ICS oversight - good governance arrangements will be key

01 July 2021

The new NHS system oversight framework sets out NHSE/I’s approach to the oversight of ICSs – we start to unpick the detail.

Last Thursday (24 June) the NHS system oversight framework for 2021/22 was issued. The framework sets out NHS England and NHS Improvement’s (NHSE/I) approach to the oversight of integrated care systems, CCGs and trusts, with a focus on system-led delivery of care.

Hot on the heels of the recently published ICS design framework, which we wrote about last week, ICS leadership, partner organisations and providers have another document to absorb. So what are the key takeaways?

Lots to digest - capability and capacity will be key

The framework defines how ICS performance will be measured and the level of support and oversight they will need within the current statutory framework but also accounting for the local flexibility of ICSs with defined parameters for tailoring to local circumstances.

It is the latest addition to a suite of essential guiding documents for ICSs alongside:

  • the NHS Long Term Plan (vision)

  • ICS white paper (aims)

  • the 2021/22 operational planning guidance (priorities)

  • the ICS design framework (structures).

It’s been said that start-ups struggle more with digestion than starvation. In their infancy, ICSs, much like start-ups, have a lot to take on board. The emphasis on local determination and control puts considerable pressure on ICS leaders. To succeed they need to be well-supported by practical tools and resources. Capability and capacity will be essential.

Oversight and governance development - good governance arrangements matter

The oversight approach set out in the framework is driven by a number of key principles that ICS leaders will need to be mindful of:

  • working with and through ICSs, where possible, to tackle problems

  • a greater emphasis on system performance and care quality outcomes

  • matching accountability for results with improvement support

  • greater autonomy for ICSs and NHS organisations with evidence of collective working and a track record of successful delivery against NHS priorities, tackling inequality and health outcomes

  • compassionate leadership behaviours.

The framework is what will guide NHSE/I’s regional teams' oversight of ICSs at system, place-based and organisation level as well as decisions about the level and nature of delivery support they need.

The following table, taken from the framework, explains this oversight approach to ICSs relative to their development.

ICSs are expected to agree a memorandum of understanding with regional teams setting out delivery and governance arrangements across the ICS, including:

  • financial governance arrangements that support the effective management of resources

  • quality governance arrangements (the National Quality Board’s A shared commitment to quality and Position statement on quality in integrated care systems set out specific requirements that ICSs are expected to have in place)

  • oversight mechanisms and structures that reflect delivery and governance arrangements

  • local strategic priorities that the ICS has committed to for 2021/22.

ICS leaders will also need to be aware of the oversight cycle set out in the framework and the ongoing monitoring process:

Alongside this the existing statutory roles and responsibilities of NHS England and NHS Improvement in relation to trusts and commissioners remain unchanged, as do the accountabilities of individual NHS organisations.

Measuring performance - oversight metrics and mandated support

Accompanying the main oversight framework is an additional document setting out oversight metrics. A single set of metrics will be used to evaluate the performance of ICSs, with performance resulting in differing levels of support and scrutiny.

These oversight metrics are aligned to the five national themes that reflect the ambitions of the NHS Long Term Plan set out in the oversight framework: quality of care access and outcomes; preventing ill health and reducing health inequalities; people, finance and use of resources; and leadership and capability.

These metrics will be key for establishing when mandated support is needed. Mandated support will apply when ICSs, NHS or FT trusts or CCGs have serious problems and concerns exist about whether leadership can make the required improvements. A trust of ICS in mandated support will be subject to enforcement action.

The Care Quality Commission (CQC) will play an active role in recommending trusts for mandated support. The CQC, through the Chief Inspector of Hospitals, will recommend to NHSE/I that a trust is mandated to receive intensive support when it is rated ‘Inadequate’ in the well-led key question and provide the reasons for the recommendation and the specific areas of improvement required.

Once an ICS, trust or CCG is mandated for support, NHSE/I regional teams will agree criteria with them that must be met in order for them to exit it. The support will be delivered through the nationally coordinated Regional Support Programme (RSP), a new integrated and system-focused recovery that replaces the previously separate quality and finance ‘special measures’ regimes for provider trusts.


  • Now is the time for ICS leaders to consider the nature of the support they need and what they might need to do differently to drive improvement using that support.

  • ICS leaders should familiarise themselves with the metrics they will be judged on and put in place effective performance management and governance.

  • ICS leaders should already be thinking about the memorandum of understanding they will need to agree with regional NHSE/I teams to set out delivery and governance arrangements.

The timescales are challenging and there is much to be done. GGI is here to help navigate this important journey towards integrated care. No one is better placed to advise you. Find out more about how we can help.

If you have any questions or comments about this briefing, please call us on 07732 681120 or email advice@good-governance.org.uk.

Meet the author: Daniel Taylor

Engagement Consultant

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Prepared by GGI Development and Research LLP for the Good Governance Institute.

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