Introduction and assessment process
1. This annex outlines the additional criteria and evidence that will be required to support advanced foundation trusts wishing to be assessed and designated as an integrated health organisation (IHO) so that they can take on an IHO contract.
2. The 10 Year Health Plan sets out that high-performing advanced foundation trusts can hold the health budget for a defined local population through an IHO contract. The IHO model provides the vehicle to overcome organisational boundaries to invest in models of care that should deliver better outcomes and better productivity. IHO contract holders will work alongside single and multi-neighbourhood providers to deliver new models of neighbourhood-based care.
3. The IHO model is a contract-based delivery mechanism, not a new type of organisation. IHO contract holders will hold capitated budgets for a defined population, commissioned by their ICB where the ICB determines it to be the right solution for local transformation and allocative efficiency. IHO contract holders will not be expected to provide all services under the scope of the contract and so will need to work with a wider network of providers to deliver services; this might include sub-contracting arrangements or some delegation of commissioning responsibilities.
4. The defining characteristic of an IHO contract holder is taking on responsibility for improving outcomes for a defined population. This is a shift from pathway and patient to population focus. Therefore, the capabilities required to hold an IHO contract will be additional to those required to be a high-performing trust. Trusts seeking IHO designation will need to meet additional criteria. This additional ‘IHO module’ aligned to the advanced foundation trust assessment approach will consider the candidate’s ability to take on leadership for population health improvement, lead beyond organisational boundaries, and manage additional financial and clinical risk. To secure designation as an IHO, designation assessment will also consider the ICB’s intentions and wider stakeholder support. A separate assurance of commissioner and provider capabilities to manage contract specifics will take place prior to the start of any contract.
5. The IHO model is evolving. Organisations designated as IHOs in 2026 will work with NHS England and their commissioners to co-develop the model during 2026/27; the first contracts are set to be awarded in 2027. For trusts undergoing designation in 2026/27, the assessment will support a developmental understanding of what will be required to work towards mature IHO arrangements, while also looking for evidence of leadership capability and a step change towards population health and system benefits. There may be areas tested in greater detail as part of the contract assurance process depending on the maturity of the initial plans and in support of this co-development phase. We plan to revise the assessment criteria following the development of the first IHO contracts to ensure early learnings are incorporated as the model evolves.
6. Advanced foundation trusts wishing to be designated as an IHO will self-assess against the criteria set out in the tables below. These will be triangulated through the review of evidence (including interviews and stakeholder feedback) on the following:
- strategic vision for how the trust would use an IHO contract, working with system partners to shift care out of the acute sector and into effective community-based and neighbourhood health services to improve population health outcomes
- population health management – understanding of their local population, including underserved populations (inclusion groups), drivers of risk, local community assets (including existing provision) and show desire to co-design services with their communities and embed patient voice within IHO development
- working beyond organisational boundaries and in partnership with other organisations, the ability to act as a trusted convener and broad support from system partners for IHO proposals
- organisational maturity and leadership capability to take on a population-based IHO approach
- board willingness and capability to hold and manage a capitated IHO contract, including:
- proposed IHO governance model, including plans to develop, or bring in, the expertise and decision-making arrangements required to manage a population-based contract and make effective decisions about a wider range of services, including those where the trust has no current operational experience, including primary care
- board understanding of the ‘integrator’ functions that will enable the IHO to generate data and insight to support detailed planning of services and allocation of resources for specific populations to deliver more integrated and efficient pathways, within existing resources in local areas
- ability to manage the additional financial, commercial and clinical risk associated with capitation and subcontracting and plans for robust quality and financial governance
7. In order to support the development of proposals, further details on the IHOs’ purpose, scope and role in the system and how they will be operationalised and overseen will be shared later in 2025 via a document considering the new system archetypes to deliver the 10 Year Health Plan.
Assessment criteria
Our assessment for IHO designation in 2026/27 focuses on the changes required to transition from a high-performing organisation into the decision-maker with the responsibility of designing services and allocating resources to improve population health. We will consider the applicant’s strategy, case for change, and plans to develop mature IHO arrangements, alongside evidence of core competencies required to manage risk and contracting responsibilities.
IHO assessment criteria: leadership and planning criteria – strategic vision for IHO to improve population health outcomes
| Board statements to support The board has assured itself that… | Key evidence |
|---|---|
| 1. The elements of the trust’s overarching strategy set out how they will deliver the strategic aims of the IHO alongside continuing to deliver their existing provider commitments. | Medium term plan Case for change – this should include consideration of key challenges and plans for improvement, and key objectives for year 1. Additional work undertaken or planned to assess changes to organisational and clinical quality strategies to deliver the strategic vision |
| 2. The trust has plans and confidence in its ability to work with other providers, including via subcontracting, to deliver the neighbourhood model with a shift from hospital to community. | Medium-term plan Developed gap analysis of existing involvement in out-of-hospital care pathways and broader population health requirements. This should consider: – pathways where the IHO may be taking on new responsibilities (for example, enhanced primary care) – approach to working with ICBs to support the knowledge and skills transfer of key commissioning activities – opportunities to develop new neighbourhood health infrastructure and primary care leadership to support delivery of strategic aims Any identified challenges and risks identified that require action to support readiness to shift care from hospital to community. |
| 3. The trust demonstrates it has an understanding of the digital and analytical requirements to achieve its strategic aims as an IHO and has plans for developing or acquiring these capabilities in the medium term. These requirements may include functions to deliver: – population insight – care model planning – proactive care management and operational management – care delivery The trust demonstrates it has an understanding of the gaps in its knowledge around costs and activity across the whole pathway, and has plans to address these gaps. | Gap analysis of existing digital and analytical capabilities and those required to take on an IHO function. Organisational development plans to build capability and capacity for: – analytics: including self-appraisal of confidence in building advanced analytics capability to understand population needs, drivers of risk, costs and activity within their defined population – robust information governance to enable both secure de-identified data analysis of the defined cohort, and re-identification to enable care delivery – data collection to address gaps in understanding around cost bases and activity levels |
| 4. The trust has a track record of looking beyond the performance of the trust’s organisational boundaries to effectively support integration, focus on population health and tackle inequalities, including: – the trust can act in ways outside its own organisational interests for the benefits of patients and the wider system – the trust can align partners to work towards a single local strategic vision – the trust has a developed knowledge of local system architecture and assets – the trust has a plan for strong place-based leadership | Stakeholder mapping of existing relationships and network management. Evidence that key partners support the trust as a leader (including ICB, other trusts, primary care organisations, provider collaboratives, the local authority (including public health teams) and voluntary, community and social enterprise (VCSE) organisations. Evidence or examples where the trust has led or significantly contributed to system goals to benefit the wider system or population health in a pathway service line that is not delivered directly by the trust, such as through integrated working. Proposal for the development of standard operating processes across teams and service lines (including primary care). Evidence of regional and national engagement around sharing knowledge, expertise and best practice. |
IHO assessment criteria: leadership and planning criteria – corporate governance
| Board statements to support The board has assured itself that… | Key evidence |
|---|---|
| 1. The trust has considered governance structures and operating models required for an IHO and how these may differ from the operational oversight of existing provider functions. There are plans to provide the appropriate executive and non-executive capacity for the purposes of: – strategic leadership of the IHO – ensuring expertise and knowledge across clinical areas and sectors – risk management, including effective distribution of gains and losses to incentivise demand reduction, clinical risk management across sectors – managing conflicts of interest between the IHO and provider functions – negotiating and running procurement and contracting processes | Self-assessment of the current governance structure related to the requirements of an IHO with identified challenges and mitigations, including an analysis of the expected skill set required to develop the IHO. Options appraisal of potential governance structures or operating models for an IHO in year 1 including description of assurance mechanisms that test how decisions relating to IHO contracts are made and approaches to build capability where there’s a known gap. This should also consider how the trust plans to ensure representations in IHO conversations from primary care, mental health, community and acute sectors. |
| 2. The trust understands the additional risks associated with an IHO and what will be required to manage risk effectively. The trust has risk management plans related to IHO functions differ to those related to delivery of existing provider commitments. | A risk management framework required for the IHO operating model. Including: – consideration of the risk culture – consideration of the risk appetite – impact on risk policy, risk assessment and controls – consideration of clear lines of responsibility for monitoring and addressing issues in integrated teams. – description of different financial governance for the IHO and other provider contracts – evidence of use of risk sharing agreements |
IHO Assessment criteria: quality – quality governance
| Board statements to support The board has assured itself that… | Key evidence |
|---|---|
| 1. The trust is aware of the national quality strategy priorities across primary, community, mental health and acute sectors. The trust understands the different approaches to monitoring quality and managing risk across primary, community, mental health and acute sectors. | Evidence of contribution or leadership in system, place or collaborative quality strategy or improvement approaches outside of the trust’s key area of delivery. Analysis of the gaps in the leadership’s knowledge of quality strategies across sectors and a plan for how these gaps will be addressed. |
IHO assessment criteria: Financial performance and oversight – contracting, procurement and commissioning oversight
| Board statements to support The board has assured itself that… | Key evidence |
|---|---|
| 1. It has the skills to deliver contracting and procurement at a large scale It understands the principles underpinning good commissioning and is aware of the capabilities required to deliver core functions. | Evidence of effective contract management. Evidence of procurement processes and positive supplier relationships. Plans to work with ICBs to support knowledge and skills transfer of key commissioning activities, including thinking around sharing or transferring of ICB commissioning responsibilities and teams; this should be in the context of core functions (for example, needs assessment, planning, financial management and service development) and specifically for those services where IHOs may be taking on new responsibilities. |
IHO Assessment criteria: Financial performance and oversight – Financial governance
| Board statements to support The board has assured itself that… | Key evidence |
|---|---|
| 1. The trust has plans for appropriate board and sub-board capacity to manage the finance governance of the IHO contract separate to the delivery of trust financial performance. The trust has plans to manage the additional financial risk associated with the IHO contract. | Evidence of the board’s assessment of the risks of managing a capitated budget contract and its plans to manage and mitigate the risks alongside its ongoing trust financial governance arrangements. Skills and capacity self-assessment related to an understanding of the differing risks associated with capitated budgets, and initial plans for mitigation. Medium term plan. |