Consultation on the NHS Performance Assessment Framework

In May 2025 NHS England consulted on an updated NHS Performance Assessment Framework, proposing a new approach, methodology and metrics for the assessment of integrated care boards and NHS trusts and foundation trusts.

On 22 May 2025, NHS Providers submitted a response reflecting its members’ views.

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

On behalf of an organisation.

2. Describe the organisation or group you belong to.

NHS Providers is the membership organisation for the NHS acute, mental health, community and ambulance services that treat patients and service users in the NHS. It helps those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate.

NHS trusts in England collectively account for £132bn of annual expenditure and employ 1.4 million people.

3. What is the name of your organisation?

NHS Providers

4. 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?

• Strongly agree
• Somewhat agree
• Neither agree or disagree
• Somewhat disagree
• Strongly disagree

5. 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?

• Strongly agree
• Somewhat agree
• Neither agree or disagree
• Somewhat disagree
• Strongly disagree

6. To what extent do you agree that ICB segmentation should continue to consider system performance?

• Strongly agree
• Somewhat agree
• Neither agree or disagree
• Somewhat disagree
• Strongly disagree

7. To what extent do you agree that segments 1 and 2 should be limited to organisations achieving financial balance (surplus or breakeven)?

• Strongly agree
• Somewhat agree
• Neither agree or disagree
• Somewhat disagree
• Strongly disagree

8. 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? 

• Strongly agree
• Somewhat agree
• Neither agree or disagree
• Somewhat disagree
• Strongly disagree

9. Do you have any comments about the proposal and the impact on advancing equalities and/or reducing health inequalities?

The arrangement of the oversight metrics around the four core purposes of integrated care systems (ICSs) was a welcome step, which we commended during our early engagement on the draft
framework in 2024. Combining short, medium and long-term metrics, as presented in last year’s framework, ensures that providers and integrated care boards (ICBs) do not lose sight of the longer term aims for the service at the same time as delivering against the immediate operational and financial priorities – a very real and live challenge at the moment.

We appreciate the need to link assessments of providers and ICBs to the delivery of priorities set out in the government’s mandate and the latest operational planning guidance. We also acknowledge the benefits of a shorter, more streamlined list of metrics in principle. But this should not come at the expense of important longitudinal objectives, relating to tackling inequalities in outcomes, experience,
and access, and to supporting broader social and economic development.

The consultation document indicates that the framework and accompanying metrics will be reviewed again following publication of the 10-Year Health Plan and Dr Penny Dash’s review. While justifiable
on this occasion, we are generally concerned that revising the metrics annually to align them with government priorities may not enable the regulator to effectively identify challenged organisations; and such frequent updates may also introduce uncertainty around strategic investment and areas of focus.

In summary, we feel there is a missed opportunity in the current draft of including more of the metrics considered in last year’s version of the framework. The approach to developing performance metrics should provide a suitable balance between short, medium and longer-term objectives. We are hopeful that the next iteration of the metrics will be better aligned with the government’s three shifts and the core purposes of ICSs.

10. Do you have any other comments?

Overall, the revised framework is a significant improvement on the previous draft. We particularly welcome:

• Improved clarity around roles and responsibilities, including the notable shift in ICB responsibilities away from provider oversight and towards strategic commissioning and the fulfilment of the ICS’ core purposes.
  
  
• NHS England’s (NHSE) efforts to engage and to work collaboratively with providers, ICBs, and stakeholder organisations in developing the principles of this updated framework over the past two years.
  
  
• The proposal of quarterly review meetings to enable ongoing dialogue and openness about challenges for trusts in any segment. These meetings should be framed through an improvement lens, rather than as segmentation reviews.
  
  
• The decision to remove capability assessments from the decision-making on segmentation. We are pleased that those assessments will be preserved and used to inform and target NHSE’s intervention and improvement response. We look forward to seeing NHSE’s furtherguidance on the process.
  
  
• That provider segmentation scores will no longer be adjusted for system considerations.
  
  
• The inclusion of system performance considerations in the assessment of ICB performance.

However, the following areas require further clarity and consideration, which we would welcome further opportunities to work with you on:

• The distinct role of NHS regions as opposed to central NHSE teams, specifically in relation to provider oversight.
  
  
• The draft guidance on segmentation still asks providers to escalate concerns about performance, finance or quality “through their ICB”. It is essential that providers also have direct access to their statutory regulator to escalate concerns, in circumstances where that is more appropriate, and when unrelated to ICBs’ contractual, commissioning or system plan oversight responsibilities.
  
  
• The NPAF does not explicitly address group models and other shared leadership arrangements where one decision-making body effectively controls two or more trusts. We recognise that trust regulation and support does not currently reflect the group model in the way it may need to in the future - we would welcome supporting further thinking on this.
  
  
• It is unclear how incentives, rewards and penalties will be applied, and what this will mean for trusts in groups/shared leadership arrangements. This includes how segmentation under the NPAF will inform pay incentives for VSMs.
  
  
• We note the intention ‘to embed earned autonomy and incentives… into the operating framework’. Foundation trusts have some freedoms in law, which can only be curtailed through regulatory intervention under the provider licence. We welcome additional flexibility, freedoms and absence of intervention for those organisations performing well, however, existing statutory powers should be respected unless providers are subject to regulatory intervention. The concept of ‘earned autonomy’ can muddy these issues.
  
  
• We need to understand how “the extent to which providers are effectively collaborating” can be measured. It is important to recognise that collaboration is an important means of achieving specific outcomes, but it is not an end in itself.
  
  
• We are keen to understand how organisations’ performance will be benchmarked against their peers and look forward to seeing your forthcoming guidance on the methodology. We also need to understand how the new interactive scorecard and benchmarking data relate to the government’s plan to introduce league tables. The publication of benchmarking data may effectively create league tables for those metrics. We need to avoid the unintended consequences of such rankings, which risk creating perverse incentives if they skew priorities towards a narrow set of finance or performance indicators, or shift the focus to short-term targets at the expense of strategic transformation and improvement. There is also a risk of judging organisations solely on metrics, without factoring in the wider context they are operating in, particularly the external factors which impact performance but which may be beyond their control. 
  
  
• Achieving financial balance is crucial for long-term sustainability. The current picture of provider and ICB financial health signals the need for realism about what can be achieved and by when. It is right that the highest segments should be reserved for the best performers. However there is a risk that, if the financial task is not deliverable for a large proportion of trusts for reasons beyond their control, there will be an over-concentration in the bottom segments. It will be important for segmentation to provide an accurate and meaningful picture of trusts’ performance in addressing the challenges within their control. Over-concentration in the bottom segments may also present practical problems for NHSE in terms of oversight capacity and providing the necessary intervention and improvement response.