NHS Improvement and Assessment Framework 2025-26 – Analysis and Implications

by | Feb 26, 2025 | Articles, Board of Directors, CQC, Governance, NHS, NHS Quality, Quality Assurance, Strategy

Introduction: The NHS Improvement and Assessment Framework (IAF) for 2025/26 is set to replace the current NHS Oversight Framework, reflecting a new operating model for the NHS. It is being introduced in the context of significant pressures (elective backlogs, urgent care demand, financial constraints) and a national push for system-level working through Integrated Care Systems (ICSs). The new framework aligns oversight with national priorities while granting greater autonomy to high-performing systems, all underpinned by the Secretary of State’s mandate for a more devolved, accountable NHS ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ) (NHS England » Our new operating model: supporting you to deliver high quality care for patients). Below is a structured analysis of the forthcoming framework, comparing it to the previous approach and examining policy shifts, national strategic direction, stakeholder feedback, and impacts on ICSs and provider collaboration. A detailed breakdown by key policy areas is also provided.

1. Comparative Analysis: New vs. Previous Frameworks

Structural and Operational Changes: The 2025/26 IAF represents a more “systematised” approach to oversight compared to the previous NHS Oversight Framework (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). Key differences include:

In summary, the 2025/26 framework shifts toward a more structured, transparent, and stratified oversight model, with greater autonomy for strong performers, more proactive support for those in difficulty, and a stronger improvement ethos. It addresses past concerns about role confusion and duplication by clearly delineating when ICBs lead oversight and when NHS England steps in (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework) (NHS England » Our new operating model: supporting you to deliver high quality care for patients). Whether these changes achieve the intended balance of local empowerment and robust accountability will depend on implementation (e.g. consistent regional application of the new segmentation criteria (NHS Oversight Framework 2022/23: what you need to know | NHS Confederation)). The next sections examine the policy shifts around this framework and how national strategy and stakeholder input have shaped its design.

2. Policy Changes Introduced Alongside the New Framework

The new IAF is accompanied by shifts in NHS policy meant to respond to current national priorities and pressures. These policy adjustments set the context for the framework:

Overall, the policies introduced with the 2025/26 framework reflect an attempt to balance urgent short-term performance recovery with longer-term transformation. By narrowing priorities, empowering local systems, insisting on evidence-based actions (“comply or explain”), and holding leaders accountable for both outcomes and financial stewardship, NHS England is responding to political and operational pressures with a new compact. The framework is essentially the mechanism to enforce and support these policies on the ground, ensuring that national goals (e.g. cutting waits, shifting to prevention, restoring financial stability) are translated into system and provider-level delivery (NHS England » 2025/26 priorities and operational planning guidance) (NHS England » 2025/26 priorities and operational planning guidance).

3. National Policy Context and Secretary of State’s Priorities

The evolution of the IAF is deeply influenced by broader national health policy shifts and the priorities set by the Secretary of State (SoS) for Health and Social Care. The current government’s agenda (as reflected in the 2025 Mandate to NHS England and the forthcoming 10-Year Health Plan) has steered the framework’s focus and design ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ) ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ):

  • From Central Control to Devolution: A major theme in the SoS’s approach is moving from a “top-down centralised model” to a “more devolved system” of healthcare management ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). The Secretary of State has explicitly charged NHS England with decentralizing decision-making to ICBs and trusts. In the 2025 mandate, NHS England was directed to “develop an updated NHS Oversight and Assessment Framework” that empowers well-performing local organisations with freedoms and flexibilities while intervening in the most challenged systems ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). This political steer directly led to the framework’s differentiated oversight model. The idea of rewarding excellence with more autonomy (and even financial incentives) comes from the SoS’s priorities for a culture of high performance and local innovation ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). The new framework’s promise of greater autonomy for Excelling rated ICSs and trusts is thus a reflection of ministerial policy to let strong local leaders “run things” with less interference, in line with devolution principles.
  • Clear Accountability for Performance: At the same time, the SoS has been emphatic about accountability for results, especially regarding waiting times and patient access. Cutting elective backlogs and ambulance/A&E waits is politically paramount, and the SoS expects tangible improvements. The 2025 mandate calls the current waiting list size “unacceptable” and demands the NHS “deliver shorter waiting times and improve performance against constitutional standards” ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). To ensure this, the SoS is driving a more rigorous accountability framework. The NHS is being asked not only to plan for improvement but to publicly demonstrate progress. This has influenced NHS England to incorporate publicly reported ratings and robust oversight in the IAF. For example, publishing one-word ratings for ICBs and highlighting where improvement is needed aligns with the government’s desire for transparency and a clear line of sight on system performance (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). The SoS’s focus on outcomes and patient experience (e.g. making patient choice a priority, as noted in mandate Objective 1) means the framework must keep the pressure on systems to deliver on key access metrics, or face escalation.
  • National Strategic Shifts (“3 Shifts”): The government’s longer-term vision, to be formalized in a new 10-Year Plan, centers on three strategic shifts: from hospital to community care, from treating illness to preventing it, and from analogue to digital ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). These priorities of the Secretary of State permeate the 2025/26 planning guidance and thus the framework:
    • Community over Hospital: There is a policy drive to bring care closer to home and reduce reliance on hospitals for avoidable admissions ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). This can be seen in the framework’s encouragement of neighbourhood health models and system metrics for things like preventing hospital admissions and speeding up discharge. ICBs will be assessed on how they develop services like community diagnostics, virtual wards, and integrated primary/community teams that can ease hospital pressures (NHS England » 2025/26 priorities and operational planning guidance). The SoS’s community-first vision means ICSs are expected to collaborate with social care and public health partners; accordingly, the IAF considers ICBs’ partnership work in its capability reviews (e.g. input from Health & Wellbeing Boards and local authorities) (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework).
    • Prevention over Treatment: National policy is prioritising prevention to improve population health and reduce future demand. The SoS has highlighted tackling health inequalities and the big killers (cancer, CVD, suicide) through preventive action ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ) ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). In response, the framework and planning guidance urge systems to shift toward prevention and early intervention – for instance, focusing on managing chronic conditions in primary care, improving childhood immunisations, and addressing social determinants via ICS partnerships. While acute waiting times dominate short-term priorities, the inclusion of prevention metrics and the requirement for ICSs to have strategies on inequalities signal that the SoS’s prevention agenda is influencing oversight criteria. The SoS’s insistence that the NHS contribute to keeping people in work and healthy (part of the government’s economic goals) also underpins new measures – e.g. expecting ICBs to integrate employment and health support.
    • Digital Transformation: The Secretary of State’s agenda includes a significant digital push – “analogue to digital” – aiming to modernize NHS data systems and use technology to improve productivity ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). This priority is reflected in NHS England’s plan to implement the Federated Data Platform nationally and to invest in digital tools. The new operating model (to which the IAF is linked) emphasizes data-driven decision making and digital integration as enablers of better care (NHS England new operating model for 2025/26 – CF) (NHS England new operating model for 2025/26 – CF). Thus, the framework will likely monitor digital progress (for example, uptake of the data platform, digital maturity of trusts) as part of system capability. The SoS’s push for digital innovation also aligns with the “comply or explain” approach – if there are proven digital solutions (like e-rostering, remote monitoring) that improve outcomes, systems might be expected to implement them or justify not doing so.
  • Secretary of State’s Oversight and Mandate: The SoS has also tightened the reins through formal mandate objectives that NHS England must pursue. One mandate objective specifically required NHS England to overhaul its operating model and oversight approach (leading to this framework) ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). Another is driving efficiency – with a target of 2% annual productivity and ensuring financial balance ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ) ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). The IAF therefore puts a strong emphasis on financial performance and productivity improvement at system level, mirroring the SoS’s priorities. The SoS will receive reports on ICBs’ and providers’ progress against these objectives, and the framework provides a mechanism to gather and structure that performance information.
  • Influence on Culture and Incentives: Finally, the tone from the top (SoS and government) has influenced the culture the framework seeks to instill. There is a notable emphasis on “grip” and delivery – making sure NHS organisations are tightly managing operational basics (e.g. waiting lists, ambulance handovers). But equally, ministers have signaled support for innovation and “doing things differently” to solve problems. For instance, scaling best practice quickly is a refrain (the mandate quips that the NHS has “more pilots than the RAF” and needs to generalise successful innovations) ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). The IAF’s focus on sharing good practice and peer learning is aligned with this ethos (). Moreover, the inclusion of potential financial rewards for top performers (such as additional capital or flexibilities) is directly traceable to the Secretary of State’s approach of using incentives to drive improvement ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ). This is a new development – historically the oversight framework did not explicitly tie to financial reward; it is now being contemplated as a tool to reinforce excellence, showing how the SoS’s priorities (both punitive for underperformance and rewarding success) have shaped the framework.

In summary, the national policy landscape – a government keen on visible results, system reform, and innovation – is mirrored in the 2025/26 Improvement and Assessment Framework. The Secretary of State’s influence is evident in the framework’s dual focus on accountability for core targets and empowerment of local systems, its incorporation of the government’s strategic shifts (community care, prevention, digital), and the introduction of incentive-based oversight. This ensures the framework is not just an NHS England initiative, but a key instrument for delivering the government’s health priorities and holding the service to account against them.

4. Stakeholder Responses to the New Framework

The proposed changes have elicited a range of reactions from key NHS stakeholders. Below is a summary of responses from major bodies and experts – including NHS Providers, the NHS Confederation, and Carnall Farrar – highlighting support, concerns, and suggestions:

  • NHS Providers (Trust Perspective): NHS Providers, representing hospital and community trust leaders, welcomed the intent to clarify roles and empower systems but raised several concerns during the framework’s consultation. They noted that the draft framework’s aims – such as collaborative system working, sharing best practice, and clearer accountability – are positive in principle (). In particular, trust leaders appreciate the emphasis on aligning priorities across ICS partners and addressing long-standing ambiguities about ICB versus NHS England responsibilities (). However, NHS Providers’ response expressed disappointment with aspects of the consultation process (short timeframe, lack of detail on metrics) and pointed out potential issues in implementation () (). Key points from their feedback include:
    • Metrics and Transparency: The absence of the actual metric set in the consultation made it “impossible to say” if the new ratings and segmentation would be fair or drive improvement (). They urged NHS England to engage further on the development of these metrics, stressing that what gets measured will dictate provider behavior.
    • Multi-ICB Provider Oversight: Providers were worried about how trusts that span multiple ICSs would be overseen (). Most trusts serve patients from more than one ICB, and some large trusts are core members of multiple systems. NHS Providers asked for clarity on how conflicting views between ICBs about a provider’s performance would be handled, and whether a provider’s data across different systems would be aggregated. Without clear protocols, a multi-site trust could face confusion or duplicate demands from different ICBs ().
    • Retaining NHSE Accountability: While supporting more ICS-led oversight, NHS Providers emphasized that NHS England must retain ultimate responsibility for regulation of trusts. They noted a change between earlier drafts – a line stating “NHS England makes final decisions on segmentation and enforcement” for providers in well-performing ICBs had been removed – and argued this should be reinstated (). Trust leaders want assurance that if an intervention (or enforcement action) is needed, NHS England will step in regardless of an ICB’s status, given NHSE’s statutory duties ().
    • Consistency and Objectivity: There were worries about potential subjectivity, especially in the new capability ratings for ICBs. NHS Providers echoed concerns that some criteria might be interpreted variably by regions, and urged a “robust process” to ensure consistent decisions () (The state of integrated care systems 2023/24 | NHS Confederation). They also highlighted the need for regional teams to be properly resourced and skilled to implement the new framework without creating new burdens.
    • Regulatory Burden: A survey of trust CEOs (referenced by NHS Providers) found that 72% felt the burden of regulation from ICBs had increased in the last year (The state of integrated care systems 2023/24 | NHS Confederation). Many trust leaders are concerned that the new framework could add “multiple layers of regulation”, with ICB oversight coming on top of NHS England and CQC oversight (The state of integrated care systems 2023/24 | NHS Confederation). NHS Providers has urged that the framework be used to reduce duplication, not add to it – a point acknowledged by NHS England’s stated commitment to streamline oversight (NHS England » Our new operating model: supporting you to deliver high quality care for patients). They will be watching closely to see if the new approach actually lightens the load on well-run trusts or inadvertently complicates accountability by inserting ICBs into the mix.
  • NHS Confederation (ICS and System Perspective): The NHS Confederation, particularly through its ICS Network, has been closely involved in shaping and responding to the new oversight approach. ICS leaders generally support the principle that they should have a role in overseeing providers, as it fits the ethos of system-led care. In a discussion paper gathering ICB chairs’ and CEOs’ views, 86% of ICSs agreed they should have a provider oversight role (System oversight: the view from ICB chairs and chief executives | NHS Confederation) (System oversight: the view from ICB chairs and chief executives | NHS Confederation). However, there is debate on how this should work in practice:
    • Universality vs. Differentiation: Nearly 70% of ICB leaders indicated a preference for all ICSs to have some oversight responsibilities for providers – not just the highest-rated ones (System oversight: the view from ICB chairs and chief executives | NHS Confederation) (System oversight: the view from ICB chairs and chief executives | NHS Confederation). In other words, many in the Confed ICS Network favor adjusting the framework so that every ICB, regardless of its capability rating, is involved in oversight (what they termed a “fixed model”). They worry that tying the role to the capability rating (the current design) could be counterproductive – it might diminish the accountability of providers in less mature systems or send a negative signal that those ICBs are not trusted to govern their patch. Some also fear it could create a stigma or a two-tier dynamic among ICSs.
    • Complexity and Clarity: In feedback to NHS England, ICS leaders described the draft oversight framework as “convoluted and complex”, questioning the clarity of how ICB capability is measured and how exactly the hand-offs between ICBs and regions would occur (The state of integrated care systems 2023/24 | NHS Confederation). They found some of the language and process in the draft confusing, and were concerned it might be too bureaucratic. The Confed called for simplification and co-design with ICBs to ensure the framework is workable on the ground.
    • Resource Implications: A consistent message from ICS leaders is that if they are to take on greater oversight duties, they need adequate capacity and resources to do so (The state of integrated care systems 2023/24 | NHS Confederation) (The state of integrated care systems 2023/24 | NHS Confederation). One joint ICB/ICP chair pointed out that regional teams increasingly expect ICBs to handle performance assurance, yet “no resources are being transferred to allow this” and simultaneously ICBs are under pressure to cut their running costs (The state of integrated care systems 2023/24 | NHS Confederation). The Confed has echoed that sentiment: additional responsibilities must come with either extra funding or reduction in other asks. Otherwise, the risk is overstretching ICBs and undermining their ability to add value.
    • Balancing Oversight vs. Partnership: ICS leaders are acutely aware of the need to maintain collaborative, trusting relationships with their provider partners. Taking on an oversight/regulator role could strain that relationship. As one ICB chair put it, “everybody wants a clear performance framework and accountability… and also partnership and shared leadership – it’s very hard to manage both” (The state of integrated care systems 2023/24 | NHS Confederation). The Confed has recommended that the approach to oversight be one of improvement and support, not just monitoring, to preserve the spirit of integration. They also suggest that any issues with the framework be iteratively addressed in partnership with ICB and provider leaders as it rolls out (The state of integrated care systems 2023/24 | NHS Confederation) (The state of integrated care systems 2023/24 | NHS Confederation).
    • CQC Coordination: The NHS Confederation has also flagged the importance of aligning NHS England’s framework with the Care Quality Commission’s new statutory assessments of ICSs. There is concern about duplication between NHSE oversight and CQC’s upcoming reviews (The state of integrated care systems 2023/24 | NHS Confederation). The Confed notes that the CQC’s “single assessment framework” (for councils, ICSs, etc.) is itself under scrutiny for lack of clarity. They advise caution in introducing multiple rating systems at once. Any inconsistency between NHSE’s view of an ICS and the CQC’s view could be problematic, so the Confed urges close working to ensure the two oversight regimes complement rather than contradict. (NHS England has stated it is working with CQC to ensure synergy (NHS Oversight Framework 2022/23: what you need to know | NHS Confederation).)

    In summary, the NHS Confederation is broadly supportive of the direction of travel – empowering systems – but advocates refinements: simplify the framework, ensure all ICSs are engaged in oversight (with support to build capability where needed), and provide necessary resources. Their perspective is that effective system oversight can add value, but only if done in a way that strengthens collaboration rather than creating a new bureaucratic layer.

  • Carnall Farrar (Independent Insight): Carnall Farrar (CF), a health consultancy with expertise in NHS strategy, has provided analysis on the new NHS operating model, including the IAF. Their commentary has been positive about the changes, framing them as a “fundamental shift” towards a more devolved and data-driven NHS (NHS England new operating model for 2025/26 – CF). Key insights from Carnall Farrar include:
    • Greater Autonomy & Devolution: CF highlights that the new model is designed to give ICBs and trusts greater autonomy with NHS England in a more streamlined, supportive role (NHS England new operating model for 2025/26 – CF). They note this aligns with the broader devolution agenda and the policies set out in the 2025/26 planning guidance (NHS England new operating model for 2025/26 – CF). In CF’s view, enabling ICBs to take more control over resource allocation and service design (strategic commissioning) while NHSE steps back to focus on assurance and support is a positive evolution (NHS England new operating model for 2025/26 – CF) (NHS England new operating model for 2025/26 – CF).
    • Performance and Accountability Mechanism: CF specifically points out the introduction of the new IAF as a key lever in the operating model – determining the “system support needs” and granting more autonomy to high performers (NHS England new operating model for 2025/26 – CF). This reflects CF’s belief that differentiating support based on performance will encourage improvement: well-run systems can innovate freely, whereas struggling systems get attention and help. They seem to endorse the philosophy that oversight can be lighter-touch for those doing well, which may incentivize systems to strive for the Excelling/Achieving status to earn more freedoms.
    • Focus on Data and Best Practice: The consultancy also notes the emphasis on data-driven decision-making and consistency through platforms like the NHS Federated Data Platform (NHS England new operating model for 2025/26 – CF) (NHS England new operating model for 2025/26 – CF). In CF’s analysis, the combination of better data infrastructure with the IAF’s objective metrics will allow for more objective, transparent oversight. This should help identify issues earlier and spread improvements faster. They view the national campaign for efficiency (capturing staff ideas on waste reduction) and the push to share best practices as important cultural components that complement the framework’s technical aspects (NHS England new operating model for 2025/26 – CF).
    • Leadership & Workforce Development: Carnall Farrar also applauds the parallel introduction of a Management & Leadership Framework as part of the operating model changes (NHS England new operating model for 2025/26 – CF). They interpret this as addressing a critical enabler for success: equipping NHS leaders with the skills to deliver transformation and meet the framework’s expectations. By professionalizing management and learning from the Messenger Review findings, NHS England is strengthening the system’s ability to improve from within – something CF sees as necessary alongside structural changes.

    Overall, Carnall Farrar’s tone is that the new framework and operating model are forward-looking and necessary reforms. They perceive the changes as aligned with creating a more efficient, responsive NHS that leverages system working. CF’s independent stance essentially validates the direction NHS England is taking, while underscoring the importance of implementation (such as truly using data for improvement and making sure high performers are actually rewarded with tangible autonomy).

In addition to these, it’s worth noting that other stakeholders have also weighed in. For example, the Healthcare Financial Management Association (HFMA) emphasized the need for financial metrics in the framework to be realistic and for clarity on how risk will be managed ([PDF] HFMA response to the NHS oversight and assessment framework …). Professional bodies like the Royal College of Nursing (RCN) responded to highlight quality and workforce considerations (NHS oversight and assessment framework | Royal College of Nursing). But the core themes from stakeholders mirror the above: support for the vision of a more empowering, improvement-focused framework, coupled with caution to ensure fairness, clarity, and true partnership in execution.

5. Implications for ICSs and Provider Collaboration

The new Improvement and Assessment Framework has significant implications for how Integrated Care Systems function and how providers collaborate within and across system boundaries:

  • Elevated Role and Accountability for ICSs: ICSs (through ICBs) will now be at the forefront of performance oversight in a way they weren’t before. This elevates ICSs from primarily planning and coordinating bodies to ones that also hold providers to account for improvement. A high-performing ICB will effectively act as a local regulator for its NHS providers, leading on assurance and turnaround efforts as needed (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). This means ICS leaders must develop new capabilities in performance management and intervention – roles that previously sat with regional NHS England teams. ICSs will need robust governance processes to monitor provider data, identify emerging problems, and support or challenge providers, all while maintaining the trust and cooperation of those providers. The annual ICB performance assessments and ratings will put ICS leadership under a spotlight; an “Insufficient Progress” rating would be visible to local stakeholders and could trigger external intervention (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). Thus, ICS Boards are incented to strengthen oversight and mutual support within their system to avoid such outcomes.
  • “System Compact” – New Working Agreements: The planning guidance indicates that a “compact” will be agreed between NHS England and each ICS, setting out mutual commitments and what each partner will deliver (NHS England » Our new operating model: supporting you to deliver high quality care for patients). This compact, linked to the IAF results, formalizes the partnership – if an ICS is given more autonomy, the compact will record how it will use that freedom and what it’s accountable for. Conversely, if an ICS needs support, the compact will outline what NHSE will do to help. For ICSs, this could mean clearer expectations and support plans. It also implies that ICSs must coordinate their providers to collectively deliver on the promises made in the compact (for example, achieving a system-wide elective improvement or financial balance target) (NHS England » 2025/26 priorities and operational planning guidance). Internally, ICSs may create similar compacts or agreements with their provider collaboratives or place-based partnerships to cascade these goals.
  • Strengthening Provider Collaboration: The framework’s system-oriented approach inherently encourages providers to collaborate rather than work in silos. Since ICBs and providers will be jointly assessed on outcomes like waiting times, they are effectively “in it together” – success will depend on collective action. For example, to hit a system’s elective recovery target, all acute trusts in that ICS might need to coordinate patient transfers or share capacity. The IAF explicitly looks at an organisation’s contribution to system priorities (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework), meaning a provider is judged not only on its own performance but also on how it supports its partners. This incentivizes behaviours like sharing best practices, aligning clinical protocols, and possibly formal provider collaborations (e.g. Provider Collaboratives for specialties or clinical networks) to tackle issues that one trust can’t solve alone. Indeed, one of the framework’s purposes is to “drive shared ownership of improvement” across the system (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework), so it is structuring accountability in a way that encourages mutual aid and peer support among providers in an ICS.
  • Managing Cross-Organisational Challenges: The new model also forces a closer look at issues crossing traditional boundaries. For example, primary care performance and social care delays will feed into ICS assessments (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework), which means ICBs must work with GP practices, community providers, and local authorities to improve those metrics. This could accelerate integration projects like pooled budgets or jointly staffed teams, as the ICS will want to address root causes that affect system outcomes. Similarly, if one provider is struggling (e.g. a trust with financial deficit or quality problems), the ICS as a whole is now implicated and will be expected to help resolve it, perhaps by deploying expertise from a successful trust to the struggling one. This is essentially a “one system, one responsibility” approach: collaboration is not just encouraged, it’s required because the system’s fate is tied together under the oversight framework.
  • Risks to Collaboration – Avoiding a New Layer: While the intent is collaborative improvement, there is a risk that if not handled sensitively, ICS oversight could be viewed by providers as just another layer of bureaucracy or even an adversarial relationship. Trusts have already reported increased regulatory burden from ICBs (The state of integrated care systems 2023/24 | NHS Confederation). To mitigate this, ICSs will likely adopt an improvement partnership model internally. We can expect ICS-level performance meetings to involve peer representatives from across the system, not just top-down scrutiny. Some ICSs may form system assurance committees with members from each provider to review data and jointly solve problems, in order to keep the process inclusive rather than top-down. The NHS Confederation has recommended such peer-review elements, and NHS England has noted the potential of peer review in future oversight models (NHS Oversight Framework 2022/23: what you need to know | NHS Confederation). In practice, if an ICS uses its provider collaborative forums to address issues (e.g. all trusts in a collaborative tackling long waits together), it can turn what might feel like “oversight” into a collective improvement effort.
  • Implications for Multi-ICS Providers: For providers that operate across multiple ICSs (e.g. specialist trusts or region-wide ambulance services), collaboration and coordination will extend beyond a single ICS. These providers will need to engage with potentially several ICBs. The framework implies that the lead ICB (perhaps where the provider is headquartered) could coordinate oversight for that provider in partnership with others, to avoid duplication (). Multi-ICS providers might negotiate a primary point of contact or a unified oversight plan agreed by all relevant ICBs. This is still an area to be refined, but it likely means providers will be pushing for standardized oversight processes across ICSs so they aren’t pulled in different directions. In terms of collaboration, such providers may act as bridges between ICSs – for instance, sharing innovations one ICS has made with another.
  • Culture Shift – ICBs as Both Partner and Challenger: ICSs were conceived as collaborative bodies, and now they must also adopt a challenge role when needed. This dual role will require a cultural shift. ICB leaders must maintain the trust of provider CEOs as system partners, yet also be prepared to have tough performance conversations and, if necessary, escalate issues to regulators. To make this work, many ICSs will likely emphasize a culture of openness and mutual accountability. If a problem arises (say, a severe quality lapse at a hospital), the ICB will convene partners to support that hospital, and only if that fails would formal intervention escalate. In effect, the ICS becomes the first line of response for performance issues – a significant change from the past when NHS England would often step in first. Over time, as relationships mature, this could strengthen the sense of shared destiny in ICSs: providers and commissioners aligning more tightly because their success is literally being measured together.
  • Shared Learning and Best Practice: The framework’s focus on identifying and spreading good practice means ICSs and provider collaboratives will serve as conduits for learning. We can anticipate more systematic sharing of improvement ideas – for example, if one trust in an ICS pioneers a successful virtual outpatient model that cuts waits, the ICB may facilitate its adoption by others, knowing that it boosts the whole system’s performance. Nationally, NHS England has committed to making best practice “available to all” and brokering this knowledge transfer (NHS England » 2025/26 priorities and operational planning guidance). This could manifest as collaborative networks or improvement programs championed by high-performing ICSs (e.g. an “academy” approach where an excelling ICS mentors a neighboring progressing ICS). Provider collaboration across ICS boundaries might also increase: for instance, provider coalitions at regional level addressing workforce or specialist services will align with the ICSs to meet common goals.

In essence, the IAF places ICSs in the driver’s seat for ensuring different parts of the local health system act in concert. Effective provider collaboration is not just desirable but essential under this model – an ICS cannot achieve its mandated outcomes unless its providers coordinate and support one another. The hope is that this will accelerate integration (breaking down traditional barriers between hospitals, GPs, community services, etc.) and lead to more coherent service delivery. However, it will test the maturity of ICS governance and relationships. Those systems that have already built strong collaboratives and trust will likely flourish with the new autonomy, while those without a history of effective joint working may find the new responsibilities challenging initially. Over time, though, the expectation is that the framework will forge stronger system cohesion, as successes are rewarded with more freedom and struggling parts of the system are collectively uplifted by their partners (NHS England » Our new operating model: supporting you to deliver high quality care for patients) (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework).

6. Key Themes of the 2025/26 Framework – Detailed Breakdown by Policy Area

The new NHS Improvement and Assessment Framework touches on multiple policy areas and strategic themes. Below is a structured breakdown of major themes and changes by policy area, along with anticipated impacts:

Performance and Access (Elective, Urgent, Primary, Mental Health)

Elective Care & Cancer: Reducing waiting lists is a top priority. The 2025/26 plan sets a goal to improve the 18-week Referral to Treatment performance to 65% nationally by March 2026, with every trust required to improve its RTT position by at least 5 percentage points from November 2024 baseline (and achieve a minimum 60% 18-week rate) () (NHS England » 2025/26 priorities and operational planning guidance). The framework will rigorously track these elective recovery metrics. It also introduces a new target to almost eliminate extreme long waits – aiming for <1% of patients waiting over 52 weeks (). Similarly, cancer wait times are in focus, with standards to treat 75% of patients within 62 days of referral and diagnose 80% within 28 days (Faster Diagnosis Standard) by March 2026 (NHS England » 2025/26 priorities and operational planning guidance). What’s changed: Compared to previous years, there is a more explicit linking of oversight to these targets – e.g. an ICS failing to hit elective trajectories might be segmented for intervention. The “comply or explain” approach means systems are expected to adopt proven elective initiatives (like high-volume surgical hubs, waiting list validation techniques, etc.) or justify why not (NHS England » 2025/26 priorities and operational planning guidance). Impact: Patients should see gradual improvements in waiting times as high-focus is maintained. Systems that succeed may be granted more autonomy (less reporting burden), whereas those lagging will trigger support teams (e.g. the Elective Recovery Taskforce) to assist. The framework also encourages mutual aid – if one hospital in a system is struggling with long waits, the ICS can facilitate patient transfers to another with capacity, with oversight pressure ensuring no pockets of unwarranted long waits remain.

Urgent & Emergency Care (UEC): The framework reinforces goals to improve A&E and ambulance performance. By March 2026, 78% of A&E patients should be seen within 4 hours and Category 2 ambulance response times should average 30 minutes or less (NHS England » 2025/26 priorities and operational planning guidance). There is also, for the first time, a specific mandate to reduce 12-hour trolley waits in ED, signaling zero tolerance for very long waits (). What’s changed: The approach to UEC is more holistic – ICSs are expected to manage UEC as a system, meaning hospitals, community services, NHS 111, and social care must collaborate to reduce pressure. The framework will track not just hospital metrics but system indicators (like delayed discharges, 111 referral rates, etc.) under the UEC domain. Best practices such as virtual wards, acute respiratory hubs, and enhanced frailty services are strongly encouraged in all systems to prevent admissions and speed up discharges (NHS England » 2025/26 priorities and operational planning guidance). Through “comply or explain,” NHS England will press every system to implement known UEC improvement measures (for example, your ICS should have a 24/7 clinical triage for ED referrals, or explain if something different works better). Impact: If effective, this should lead to faster ambulance handovers and shorter waits in emergency departments, as systems adopt a whole-pathway response. There may also be more regional cooperation (neighboring ICSs coordinating ambulance responses or sharing specialty beds). ICSs will be held accountable for metrics like ambulance response times that previously were looked at trust-by-trust or service-by-service, thus encouraging cross-organisational solutions (e.g., one ICS setting up a mutual aid divert arrangement with a neighbor if its main hospital is under severe strain). In oversight terms, persistent UEC underperformance will lower an ICB’s delivery segment rating, prompting rapid intervention or support teams being deployed.

Primary Care & Community Health: Improving access to general practice and urgent dental care is highlighted. By policy, systems must expand capacity equivalent to 700,000 additional urgent dental appointments and measurably improve patient experience of GP access (NHS England » 2025/26 priorities and operational planning guidance). The framework likely includes metrics such as the percentage of appointments delivered in primary care, wait times for urgent GP appointments, and perhaps 111 outcomes for primary care. What’s changed: There’s a new model emerging – the Neighbourhood Health Service, which emphasizes prevention and managing demand outside hospitals (NHS England » 2025/26 priorities and operational planning guidance). ICSs are tasked with developing neighbourhood teams integrating GPs, community nurses, pharmacies, and local partners to keep people well and provide care closer to home. We can expect the IAF to assess ICBs on progress with these models (qualitatively in capability reviews) and on outcomes like avoidable emergency admissions for chronic conditions. The shift to prevention is further enforced by metrics around immunizations, cancer screening uptakes, and health checks, which tie into ICB performance. Impact: For patients, this should mean better access to GPs (more appointments, perhaps enhanced hours or new pathways like pharmacists managing minor illnesses) and urgent dental issues addressed more promptly. ICSs will invest in primary care staffing and estates using their greater funding flexibility (2025/26 NHS priorities and operational planning guidance: what you need to know | NHS Confederation). Provider collaboration here means primary care networks and community providers working in tandem; the IAF will check if an ICS is effectively commissioning and supporting primary care (e.g., use of new GP access recovery plans) (2025/26 NHS priorities and operational planning guidance: what you need to know | NHS Confederation). Strong performance in primary care will support ICSs in their overall ratings, whereas poor access or quality in primary care will drag an ICS down regardless of hospital performance, reinforcing that primary care is a critical part of system success.

Mental Health: Mental health remains a priority area with specific goals: increase access for children and young people (CYP) to hit the nationally set expansion (345,000 additional CYP in treatment by 2024/25 compared to 2019 baseline) and reduce adult mental health inpatient length of stay to improve flow (NHS England » 2025/26 priorities and operational planning guidance). What’s changed: The framework brings mental health into the core of system oversight (previously, it sometimes took a backseat to acute physical health targets). Now, ICBs will be assessed on mental health delivery, such as meeting Improving Access to Psychological Therapies (IAPT) referral and recovery rates, CYP eating disorder waits, and crisis service provision. The planning guidance also emphasizes formulating plans for mental health crisis prevention and out-of-area placement reduction. Impact: ICSs will need to ensure parity of esteem – meaning mental health providers get due attention and resources in plans. Provider collaboratives in mental health (which already exist in many regions for specialised services) may be further leveraged to meet these targets. If an ICS is missing the mental health access standards, it could prevent an Achieving rating even if acute targets are met, thereby pushing systems to not neglect this area. In the long run, better mental health performance should mean shorter waits for therapy, quicker response in crises (e.g., more crisis teams to prevent A&E visits), and reduced strain on acute hospitals from mental health patients stuck in ED or beds.

Financial Sustainability and Efficiency

Financial Balance: With the NHS facing austere budgets, the framework puts heavy weight on financial management. Each ICS must deliver a balanced net system financial position – essentially break even – for 2025/26 (NHS England » 2025/26 priorities and operational planning guidance). What’s changed: In the past, financial oversight focused on individual organisations (CCGs or trusts) meeting control totals. Now, the ICS as a whole is accountable for living within its means, encouraging internal offsetting (surpluses in one organisation covering deficits in another) and collective responsibility. The IAF segmentation will reflect if a system is in deficit; an ICB could be placed in a higher intervention segment for financial issues alone. The framework also introduces the idea of rewarding high performers financially – e.g. giving Excelling systems more capital budget or fewer spending controls ( Road to recovery: the government’s 2025 mandate to NHS England – GOV.UK ) – which is a new incentive-based approach. Efficiency & Productivity: NHS England is enforcing an unprecedented 4% efficiency target for providers (2025/26 NHS priorities and operational planning guidance: what you need to know | NHS Confederation). The IAF will monitor efficiency metrics like cost per weighted activity unit, agency staffing spend, and productivity indices (possibly using tools like Model Hospital benchmarking). A “comply or explain” ethos might apply to known efficiency initiatives (for instance, every trust should implement procurement savings via the Spend Comparison Service or justify if it can’t) (NHS England » Our new operating model: supporting you to deliver high quality care for patients) (NHS England » Our new operating model: supporting you to deliver high quality care for patients). Impact: Boards will be under pressure to make tough financial decisions – stopping lower-value activities, reducing admin and management costs, and maximizing income. ICSs will act as moderators, making sure one organisation’s actions don’t harm another (for example, a cost saving by a hospital that pushes costs onto community care would be caught at system level). The framework’s integrated financial lens might accelerate moves like shared financial risk pools among providers or system-wide efficiency programs (bulk buying, shared services) to meet the stringent targets. For patients, the impact of financial measures is indirect – potentially fewer inefficiencies and wastage means more funding can be directed to priority services, but there could also be visible changes like some service consolidations or cutbacks in non-priority areas as systems reallocate resources to stay solvent (NHS England » 2025/26 priorities and operational planning guidance). A system consistently unable to manage its budget will attract regulatory intervention – e.g., financial special measures – earlier under this framework, given the heightened focus.

Workforce and Leadership

Workforce Plan Delivery: The NHS Long Term Workforce Plan (LTWP) sets out ambitious staffing growth and reforms. While that is a separate strategy, the IAF will consider whether systems are making progress on workforce metrics – for instance, reducing vacancy rates, improving retention, and expanding training placements. What’s changed: Workforce was traditionally seen as an input not directly part of performance frameworks, but now there are likely to be explicit workforce indicators. ICSs might be rated on how well they collaborate on recruitment (e.g., international recruitment hubs), staff well-being (sickness absence rates), and development of new roles (like physician associates or advanced practitioners). The Messenger Review on leadership is influencing the framework to include qualitative judgments on leadership culture and capabilities (). For example, an ICB’s capability assessment will examine how it is developing talent and inclusive leadership within the system. Leadership & Management: A new NHS Leadership Competency Framework is being implemented to professionalize management (NHS England new operating model for 2025/26 – CF). ICSs and providers are expected to adopt these standards. Impact: Over time, we should see more consistent, high-quality management across organisations. In the short term, boards may undertake self-assessments and development programs (often with NHSE support) to meet expected leadership criteria. The framework’s alignment with the Messenger Review means those systems investing in leadership development (coaching, training, promoting collaborative behaviors) could see that pay off in their capability ratings (). For staff, a focus on leadership and culture could improve morale and retention, as good leadership is linked to better staff engagement. Additionally, workforce metrics in the IAF will keep pressure on ICSs to implement the Workforce Plan – e.g., if an ICS is falling short on GP or nurse expansion targets, it will be flagged. This could prompt earlier corrective action or support, such as partnering with educational institutions or deploying targeted retention schemes. Essentially, workforce is now a shared responsibility: not just HR departments, but system leaders collectively accountable for having the staff to deliver services.

Digital Transformation and Data

Data-Driven Oversight: A significant theme is making better use of data for both planning and performance management. NHS England is rolling out the Federated Data Platform (FDP) to all organisations, providing unified data tools for waiting list management, theatre utilization, bed availability, and more (NHS England » Our new operating model: supporting you to deliver high quality care for patients). What’s changed: In previous years, data was often available but fragmented. Now, there’s a concerted push to standardize data systems and analytics. The IAF itself will benefit from this by having more real-time and granular metrics. There may be an expectation in the framework that ICSs use these data tools (“Evidence of effective use of data in decision-making” could even feature in capability reviews). Digital priorities like achieving foundational standards (electronic patient records in every trust by a set date, for instance) and interoperability across the ICS will likely be monitored. Impact: Better data should lead to faster identification of problems (e.g., spotting a backlog in diagnostics before it becomes a crisis) and a more evidence-based dialogue between NHSE and systems. The NHS Federated Data Platform will enable benchmarking and highlight variation, which the oversight process can then target for improvement (NHS England new operating model for 2025/26 – CF) (NHS England new operating model for 2025/26 – CF). For patients, digital investment may translate to improvements like smoother referrals (since systems share info) and potentially fewer times having to repeat information. The framework’s emphasis on data also means that ICSs will invest in analytical capability – hiring data analysts or establishing system-wide analytics hubs to crunch performance data continuously. Additionally, digital innovation such as virtual consultations, AI in diagnostics, and remote monitoring could be spread more rapidly, as systems that succeed with these will have their results showcased and others will be encouraged to follow suit (with “explain” required if not). Cybersecurity remains a backdrop concern; high-performing systems will be those that also maintain robust digital resilience.

Quality and Patient Safety

Quality Assurance: The framework maintains focus on care quality and outcomes, working alongside the CQC’s regulatory role. ICSs are expected to keep up quality surveillance of services in their patch, including safeguarding, patient experience, and clinical outcomes. What’s changed: There’s an increased integration of quality into system oversight. For instance, if maternity services in a system are flagged (as maternity is a national priority area following multiple reviews), the ICB is responsible for ensuring the Ockenden report actions or the Maternity Transformation Plan is implemented locally (NHS England » 2025/26 priorities and operational planning guidance). The IAF may include specific quality metrics (mortality rates, readmissions, infection rates, etc.) under its domains. Additionally, the new framework’s capability assessment for providers introduces explicit governance ratings – “no material concerns”, “some concerns”, “major concerns” – partly informed by CQC well-led ratings (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). Impact: Providers will need to maintain good governance and respond to any CQC findings promptly, as these will feed into the NHSE oversight decisions (e.g., a CQC “Inadequate” in well-led could directly trigger a higher intervention segment for a trust). ICSs will coordinate quality improvement efforts, perhaps convening quality collaboratives (sharing learnings on issues like pressure ulcers or medication safety across organisations). Patients should benefit from a consistent focus on quality alongside access – the framework is not just about hitting numbers, but sustaining standards. If a serious quality issue arises (say a spike in never events or a scandal at a trust), the framework ensures it is not seen in isolation: the ICS and NHSE would together intervene, with potentially a peer support team or taskforce deployed. By measuring and publishing quality indicators at system level (and the CQC starting ICS-level assessments of quality of care), there is greater transparency and hopefully accountability to maintain safety and effectiveness, not just speed of treatment.

System Governance and Accountability

ICS Governance: With ICBs now being assessed on their capability in six core areas (likely including governance, partnerships, finance, workforce, digital, and performance management), there is a strong incentive for ICSs to get their governance structures right (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). What’s changed: The Health and Care Act 2022 set the statutory footing for ICSs, but 2025/26 is the first full cycle where NHS England will do a formal annual performance review of each ICB and publish a rating (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). This elevates accountability – ICB Chairs and CEOs will receive a letter each year with their assessment (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework), and poor ratings will bring reputational and regulatory ramifications. The new framework also requires ICBs to hold up evidence in their self-assessments and undergo 360-degree feedback from partners (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework), making governance a shared concern (for example, local authorities and Healthwatch opinions will count). Impact: We can expect ICBs to strengthen their Board functioning and committees (audit, quality, etc.) to demonstrate good governance. They will also likely invest in organisational development for the ICB team to build capabilities in areas where they’ll be rated (like strategic commissioning proficiency, or how well they involve the community in decisions). The publication of ICB ratings might introduce an element of reputation management – strong ICSs will want to be seen as leaders (perhaps even fostering healthy competition to be an “Excelling” system), whereas those rated low will need to answer to their stakeholders and the public. This transparency is new and could drive more proactivity at the system level.

“One NHS” Approach to Accountability: The framework links the fate of providers and ICBs. A key design is that an ICB’s capability view “informs its role in oversight of providers” (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). So, if an ICS is well led and delivering, it gets more responsibility; if not, providers might be overseen more directly by NHSE. What’s changed: Previously, providers might bypass the system and deal directly with the regional team on many issues. Now there is a clearer chain: ICB as first line of oversight (in most cases), with NHSE as escalation. This should streamline performance conversations and reduce duplication, as NHSE has pledged: “providing consistent and coordinated oversight to reduce duplication and prevent providers from being bombarded with conflicting instructions” (NHS England » Our new operating model: supporting you to deliver high quality care for patients). Impact: Providers will increasingly look to their ICB as a key accountability partner, not just the centre. We may see more joint ICB-Provider boards or committees to handle oversight in a unified way (some systems already run “system performance meetings” bringing all parties together). Ideally, this creates a more collaborative form of accountability – where improvement is co-produced. However, if an organisation is in serious trouble, NHSE will intervene decisively (with things like turnaround teams or even replacing leadership). The difference now is that the ICS will be part of that solution, not sidelined. In turn, the Secretary of State can hold NHS England (and indirectly ICSs) accountable via the mandate, creating a line from national priorities to local delivery.

Transparency and Public Accountability: The new framework increases what information is publicly available: ICB annual assessments (with narrative and ratings) will be published (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework), and NHS England will publish a summary of all ICS assessments. Provider segmentation statuses (1-4) and any special measures are also likely to be public (historically, segmentation was known in the system but not always by the public; this may change with more explicit ratings like “under review” or “requires support” being published) (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework). Impact: This transparency could drive improvement through public pressure – local media and Health Overview Scrutiny Committees may question an ICB rated “Insufficient Progress,” prompting political accountability at local level. Conversely, an “Excelling” ICS might attract positive attention and be seen as a model to emulate. For providers, being labeled as having “major concerns” in governance (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework) or being in segment 4 will certainly be a flag that garners attention, adding impetus to fix problems quickly. The system overall becomes more understandable to the public: rather than obscure performance data, there will be clearer labels on how local NHS organisations are doing. This is in line with the SoS’s priority for accountability and the need to maintain public trust that the NHS is addressing issues.

Conclusion: The NHS Improvement and Assessment Framework 2025/26 marks a significant evolution in how the health service is regulated and supported. By introducing clearer accountability, aligning with national priorities, and fostering system-wide collaboration, it aims to drive improvements in care delivery amidst a challenging context. Key changes – from the introduction of ICB capability ratings and “comply or explain” enforcement, to the promise of earned autonomy – seek to balance freedom with accountability. Policymakers and NHS leaders should find that this framework provides sharper tools to identify problems and share solutions, while also requiring them to work in much closer partnership across organisational boundaries. The success of the framework will depend on diligent implementation and continuous feedback, but if its principles are realized, the NHS could become more agile, equitable, and sustainable in delivering its objectives for patients (NHS England » Our new operating model: supporting you to deliver high quality care for patients) (NHS England » Consultation on the draft updated NHS Oversight and Assessment Framework).