

ICBs are looking at avoiding duplication and using economies of scale to complement local delivery. This applies to both corporate and frontline services. Sharing public estates is a key area of interest and systems are using tools such as SHAPE Atlas to map their existing estates and make strategic decisions. For example, in South Yorkshire , ICB staff have relocated to South Yorkshire Fire and Rescue headquarters, making better use of existing public property. Colocation is increasingly used by place-based teams to drive integration and improve service delivery.

Thinking holistically about the workforce and undertaking integrated workforce planning is also an area of opportunity. An ICB chief people officer explained that workforce teams within NHS providers and local authorities are focused on the operational, while the ICB has a remit, skills and expertise to take a wider approach:

“Nobody else has got the bandwidth to think about that beyond the ICS. For me, that’s part of our job.”

Holistic thinking involves considering health and care needs, population health, system strategy and current capacity and skills within the system for a workforce for the future. ICSs are sharing and blending roles, for example in Greater Manchester , where integrating their workforce has provided better personalised wraparound care and improved staff experience and retention. NHS Employers’ guide to integrated workforce thinking is a useful resource for ICSs on this journey.

ICSs are tackling issues such as elective care waiting lists, flow and discharge through strong collaboration between system partners, clinical and staff engagement and data analysis. For example, an ICB chief executive described “bringing relevant senior clinicians together to tackle increasing surgical productivity across our three acutes,” which has “led to further improvements in discharge rates and marked length-of-stay reductions for some procedures.”

Systems are also using digital innovation and technology to drive the right type of activity. Cheshire and Merseyside ICS has implemented a high-impact waiting-list initiative across all its acute hospitals. The system has deployed an AI-backed decision support model to help find, prioritise and support some of the highest-risk patients on waiting lists. An NHS England assessment of the first 125,000 patients to be managed through the system found a two-thirds reduction for ICU for the highest-risk patients, 125 bed-days saved for every 1,000 patients on the waiting list, an 8 per cent reduction in emergency admissions and reductions in avoidable harm.

Leaders across the system want to learn from one another, especially as many experienced staff have left since the pandemic. The NHS Confederation is working with partners on the development of an analytics and knowledge network, to share best practice and use benchmarking to improve services and care and reduce unwarranted variation. One ICB chair shared that NHS England’s Model Health System tool , which provides systems and providers with benchmarking quality and productivity data, is key to this. Based on a forecast of their system finances, “if they could get all of our acutes working fully to model hospital, we could halve the deficit.” The NHS Confederation will continue to convene members from across the health and care sector to share learning and insights on a system approach to productivity.

The NHS can also learn from local government, which is strictly required to balance its budgets:

“We are used to transforming services all the time. […] I have said to our ICS to use those skills and experiences in local authorities.” ICP chair

Shifting resource upstream

ICS leaders are not just focused on technical productivity and saving costs but creating better value for patients and improving outcomes by shifting resource upstream. This means increasing investment in primary care and community based services to prevent worsening ill health as well as designing new models of care. 91 per cent of survey respondents agree that their system has made a strategic commitment to shift the allocation of resources to allow more people to be treated in their local community and access more care closer to home. 

“While developing a value proposition for the NHS is important, if we do not fundamentally change the delivery model and place some focus on this, the NHS will become unaffordable.” ICB chief executive

However, only 54 per cent of respondents agree that their system is making progress towards this and 35 per cent are unsure, highlighting the gap between ambitions and reality. This was reflected in the Darzi review, which made clear the longstanding dissonance between strategy and delivery of the ‘leftward shift’. In fact, between 2006 and 2022, ‘the share of the NHS budget spent on hospitals increased from 47 per cent to 58 per cent.’

Nearly half of qualitative responses indicated that financial constraints, and particularly acute financial deficits, were holding back systems’ ability to make this shift. One ICP chair remarked that “the right thing is still to move people out of hospital into another care setting. But somebody has to pay for the healthcare and that’s the challenge that we’re running into right now.”

ICS leaders point towards the difficulty in freeing up money for transformation and shifting care upstream when their acute and mental health secondary care providers are financially challenged. An ICB chief executive shared that the “tightness of the overall financial position is driving us to slow down the (relatively small) investments needed to pump prime these changes.” An ICB chief financial officer further highlighted the scale of the challenge that is slowing progress:

“We can only shift resource if we can shift cost. So our focus is about how we move the cost base as opposed to the resource base.”

However, they shared how they were able to make incremental progress:

“If we can non-recurrently pump prime something, let’s do something different and then we can take the savings out.”

Current financial flows and contracts are fragmented and work against integration, with different parts of the NHS, primary care, community care and acute care not financially incentivised to work better together. According to one ICP chair, “most resource (money), is still needed in the acute system. Financial models and processes are needed to enable money to be spent in one budget that will deliver savings multiple years later, and possibly in another budget.”

Other key barriers mentioned included a resistance to change from key stakeholders such as local politicians, lack of joined-up data to inform decisionmaking and the current GP contract, which can limit ICBs’ ability to shape incentive regimes around local needs. The current one-year financial allocation process also limits the ability to shift resources over the long term, as discussed further in this report and highlighted by the Darzi report. These findings are reflected in upcoming research by the NHS Confederation into unlocking prevention in ICSs.

When systems do succeed in shifting resources in a different way, the positive outcome for their populations is clear. For example, in one ICS, “coming out of covid, we had 200 people waiting for care assessments for domiciliary care and we now have only two. We put more money into that system, and we do not have a waiting list for domiciliary care.”

Case study: New GP funding formula in Leicester, Leicestershire and Rutland (LLR)

The ICS has developed its own funding distribution formula to derive a Health Equity Payment to address problems with the Carr-Hill formula. Some of the characteristics are to:

• compensate for inaccuracies in the Carr-Hill formula’s assessment of need by levelling-up funding in low-funded practices
• use current, comprehensive, anonymised primary and secondary care
• invest in primary care so that no practice receives less than their Carr-Hill formula amount.

The LLR method bases the allocation upon case mix adjusted morbidity, deprivation, new registrations and communication issues. The Health Equity Payment is calculated using three main criteria:

• Core staff component, including a rurality element (41.3 per cent).
• Needs-related component (52.9 per cent), adjusted for multi-morbidity of actual patients; communication issues (complex needs and language barriers require longer consultation time to deliver equivalent care); list turnover (newly registered patients tend to use more GP time for a given morbidity).
• Deprivation, adjusted for IMD (5.8 per cent).

Analysis shows early positive outcomes. Uniquely, the model stratifies several independent databases according to its assessment of funding for need (GP Patient Survey [GPPS], CQC and primary care workforce data). Changes in GP Patient Survey indicators such as satisfaction with contacting the practice, overall experience of making an appointment, satisfaction with general practice appointment times, or frequency of seeing or speaking to preferred GP show a narrowing of the gap between the lowest funded practices in receipt of the payment.

This effect is not seen in practices assessed as better funded and not requiring payment. This indicates both that funding drives performance and that where you equalise funding according to the LLR model you equalise GPPS performance. It also seems to have mitigated long-term deterioration of patient experience in the lowest funded practices.

Improving system working

“Accountability is important. But too many people holding people to account, rather than doing the job, can be counterproductive.” The Darzi report

System leaders welcome appropriate accountability and recognise the important role played by regulation and oversight in healthcare provision, but highlight that the current framework is severely flawed. System accountability arrangements are multi-layered. Individual NHS providers (trusts, foundation trusts and primary care providers) are accountable to ICBs and national bodies, including DHSC, NHS England and the CQC. ICSs collectively are accountable to their local populations (foundation trusts are formally accountable to their local populations through council of governors) and partners within them are mutually accountable for the delivery of the integrated care strategy. ICBs are accountable upwards to national bodies. Balancing multiple masters can be challenging, as one ICP chair summarised:

“The ICS is a multi-tiered arrangement that is both centrally controlled and responding to local demand. Progress can always be made but the current arrangements cannot optimise the outcomes for residents.”

There is a clear commitment from within the system, national government and regulators to get system oversight and accountability arrangements right, but our research shows that frustrations remain and more work is needed to provide clarity and consistency. An ICB leader described the accountability relationship between providers, the ICB and the centre as a “journey or a continuum away from individual sovereign organisations into system working.”

Intra-system accountabilities are being embedded

Over half of ICS leaders (57 per cent) feel that accountabilities within their system are well defined. Qualitative comments revealed that ICSs are in the process of embedding an operating model across all system partners, with some further ahead than others. In the words of one ICB CEO: “We have defined a system decision-making framework which articulates responsibilities and different levels and organisation.” Almost half of respondents indicated that a system accountability framework is being systematically reviewed and evolved by all system partners.

A joint ICB and ICP chair described being on the panel for provider appointments as a helpful way to build system working into governance processes. In the words of one ICB leader: “We’re working on the accountability issue on a weekly basis, sometimes almost three times a week when an issue arises and there’s therefore a gradual shift toward more local decision-making with clear accountability hardwired in. That is the healthiest way to shift accountability more locally.”

However, some felt there is still work to do to establish the operating model, for example between place and system programmes. Others reflected that even if accountabilities were defined, implementation did not always follow. In the words of one ICP chair:

“System accountabilities are crystal clear but what is probably less clear is how those accountabilities are delivered at different levels.”

A minority of ICS leaders flagged major concerns. One ICP chair said he didn't feel he was working “within a genuine partnership”, and an ICB chair reflected that “too much central control and ring-fencing makes local accountability ambiguous.”

ICB and NHS England ways of working

NHS England’s operating framework clarifies that NHS England will work ‘with and through’ ICBs to deliver oversight of providers. Despite these encouraging words, our research suggests that the centre is yet to achieve the significant cultural shift needed to support a system that has moved from an organising principle of competition to one of collaboration.

ICS leaders shared mixed views on how clearly accountabilities are defined between the ICB and NHS England’s regional team, ranging from clear agreement to duplication and confusion. Just over half of respondents (52 per cent) felt that accountabilities were well defined between the ICB and NHS England regional team in their patch. A number of respondents had positive reflections on ways of working with their NHS England regional team:

“We have an excellent relationship with our regional director and team: it’s ‘with and through’ in practice. Where there are hiccups, we can raise and resolve them quickly.” ICB chair

“There is an open and engaged conversation with a clear oversight framework. We have a regular and productive relationship with the regional team.” ICB chair

Regional variation in experiences was notable. All ICB leaders responding to the survey from the North East and Yorkshire region (representative of all four systems in the region) agreed that accountabilities were well defined with their regional team. This reflects a model of true partnership with the region’s four ICBs, known as the ‘four-plus-one model’ whereby the regional team works with and through them in overseeing the performance of NHS trusts. This is most akin to the model described in NHS England’s operating framework which, for most of the country, remains an aspiration. 

Some ICS leaders shared frustrations at duplication caused by NHS England regional colleagues not observing the arrangements set out in the operating framework. The consequences of this can be severe, leading to prolonged decision-making and adding to the regulatory burden on providers. As an ICB chief executive explains:

“While accountabilities are defined, day-to-day working does not always result in ‘system first’. There are examples of when NHS England bypasses ICBs resulting in duplication and confusion.”

The most commonly cited example of this was regional teams liaising directly with providers in ways which disempowered ICBs. 

“I don’t expect them to not speak with local providers – but I do expect them to let me know when they do – and why.” ICB chief executive

Several ICS leaders called for more clarity on accountability and the levers and tools ICBs hold to perform their dual role in system oversight and as system convenor. An ICP chair described this as “an unresolved conflict both regionally and nationally where the responsibility for outcomes is devolved but the power to act locally at system level is not to the same degree.” Another ICB and ICP chair referred to this as a “design flaw” which complicates system working, whereby the ICB has “accountability without authority and no levers.” Some systems are facing the added challenge of significant leadership churn across NHS and local authority partners. These concerns align with the suggestion in the Darzi report that the roles and responsibilities of ICBs need further clarity.

ICS leaders were also split in their opinions and experiences of working with NHS England’s national team. Only 40 per cent of respondents felt that accountabilities were well defined between the ICB and NHS England national team. Twenty-four per cent of ICS leaders surveyed disagreed, including 7 per cent who strongly disagreed. Some respondents noted improving ways of working. One joint ICB and ICP chair reflected:

“I believe that although it has been very challenging our accountability with the national team is clear and constructive in nature.”

However, many ICB leaders shared instances of national directors directly approaching providers, bypassing the ICB and/or regional office, or contradicting what region/ICB/provider(s) have agreed. NHS England’s policy and guidance is often experienced as overly bureaucratic, time consuming and out of touch with system working, with a prime example cited as being the development of guidance on the annual appraisal of trust and ICB chairs, which initially contained 64 questions. ICB leaders also highlight that directions from NHS England’s national team can also sometimes be contradictory, for instance in delivering safe staffing levels while reducing staff numbers to cut costs and meet financial targets.

System oversight

NHS England and the CQC have worked hard since the 2022 act was passed to develop frameworks for system oversight that provide clarity, but the survey demonstrated that some ICS leaders feel that this has not yet been achieved. According to the draft NHS England oversight framework , NHS England will only delegate responsibility for provider oversight to ICBs with higher capability scores. NHS England’s new oversight framework was described as ‘convoluted and complex’ and some questioned the subjective nature of measures used to calculate ICBs capability. To note, NHS England is still iterating the oversight framework in response to its formal consultation.

“There is no clarity. [The NHS England regional team] increasingly expect the ICB to take on the oversight and assurance role, however no resources are being transferred to allow this, plus the ICB is expected to reduce running costs significantly. It is also unclear whether providers recognise the role of ICBs in oversight and assurance.” Joint ICB and ICP chair

One ICB and ICP chair described the challenge of balancing an oversight and convenor role:

“Everybody wants to have a very clear performance framework and accountability and wants partnership and shared leadership and all that kind of stuff. And I think it’s very hard to manage both.”

Balancing this dual role will be particularly challenging for ICBs in the current context of financial challenges explored in the section 'Balancing today's challenges and building for tomorrow'.

If the oversight framework is not administered correctly, it poses a big threat to partnership working. A survey of trust chief executives by NHS Providers demonstrated the strength of feeling about the burden placed on providers by multiple layers of regulation, including the ICB. Seventy-two per cent said that the burden of ICB regulation had increased, compared to 48 per cent from NHS England and 36 per cent from CQC. In the context of NHS England increasingly devolving an oversight role to ICBs, it is concerning that NHS England’s regulatory burden did not reduce in parallel. This is evidence that the new operating model is not working in terms of role definition. 

CQC’s capacity to conduct assessments has also been called into question by Dr Penny Dash’s review of the CQC. Her interim report , which was based on wide engagement across the health and care sector including CQC staff, found evidence of significant operational challenges. It highlighted major concerns around the CQC’s single assessment framework, including a move away from a focus on outcomes, a lack of clarity around how different ratings are arrived at for each quality statement, and concerns around how data is used to inform judgements. In this context, any imminent roll out of the assessment framework for ICSs – including the use of one-word ratings – would be ill advised. In our research, ICS leaders shared concerns about duplication between NHS England and the CQC’s role in system oversight. The next phase of the CQC review will look at the overall regulatory landscape and burden, which, as revealed in the Darzi review , has doubled in size in terms of staff numbers over the past 20 years.

Supporting devolution within systems

As partnerships between the NHS and local government, ICSs will play a key role in supporting a more devolved model of health and care. They are part of a devolved accountability model, whereby functions previously held by DHSC or NHS England are, over time, delegated down to ICBs. In turn, ICBs delegate to other spatial levels within the ICS, including provider collaboratives, shared group models, place-based partnerships and neighbourhood teams. Alongside this, ICPs play a key role in bringing together the broad spectrum of partners with remits across both healthcare and the wider determinants of health to improve the health and wellbeing of their local population. The Improving system working 45 – The state of integrated care systems 2023/24: tackling today while building for tomorrow NHS Confederation is conducting research with chairs and chief executives in shared group leadership models, which has highlighted that success depended on local leadership, devolution and ownership and the need for simplifying system governance and accountability arrangements to support cohesive decision-making. 

Place is often the best spatial level for addressing service integration, for example in relation to urgent and emergency care. However, as our research reveals, the need to focus on financial and operational recovery has slowed the pace of devolved decision-making, which in turn drives service innovation, productivity and improvement: all crucial to long-term financial sustainability.

Just under half of ICS leaders surveyed felt their system devolves decision-making to the most local level, as close to communities as possible. This response is similar to last year’s survey, with an increase of only 3 per cent of those who agreed, indicating that little progress has been made. An ICB and ICP chair described the role of the ICB as “setting strategy, allocating resources, system oversight and assurance”, with delivery being “the clear responsibility of places.” Many others described a similar model but were at different stages of embedding this in practice.

A minority of systems have a more devolved model whereby resources and responsibility are delegated to place level, with governance arrangements that support this.

Case study: A devolved operating model in the Black Country ICS

The Black Country ICS has a clear operating model based on devolution that has been agreed by all system partners and its place-based partnerships are genuinely place led. All four places in the system – Dudley, Sandwell, Walsall and Wolverhampton – have established place partnerships involving local authorities, voluntary sector organisations, as well as those in wider partners including housing, which they have used to identify the key health and care issues to address in their respective places. Each place has an ICB managing director that oversees the budget and commissioning responsibilities. Simultaneously, the ICB and ICP have identified work that it is appropriate to undertake at a system level, or in some cases at a wider level, working with the West Midlands Combined Authority. This is underpinned by an outcomes framework that supports targeted investment and impact measurement. 

Informal delegation was introduced with defined responsibilities, with the health and wellbeing boards directing population health priorities. The ICB and the place integrated commissioning committee acts as the commissioning vehicles, while the place based partnerships lead the transformation and strategy for integrating care. Place-based partnerships and neighbourhoods concentrate on local healthcare delivery, transformation and integration. Having a clear, delegated framework for strategy and service commissioning enables focused transformation of delivery of healthcare services across the system.

A place leader we interviewed described one of the barriers to achieving this level of delegation and offered an alternative way forward: 

“ICBs take a line from NHS England as a reason not to delegate, but even if you don’t transfer the budgets you can delegate the management of the budget and the commissioning of services.”

An ICP chair urged ICB colleagues to “allow other organisations to take the lead sometimes rather than feeling they have to do everything themselves.” Some respondents challenged the question and emphasised that devolution should occur at the right level and where appropriate. In the words of an ICB chair:

“The challenge is working out, and building a consensus, around which decisions sit where.”

ICBs are operating with reduced budgets and are being tightly managed on finances. This is reflected in our research, with financial constraints leading to centralisation as well as a lack of support from the centre cited as key barriers to devolved decision-making.

“We have made more progress in one of our ‘places’ than the other. This is challenging as local partners want to pursue local agendas and that’s a challenge in an era of so much top-down direction.” ICB chief executive

Another explanation given for the slow pace of devolved decision-making is the need for improvements in the capability and capacity of local leaders at place, neighbourhood and in provider collaboratives to enable this to happen. There is also variation across places in terms of their capacity and readiness to take on more, exacerbated by the financial challenges facing all partners. A place leader we interviewed emphasised the need to protect committed funding in support of partnership working.

“We drip, drip bits of responsibility and decision-making to them on the basis of more will come when maturity in our system working happens. Timing on this is critical because at the moment we’ve got a massive recovery job to do.” ICB leader

A majority of respondents shared that they intended to accelerate devolution in the upcoming year to both places and emerging neighbourhood teams. 

“While there are still many neighbourhoods which are embryonic, the engagement with many is developing well, the primary care providers share the ambition, the voluntary sector is engaged through board representation and local initiatives – the year ahead will have particular focus on their development.” ICB chair

The NHS Confederation is undertaking research to understand different models of place and neighbourhood working, which will make several recommendations to systems and national government.

How the centre can enable the change

ICSs need support from national government and arm’s-length bodies to deliver on both their priorities for today and tomorrow. As was echoed in the Darzi report , across the health and care system there are areas, in particular capital and social care, where more money is urgently needed to boost overall system productivity. A new government provides new opportunities for improving ways of working in terms of oversight and financial planning and facilitating the shift to more preventative care. The government’s upcoming ten-year health plan provides a springboard for action.

Addressing the funding gap in social care and capital investment

It is clear the government will likely need to plug this year’s funding gap, meeting the Health Foundation’s 4.5 per cent per annum increase for the rest of the parliament. But ICS leaders want to see increased investment in social care, local government and capital, not to just look at NHS finances in siloes. 

ICS leaders warn that the lack of funding for social care is one of the biggest barriers to systems’ progress over the next two years, which is especially concerning as this was seen as one of the biggest opportunities for joint working between NHS and local authority partners. They are keenly aware of the interdependencies between health and care, and the need to support a chronically underfunded social care system. In fact, the Darzi review pointed out that the ‘impact of delayed discharges is equivalent to 12 per cent of all NHS beds.’ Successive governments have repeatedly delayed reform, including recently scrapping the Dilnot reforms, demonstrating that social care has not been ‘ valued or resourced sufficiently .’

As one ICP chair shared:

“We talk about one per cent of the NHS budget going into social care. If we could make it 5 per cent, that would be transformational. That's the sort of scale that says we're committed and means that we would necessarily have to change the way that we deliver NHS care.”

In the context of local government’s financial challenges, a funding solution for social care will be essential for ensuring continued integration between health and care services. 

ICS leaders continue to highlight the gap in NHS capital funding and inefficiencies in the capital allocation process as a barrier to better productivity. In fact, lack of capital funding was a close sixth option when asked about their biggest barriers. The Darzi review sounded the alarm on the raiding of capital budgets and the overall shortfall, which means England falls behind comparator countries in terms of capital investment. The NHS Confederation has called for a £6.4 billion annual capital funding increase for the NHS at next year’s three-year Spending Review and is working with members to identify new ways to raise capital funding and improve the capital allocation process.

Payment reform and better financial planning

A new government provides an opportunity to think radically about how money is allocated. This includes payment mechanisms as well as the financial planning and allocation process. 

It is clear from our research and from the reviews by Patricia Hewitt and Lord Darzi that the current financial planning process is inefficient and inhibits partnership working. The centre should provide as much information and certainty to local leaders as possible to drive the right decision-making. Multi-year funding settlements are the only way for ICSs to deliver on their long-term ambitions – in particular changing models of care and improving population health.

Recommendation: Multi-year funding settlements 

Instruct relevant departments – in this case the DHSC to NHS England – to outline Spending Review length funding allocations for both revenue and capital. This would bring the NHS in line with the government’s commitment to give councils multi-year funding settlements. Allow for a proportion of this funding to be front-loaded to be spent in the first year for outcomes-based care for the length of a Spending Review and place a moratorium on further ringfenced non-recurrent funding. Instead, give ICBs and trusts the realistic full sum available for the year based on agreed outcomes, rather than delivering it piecemeal.

The current NHS payment system is also in need of urgent reform. NHS Confederation research into payment mechanisms highlighted that current payment mechanisms work against integration by incentivising more activity in the acute sector at the expense of other areas of care that intervene earlier to prevent worsening ill health and provide better value. Fractured financial flows make it difficult for different parts of the NHS to work together effectively Changing payment mechanisms can support both better technical productivity and allocative efficiency, in particular supporting ICSs to shift resources upstream, which they are committed to doing. 

Future versions of the NHS Payment Scheme, including for 2025/26, are an opportunity to remove some of the current barriers and move towards the right incentives for integrated care, for instance towards outcomes-based payments in some settings. In the meantime, ICBs should be supported to experiment locally with their payment mechanisms. The NHS Confederation is committed to supporting systems to innovate and develop novel approaches. Looking ahead, and with the right building blocks in place, risk-weighted capitated payments could better support the ambitions of ICSs.

Supporting shifting resources upstream

Alongside better incentives for out-of-hospital care and multi-year funding settlements, ICS leaders want national partners to support the shift in resources upstream by improving sharing of learning and evidence and rebalancing priority-setting and oversight to incentivise such activity. For example, NHS England and the CQC could draw on locally developed outcome-based measures to oversee performance of providers and ICSs. While giving them the right autonomy, ICS leaders would find helpful some headline, long-term outcomes-based measures nationally to demonstrate the government is committed to making the shift towards prevention. 

An ICB chair said they want national bodies to look beyond access and ‘start to value and acknowledge these things.’ Another ICB chair would like national partners to ‘make at scale, the evidence case, building not just the direct health benefits but also wider and often greater economic and social benefits.’ Other asks included tackling primary care contract reform, more management support in ICBs and investing in the public health grant. The latter could make a real difference according to an ICP chair: “Fund [the public health grant sufficiently so we can redirect people into proper prevention rather than just try to manage them when they enter the NHS system.” 

Strong partnership working with local authorities and the voluntary sector as well as better use of the Better Care Fund (BCF) were cited as local enablers that the government should continue to support. Recent revisions to the BCF to extend its cycle, put greater emphasis on integration and provide additional funding were a step in the right direction, but its implementation needs greater consistency and its funding protected . The timing of the BCF guidance and its funding allocations should be fully aligned with the planning cycle, for systems to use effectively and consistently in planning and delivering services and support.

Recommendation: New payment scheme 

Ensure the 2025/26 NHS payment scheme, as well as future iterations, supports the shift towards integration and more preventative healthcare by incentivising out-of-hospital care and allowing more flexibility and local variation. Work with systems to pilot new payment systems and scale them where they prove valuable.

Empowering ICBs to deliver

System oversight arrangements have come under particular scrutiny this year, with NHS England consulting on its oversight framework and a review led by Dr Penny Dash into the operational effectiveness of the CQC, much of which was highlighted in the Darzi report . This follows the review by Patricia Hewitt into ICSs’ autonomy and accountability a year earlier. These reviews provide a helpful roadmap for a new government to ensure oversight incentivises system working and a more balanced focus on short- and longer-term goals. But examples from both ICB and ICP leaders demonstrate that there is still a lot of work to be done to provide clarity and consistency and to cement the ways of working that were agreed in NHS England’s operating framework.

Recommendation: Evolve and embed the new operating model 

Both the government and NHS England should embed the new operating model by working ‘with and through’ ICBs to tackle issues in the wider system. This should be done consistently across regions. NHS England should ensure its own role in oversight is proportionate to the level of oversight afforded to an ICB through the oversight framework to ensure it does not simply add a new layer. This should be iterated and evolved in close partnership with ICB and provider leaders

When the health and care system faces extreme operational and financial challenges, now is a crucial time to get the basics right and ensure ICBs are empowered to deliver.

A first important step is ensuring that the system and the centre work together effectively as partners. The variability we uncovered in NHS England regional and ICB relationships is concerning and indicates that NHS England’s operating framework is not being embedded evenly across regions. Moreover, experiences of both providers and ICBs are evidence that the new NHS England operating model is not currently working as effectively as it could in terms of role definition. 

Oversight plays an important role in driving focus, but currently it does not incentivise an equal focus on short- and longer-term issues. One positive step would be to set out an expectation that ICBs will commission based on population health outcomes, not just activity. DHSC/NHS England could draw on locally developed, outcome-based measures to oversee performance of providers and ICSs. These should be used across NHS England’s oversight framework, CQC’s ICS assessments and DHSC’s oversight.

Recommendation: Oversight should incentivise a balance between today and tomorrow 

The government, NHS England and the CQC should hold ICBs to account on their four purposes alongside a small set of locally and nationally determined priorities. This applies both to formal oversight/accountability structures and in day-to-day working, for example by giving more time in performance meetings to focus on longer-term issues.

ICB leaders feel they are being handed more responsibility without being given the levers and tools needed to deliver. System leadership requires a different set of skills and competencies than the more traditional top-down NHS regime, focused on coalition-building and problem-solving across the partnership. ICS leaders need coordinated support for leadership and development and protected continuous professional development in line with the recommendations made in the Messenger review. Currently, leadership programmes provided by NHS England are predominantly focused on provider organisations, but ICS leaders also need tailored support. In some cases, they need further support and direction from national government and national bodies to progress particular issues, with freedom to tailor this to fit local circumstances. Area ICS leaders want more support or guidance, include having appropriate levers for oversight and support for developing commissioning capabilities.

Recommendation: Give ICBs levers to devolve 

DHSC, NHS England and other national stakeholders should consider how to give ICBs more levers to progress the devolution of decision-making to place and neighbourhoods, without prescribing specific actions or timelines. To support this, DHSC should make integration at place a key theme of its ten-year reform plan for health.

Conclusion and summary of recommendations

ICS leaders agree with the new government’s assessment of the changes that are needed to stabilise the health and care system and improve outcomes, from shifting resources towards prevention and care closer to home, enhancing devolution including the role of mayoral combined authorities, to moving to a neighbourhood health service. ICSs and national government can be key delivery partners in making these changes, which are the only way to put the health and care system on a sustainable footing and improve the health and prosperity of the nation. 

However, the operating context is challenging, particularly given the financial challenges facing the NHS and local authorities. A relentless focus on NHS finances risks crowding out the longer-term transformation ICSs were established to deliver. The unbalanced focus on short-term operational and financial issues risks undoing the progress that has been made in partnership working that is critical to integrating services for the benefit of the public. System leaders are doing what they can, trying to balance short- and longer-term goals, but there are some things they need from national government and national bodies to be able to be partners in change, from how money is allocated to the autonomy they are given to allocate money and deliver their statutory functions. 

Based on our research findings, we make a number of recommendations to national government and national bodies, including for consideration as part of the development of the ten-year health plan:

1. Multi-year funding settlements 

Instruct relevant departments – in this case the DHSC to NHS England – to outline Spending Review length funding allocations for both revenue and capital. This would bring the NHS in line with the government’s commitment to give councils multi-year funding settlements. Allow for a proportion of this funding to be front-loaded, to be spent in the first year for outcomes-based care for the length of a Spending Review and place a moratorium on further ringfenced non-recurrent funding. Instead, give ICBs and trusts the realistic full sum available for the year based on agreed outcomes, rather than delivering it piecemeal. 

2. New payment scheme 

Ensure the 2025/26 NHS payment scheme, as well as future iterations, supports the shift towards integration and more preventative healthcare by incentivising out-of-hospital care and allowing more flexibility and local variation. Work with systems to pilot new payment systems and scale them where they prove valuable. 

3. Evolve and embed the new operating model 

Both the government and NHS England should embed the new operating model by working ‘with and through’ ICBs to tackle issues in the wider system. This should be done consistently across regions. NHS England should ensure its own role in oversight is proportionate to the level of oversight afforded to an ICB through the oversight framework to ensure it does not simply add a new layer. This should be iterated and evolved in close partnership with ICB and provider leaders. 

4. Oversight should incentivise a balance between today and tomorrow 

The government, NHS England and the CQC should hold ICBs to account on their four purposes alongside a small set of locally and nationally determined priorities. This applies both to formal oversight/accountability structures and in day-to-day working, for example by giving more time in performance meetings to focus on longer-term issues. 

5. Give ICBs levers to devolve 

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