1. Introduction

1. The National Health Service Act 2006 (as amended by the Health Service and Care Act 2022) established integrated care boards (ICBs). ICBs are statutory organisations that commission health and healthcare services for their area and work with local services, including local authorities and wider partners, to improve population health and deliver shared strategic priorities.

2. Under the terms of the NHS Act (as amended), NHS England is required to undertake a performance assessment of each ICB in respect of each financial year and publish a report containing a summary of the results of each assessment.

3. The NHS continues to operate in a challenging landscape with competing priorities and an evolving operating context and we recognise that activity, even that required under statute, must be proportionate value-adding and an effective use of resources. NHS England distributed over £120bn of public funding to ICBs in the 2024/25 financial year and we believe that it is a right and proper use of our resources to publicly set out our views of how effectively ICB have performed within that envelope to support public accountability as well as recognising areas of good practice and where further improvement is required.

4. This guidance sets out details of the areas the annual assessment will cover and should be read in conjunction with the 2024/25 priorities and operational planning guidance.

2. Assessment approach and process

2.1 Scope and purpose

5. NHS England has a legal duty (Section 14Z59 of the National Health Service Act 2006 as amended by the Health and Care Act 2022) to annually assess the performance of each ICB in respect of each financial year and publish a summary of its findings. The assessment must assess how well the ICB has discharged its functions (both its powers and its duties) during the year. It must include, but is not limited to:

• the duty as to improvement in quality of services
• the duty as to reducing inequalities
• the duty to obtain appropriate advice
• the duty to have regard to the wider effect of decisions (the triple aim)
• the duty in respect of research
• the duty on public involvement and consultation
• the financial duties
• the duty to have regard to local assessments and strategies

6. The outcome of the annual assessment will take the form of a letter from the relevant NHS England regional director to the ICB chair. The purpose of the assessment is to assess the ICBs performance and how well it has discharged its statutory functions. In particular, it will:

• objectively consider how effectively each ICB has led the NHS in its system
• provide a clear process of accountability for each ICB to NHS England in the discharge of its functions
• consider the delivery and achievement of objectives to inform future plans
• identify instances of good practice and support the sharing of this with others who could benefit
• reflect on progress towards longer-term strategic priorities
• review the extent to which any supportive interventions have been successful

7. NHS England will complete the annual assessments and share the outcome in a letter from the relevant regional director to the ICB chair by the end of July 2025.

8. NHS England is required under the NHS Act (as amended), to summarise the outcomes of all annual assessments and will publish a report containing this information on its website.

2.2 Assessment process

9. The annual assessment will be structured across 5 sections. The sections will consider the ICB’s overall system leadership and its contribution to each of the 4 core purposes of an integrated care system (ICS):

• improving population health and healthcare
• tackling unequal outcomes, access and experience
• enhancing productivity and value for money
• helping the NHS support broader social and economic development

10. In each section of the assessment, NHS England will detail any areas of strong or outstanding performance for which the ICB could act as an exemplar or peer to others. Any areas of significant challenge will also be detailed, including any specific support NHS England is providing to facilitate improvement.

2.3 Approach and evidence sources

11. The assessment approach has previously been developed in collaboration with ICBs to minimise additional burden while maximising value and meeting the specific requirements set out in the NHS Act (as amended). It draws, wherever possible, on existing processes and information rather than requiring additional effort. All sections of the assessment will be underpinned by consideration of 4 main questions:

• to what extent has the ICB delivered on the national priorities set by NHS England?
• how far has the ICB achieved the local ambitions articulated in its joint forward plan?
• how has the ICB responded to diagnosed support needs and what progress has it made towards any agreed improvement goals?
• How capably has the ICB led the NHS and wider integrated care system?

12. In considering these questions NHS England will reflect on a range of evidence, including, but not limited to:

a. ICB self-reflection

• NHS England will meet with each ICB’s leadership team as part of the annual assessment process. This meeting will be the ICB’s opportunity to set out its reflections on progress against its statutory obligations and national and local objectives. NHS England will highlight the key messages it intends to convey in its assessment.

b. The ICB’s annual reports and accounts

• Under the terms of the NHS Act (as amended), each ICB must prepare an annual report setting out how it has discharged its functions in the previous financial year. This must in particular, include an explanation of how the ICB has discharged its statutory duties and review the extent to which it has exercised its functions in accordance with its joint forward plan. Each ICB is required to provide a copy of their annual accounts to NHS England who will consider the evidence within them as part of the annual assessment process.

c. Feedback from system partners

• Under the terms of the NHS Act (as amended), NHS England and the ICB must consult with health and wellbeing boards as to how effectively the ICB has contributed to the ambitions set out in the joint local health and wellbeing strategy.
• NHS England will also seek feedback from the integrated care partnership (ICP) including its view on how effectively the ICB has supported the delivery of the integrated care strategy. Where the ICP and ICB have shared leadership, consideration of any action to prevent conflicts of interest will also be appropriate.
• The ICB and NHS England should also discuss together the range of stakeholders from whom opinion will be sought to support both parties’ annual reflections and how this will be done. These stakeholders are likely to include:
  • NHS trusts and foundation trusts (or provider collaboratives)
  • primary care networks
  • clinical networks and alliances
  • patients and their carers through representative groups, for example local Healthwatch
  • local voluntary, community, faith sector and social enterprise organisations
  • the ICB’s local authority partners and/or the Health Overview and Scrutiny Committee (HOSC)

d. Routine discussions

• NHS England and ICBs hold regular discussions throughout the year, including routine performance and finance discussions, oversight meetings as described in the NHS Oversight Framework, and those on the quality governance arrangements as described in the National Quality Board’s guidance on quality risk response and escalation. The outcomes of these discussions will be used to support the annual assessment.

e. Delivery of operating plans

• Each ICB submitted an operating plan for 2024/25 detailing how it would deliver against the national priorities defined in the 2024/25 priorities and operational planning guidance. NHS England will consider the actual delivery against the operating plan, taking into account any variations to plans agreed in-year. Where there is a deficit between planned and actual performance, NHS England will highlight the areas of underperformance in its assessment and describe the remedial improvement actions ICBs are required to take.

f. Progress towards improvement goals

• As part of the NHS Oversight Framework, ICBs and NHS England together consider any support needs the ICB may have and how these can be met most effectively. Where a support need has been identified, NHS England will agree with the ICB an improvement plan and the success criteria that must be met with corresponding timescales. The assessment will consider and detail the progress that has been made towards achieving those criteria and highlight where further ICB action may be required.

g. In some circumstances, NHS England may use its legal powers of enforcement against an ICB as part of an improvement intervention. Where this applies, the assessment will consider how far the ICB has met its undertakings or directions as part of the intervention.

3. Key lines of enquiry

This section sets out a range of high-level key lines of enquiry (KLOEs) that NHS England and ICBs will consider together against the individual themes and duties that form part of the assessment. These KLOEs are not exhaustive and NHS England and ICBs will consider any other key section topics pertinent to individual system circumstances and local priorities.

System leadership

Improving population health and healthcare

Tackling unequal outcomes, access and experience

Enhancing productivity and value for money

Helping the NHS to support broader social and economic development

Publication reference: PRN01943