Classification: Official
Publication reference: PRN01700

To:

• Integrated care boards:
  • chief executive officers
  • chairs
• NHS trusts and foundation trusts:
  • chief executive officers
  • chairs

cc.

• NHS England regional directors

Dear colleagues

Evolution of our operating model

Over the past year, we have been working with colleagues across the NHS and more widely on the development of our operating model. We are grateful for the enormous amount of time and input many of you have already given as part of this work. We are conscious, however, that there is much more work to do, and are writing both to provide an update following recent headline messages, and to ask for your input and support over the coming months. Please accept our apologies for the delay in communicating this to you formally.

Lord Darzi’s recent report was clear – we don’t need another seismic reorganisation pulling focus from the important tasks, but the system we have needs to be optimised and every part of the NHS needs greater clarity on what they are accountable for. This is in line with many of the conversations we have been having with colleagues over the last year. So our work on the evolution of the operating model is designed to do just that; and to ensure that the way the NHS works supports delivery of today’s priorities and sets us up to deliver the neighbourhood health model that will underpin a health and care system that is fit for the future.

The 4 actions that will guide our refresh of the current operating framework are set out below:

• Simplify and reduce duplication, clarifying roles and responsibilities and being clear on the place of performance management.
• Shift resources, time and energy to neighbourhood health, creating momentum that makes clear the role of the provider sector in neighbourhood health and how to work with local partners.
• Devolve decision-making to those best placed to make changes, clarifying the role of integrated care partnerships (ICPs) and health and wellbeing boards.
• Enable leaders to manage complexity at a local level, supporting leaders with new strategic commissioning frameworks to include national best practice.

Achieving this will require everyone in the NHS family to work together, alongside our partners in the wider system, to fully leverage the potential of ICSs, aligned around a clear purpose and each with a distinct role to play.

As our ways of working continue to develop and evolve, and as we strive to achieve our ambition of devolving decision-making to the local level, the functions where we as NHS England add most value will also change and may reduce.

Self-managing, self-improving systems

Lord Darzi, in his recent review, was unequivocal that the current NHS model is the right one, and that our structures can support delivery of the changes that we all want to see.

Looking to the future, we want to see self-managing, self-improving systems, just as was set out in the Hewitt review. Integrated care boards (ICBs) are critical to delivery of the strategic shifts from treatment to prevention, from analogue to digital and from hospital to community, and will continue to be the system leader for the NHS, convening and working across all key partners within their integrated care system. We want systems to be empowered, and our goal is to give more freedoms for the top performers – those who are improving population health, reducing inequality of outcomes and who deliver high patient satisfaction and use resources effectively.

This also means that we will work closely with these high performers to help shape policy, frame national best practice and drive improvement. We will build on the work of NHS IMPACT to ensure systems ‘in the middle’ have the capability and support to improve, and we will refine our approach to recovery support to enable stronger and more rapid intervention for lower performing systems. We also recognise that we need to take account of contextual factors for each of the issues that are apparent in each organisation and system.

We intend to capture this approach through an updated NHS Oversight and Assessment Framework and underpin this with a new NHS Performance, Improvement and Regulation Framework.

As the NHS system leader, ICBs will need to refocus on strategic commissioning, and they will continue to be responsible for the planning and provision of services to a population. They will act as the system convener and are expected to plan, secure and arrange services in line with their statutory responsibilities. They will ensure the sustainability of primary care, rebuilding the provision of dentistry and community pharmacy, alongside developing strong GP practices and the wider primary care family that are attractive to newly qualifying GPs.

We will support ICBs through the development of a new Strategic Commissioning Framework. They will have the primary responsibility for ensuring the delivery of neighbourhood health, identifying population health needs and acting on reversible risk factors to improve healthy life expectancy and reduce utilisation of secondary care. This vital work must continue at pace for us to deliver a neighbourhood health model.

All providers in a health system must still work together to deliver transformation, integration and improvement because these changes do not signal a move away from collaboration and system working and we will also ensure that the duty to collaborate mechanisms are tested in how we work with organisations.

Importantly, ICBs will continue to have oversight of how providers deliver the outcomes that they have been commissioned for. But where performance is below an acceptable level, and the use of commissioning levers has not secured improvement, NHS England will step in with both the ICB and provider to support rapid improvement and using our regulatory powers in a defined set of circumstances.

Supporting organisations to improve

The NHS Performance, Improvement and Regulatory Framework will have clear guidelines for interventions in organisations struggling with quality, finance, or access, ensuring transparency and consistency. This will include establishing a consistent regulatory approach for underperforming organisations, mandating recovery plans and maintaining board accountability for effective delivery. As part of this approach, we will also use an independent diagnostic process to accurately assess and analyse the root causes of issues within organisations, providing targeted insights for improvement.

These changes should allow us to streamline how different parts of the health system work together to support our collective focus on improving the delivery and recovery of urgent and emergency care and elective performance, at the same time as the medium- and long-term changes required to meet the needs of our communities, shifting care to where it is delivered best in a joined-up and integrated way.

Board accountability

Strong boards are essential for all organisations if the NHS is to deliver its objectives. To be effective, boards need the right information at the right time and used in the right way. As part of our commitment to support leaders to deliver and improve, and to set them up for success, we are pleased to have published this week the Insightful Board guides for both ICBs and providers. We recognise that ICBs have a unique role in supporting the wider primary care working to be sustainable, and the Insightful Board documents support that.

These guides provide clarity around the critical information boards need to understand their organisations, and the culture and governance necessary to support information flow, so it can be used most effectively when overseeing their organisations.

Working with you

We have heard consistently that clarification was needed, and while there has been broad consensus on much of this, we acknowledge there are different views on precisely what the roles and responsibilities should be and how this should work in practice. While we have set out the direction of travel, we want to work with you on how we refine and implement this. There are no immediate changes for 2024/25, and systems must continue to deliver their plans in the way that has been agreed.

We have set up an NHS System Development and Reform programme, working closely with colleagues in DHSC. This will include a regular advisory group of chairs and chief executives, among others, to help co-create the implementation plan.

We recognise there will be a need for extensive engagement about what the evolution of the operating model will mean in practice and how we best describe and implement it. We will hold an initial webinar with you next week, at 11am on Wednesday 20 November, and plan further engagement from there.

Finally, although the next steps in evolution of the operating model have been discussed extensively with some of you, we know that much wider engagement is needed to make this a reality, and we are committed to working closely with you on next steps, including plans for implementation. 

Yours sincerely

Steve Russell, Chief Delivery Officer, NHS England
Adam Doyle, National Director, System Development, NHS England