1. Introduction

1. NHS England’s approach to assessment provides a transparent view of performance across the NHS. It is designed to support performance improvement of integrated care boards (ICBs) and NHS trusts and foundation trusts (providers) and ensure that health services are effective, efficient and centred on the needs of patients and communities.

2. We will use the NHS Performance Assessment Framework (NPAF) to assess each organisation against an agreed set of performance metrics. This view of performance will be the starting point for how we work with ICBs and providers throughout the year, helping us determine where support is needed and how improvement can be achieved in a consistent and proportionate way.

3. Since introducing the current approach to oversight in July 2022, we have engaged extensively with system leaders and other stakeholders. They told us that our approach to oversight and performance improvement needs to be consistent and our interactions coherent.

4. In response, we revised the framework and consulted on this in summer 2024. However, we did not publish the proposed framework following this consultation as several significant developments have since changed the operating context, and we have needed to evolve our approach for this year accordingly. These developments have been:

• a change in government and a new mandate for NHS England to support improvement in key areas and deliver the 3 strategic shifts in healthcare
• publication of NHS England’s updated operating model in 2024, setting out the roles of NHS England, ICBs and providers and reinforcing the role of integrated care systems (ICSs) as both strategic commissioners and delivery partners, and
• the Secretary of State’s announcement of increased public accountability for NHS performance.

5. In revising our proposals to align with the changing context of 2025/26, we have focused on providing the clarity, consistency and transparency that stakeholders across the system have asked for. We will review our approach for 2026/27 following the publication of the 10 year health plan and the review of health and care arm’s length bodies by Dr Penny Dash, to ensure that it is aligned to future priorities. Our aim is that the framework not only supports improvement and delivery but also enhances accountability to the public.

6. We published the draft framework for engagement and testing with the approval of the NHS England Board in March 2025. That draft included the changes made following the 2024 consultation. Since then, further developments, including the announcement of the running costs reduction for ICBs, have again changed the operating context. In response to early feedback and this changing context, we have developed a further proposal that simplifies our approach by streamlining the number of metrics in the framework. We are now seeking your views on the NPAF to ensure it meets the needs of the system and support improvement across the NHS.

7. The consultation is open to all interested stakeholders, including ICBs, providers and other system partners, as well as the public and other representative bodies.

2. Proposals

We consulted on a framework in summer 2024 and made updates in response to feedback. Due to changes in the operating context this framework was not published. Sections 2.1 to 2.4 set out the proposed framework and changes we have made since the framework was last consulted on.

2.1 Segmentation approach

8. The approach is based on assessing performance against a balanced scorecard of metrics across 4 domains that relate to the 4 purposes of an ICS. Individual organisations (ICBs and acute, mental health, community and ambulance providers) are measured against a range of metrics that reflect their individual contributions to the delivery of NHS priorities. An organisation’s overall score is derived by benchmarking its performance against targets or standards and their peers. This shows how each organisation compares overall with its peers and is translated into a segment to allow organisations with comparable levels of challenge or maturity to be grouped together. We will publish further guidance on the methodology in due course.

9. For ICBs only, overall delivery scores are then adjusted for challenged system performance against 6 priority areas (urgent and emergency care, elective, cancer, primary care, mental health and finance). This gives the ICB system adjusted delivery score.

10. Every ICB and provider will be allocated a segment. This indicates its level of delivery from 1 (high performing) to 4 (low performing). Segmentation, along with assessment of ICB and provider capability, will inform NHS England’s performance improvement response. Our improvement approach will seek to integrate our regional support with national tiering and provide more consistent decisions across teams, while offering high performing organisations more autonomy to shape their own improvement support. The details of our approach to capability assessment and improvement response will be included in further guidance due to be published shortly.

11. The March 2025 NPAF draft anticipated that organisations in segment 4 would receive a diagnostic to identify those with the most intense support needs and that those organisations would enter segment 5, equivalent to the existing Recovery Support Programme (RSP). Our approach to identifying organisations with the most intense support needs and their entry into segment 5 remains under consideration. As we evaluate the demand for improvement support, we will need to consider the most appropriate governance model for managing and prioritising the use of this resource, to ensure it is appropriately deployed.

2.2 Removal of the capability assessment from scoring

12. The NPAF brings a more objective, transparent and consistent approach to our segmentation decisions. The segmentation process we consulted on in 2024 included an assessment of the organisation’s capability to improve without support. This assessment involved both quantitative and qualitative elements as well as NHS England’s judgement to derive a capability rating.

13. We have heard during engagement that the use of some qualitative data along with our judgement to segment organisations would reduce objectiveness and transparency to the public. However, stakeholders did say that the assessment remains valuable for understanding the wider performance and improvement support needs of an organisation.

14. We propose to assess capability separately, rather than making the capability rating a component of the segment score. This ensures that segmentation is based exclusively on performance against delivery, making it more objective, transparent and providing for greater public accountability. However, using the capability rating to inform NHS England’s improvement response will ensure that we prioritise support for those organisations with the most intense needs and target our resources where they will achieve the best outcomes.

2.3 Removal of the system adjustment from provider scoring

15. One aim of the NPAF is to offer a simpler approach to provider segmentation. The approach we consulted on in 2024 proposed that we would use a set of ‘additional considerations’, now called ‘system considerations’, to moderate both ICB and provider scores. Our aim was to create joint accountability across national priorities such as urgent and emergency care, elective care, mental health care, primary care and finance.

16. Providers have an obligation under the NHS provider licence to collaborate with their system partners and also a statutory duty to co-operate with other NHS bodies. We have, however, heard concerns that moderating provider scores based on the performance of other organisations in the same system, but over which the provider has no control, could disincentivise improvement and insufficiently recognise high performers. We have therefore removed the system adjustment element from the provider scoring methodology.

17. Arranging healthcare services for their populations is a general function of all ICBs. Under the current commissioning and financial allocation arrangements, they remain responsible for arranging services that meet operational standards. In allocating their segment in 2025/26, we will therefore consider the performance of their system alongside their individual performance as a commissioner but review this approach in 2026/27 given the plans for functional changes to ICB responsibilities and the new Model ICB work.

2.4 Introduction of a segment limit on organisations in financial deficit

18. The NHS must live within the budget it is allocated, reduce waste and increase productivity to deliver growth against demand. The NHS priorities and operational planning guidance 2025/26 made it clear that achieving a financial reset this year is a priority. It set the expectation that every ICB and provider must deliver a balanced net system financial position in collaboration with its system partners. Where partners are not performing, NHS England must identify them and take quick action to support improvement.  

19. Therefore, we have added a segmentation override such that any provider or ICB reporting a financial deficit cannot be allocated to a segment above 3. Organisations may still be placed in segment 4 or 5 based on their performance in other areas but may not in a segment higher than 3 unless they are delivering a surplus or breakeven position.

2.5 Proposals to reduce the metric list

In light of early engagement on the NPAF document as published in March, we are also proposing an additional change to the framework which reflects the current context and priorities.

20. The approach to segmentation presented at the NHS England Board in March 2025 considered a long list of metrics for both short-term delivery of priorities and longer-term transformation and culture. It was endorsed under our consultation last year.

21. However, our approach now needs to recognise the fundamental shifts in operating context in the last 12 months with a reappraisal of the role of ICBs and the centre as well as any changes set out in the upcoming NHS 10 Year Plan. Early engagement on the NPAF framework told us that our approach is still complex and uses too many metrics. This complexity could dilute our focus on the national priorities set out in the government’s 2025 mandate to NHS England and the 2025/26 NHS priorities and operational planning guidance. We believe it is appropriate to clarify the focus of oversight for 2025/26 to fewer core measures that align with these priorities as well as a high-level view of quality of care. This will allow the NHS to focus this year on the stated recovery priorities. Longer-term transformation measures that align to the NHS 10 Year Plan and the redefined roles of ICBs and the centre will be introduced from 2026/27.

22. Annex A gives the proposed shorter list of metrics that are focused on the stated NHS priorities for 2025/26 as well as quality of care indicators for experience, safety, effectiveness and workforce.

3. Responding to the consultation

20. Those who wish to participate in this consultation are encouraged to respond by completing the online questionnaire that asks the questions below.

21. This consultation is open from Thursday 12 May to 5:00pm on Friday 30 May 2025.

Consultation questions

Are you responding as an individual or on behalf of an organisation?

1. Describe the organisation or group you belong to.
2. What is the name of your organisation?
3. To what extent do you agree or disagree that the proposed approach set out in the draft NPAF offers an objective and consistent approach to assessment?
4. To what extent do you agree that NHS England’s assessment of ICB and provider capability should be used to inform how we support organisations to improve but that it should not influence segmentation?
5. To what extent do you agree that ICB segmentation should continue to consider system performance?
6. To what extent do you agree that segments 1 and 2 should be limited to organisations achieving financial balance (surplus or breakeven)?
7. To what extent do you agree a shorter list of measures for 2025/26 will simplify the framework and allow a clearer focus on operating priorities consistent with the reset agenda?
8. Do you have any comments about the proposal and the impact on advancing equalities and/ or reducing health inequalities?
9. Do you have any other comments?

Annex A: NPAF metric list

This shorter metric list simplifies our approach to segmentation (see section 2.5 of this consultation document). 

Operating priorities

Elective

Cancer

UEC

Mental health

Learning disability and autism

Primary care

Prevention

Finance and productivity 

Finance 

Productivity

Quality and people

Patient experience

Patient safety

* The use of CQC rating will be reviewed as ongoing work to improve CQC inspections progresses and to take into account any relevant outcomes from the broader review of health and care arm’s length bodies by Dr Penny Dash.

Effectiveness of care

Workforce