Next day briefing: The Insightful Provider Board and the Insightful ICB Board

On Tuesday 12 November NHS England (NHSE) published The insightful provider board and The insightful ICB board alongside supporting documents. This non-mandatory guidance aims to support provider boards and integrated care board (ICB) boards, respectively, to turn data into useful insight. Effective governance practice around board reporting and assurance-seeking is also considered in each document. Both contain suggested measures that boards might wish to consider using for planning, monitoring and seeking assurance about progress.

This briefing provides an overview of the contents of each, with a focus on the insightful provider board, places the publications in the context of the ongoing review of the NHS oversight and assessment framework and the NHS operating framework, gives NHS Providers’ view. 

NHS England chief executive Amanda Pritchard launched the documents during her speech at NHS Providers Annual Conference and Exhibition on 12 November. In her keynote speech, she framed both documents within the context of the ‘system optimisation’ prescribed by Lord Darzi in his recent report diagnosing the challenges facing the NHS.

The insightful ICB board begins to clarify the role of ICBs as, in Ms Pritchard’s words, “focused on strategic commissioning and creating the environment for more action on prevention and more care in the community”. She said a revised NHS operating framework and oversight and assessment framework would further clarify the roles and accountabilities of providers, ICBs and NHSE.

The documents themselves, she said, aim to properly equip boards, “making sure they’ve got the right information at the right time, and can use it in the right way to both lead and track improvement, as well as responding quickly to problems. Providing, in one place, what executives and NEDs should be looking at, and [setting out] how to use it to drive better outcomes, better productivity, better decisions.”

The documents also give an indication of how the organisational and oversight structure of the NHS will be reformed to support delivery of the forthcoming 10 year plan.

Both documents are framed as supportive good practice as opposed to mandatory guidance.

For provider boards, the “document is not an exhaustive governance resource and should be read alongside other the code of governance for NHS providers and guidance on good governance and collaboration. Therefore, “non-compliance is not in itself a breach of any regulatory requirement.” This guidance is intended for boards to use to check they are covering all the bases and to seek inspiration and improvement from, if required.

The insightful ICB board reflects NHSE’s ‘expectations of ICBs’, and while not as explicit as The insightful provider board in terms of being non-mandatory, is also framed as a ‘guide’ to “help ICBs to assess the effectiveness of the information they collect and use”. 

Both documents seek to support boards to make use of data effectively in the context of increasing complexity, and to use data intelligently to gain useful insight rather than false assurance. 

The document is in three sections, covering: 

• The board’s role in governance and organisational culture, 
• Suggestions for ensuring that information boards receive and review is meaningful, and
• Domains for consideration by boards, with related key questions they might wish to consider, and measures and indicators that might enable them to gain adequate assurance about performance.

Governance and culture

Starting with the role of an NHS provider board, this section highlights the board’s responsibility for ensuring quality and safety, and for promoting the long-term sustainability of the trust as part of its integrated care system (ICS). An extensive list of what well-led boards need to do is set out, which demonstrates the wide range of issues boards should be concerned with. The guidance highlights the need for effective governance arrangements, open, curious and transparent cultures, and insightful information needed for boards to undertake these complex functions and to assure themselves of progress. 

While the guidance focuses on the need for robust, relevant information that is effectively interpreted and used, governance and culture are recognised as significantly impacting on the board’s ability to obtain and use information effectively. The need for independent board effectiveness reviews every three to five years is highlighted, as well as the importance of continuous board development and of attention to directors’ skills and experience mix.

The section sets out some fundamental principles of good governance, including processes and structures, alongside key governance questions for boards to consider.

The value of compassionate, inclusive, open and transparent cultures is highlighted, which should be fair and just, and facilitate continuous improvement, and the need for boards to be ‘problem-sensing’ is set out: early detection of closed cultures is encouraged. 

Meaningful information

Recognising that the context in which boards operate is increasingly complex, for example due to access to more datasets, this section provides an overview of board practice which seeks to prevent boards being blinded by information overload.

In this context, the guidance highlights the importance of committees effectively escalating to the board after reviewing more granular data, and also the importance of triangulation, considerations around aggregating data, making good use of analytical tools, and pitfalls to avoid.

NHSE sets out the characteristics of an effective NHS provider board: 

• Is curious
• Takes necessary actions
• Requires continuous assurance
• Supports staff and system.

Six domains to consider

The final section provides an overview of the types of information and metrics which boards may consider, and is intended to cover all NHS provider sectors.

The document makes it clear that “by its nature [the measures are] extensive and although it identifies mandatory reporting, the inclusion of metrics in these domains should not be taken to imply that all information and metrics should routinely be reported.” Boards are also told that using other ways to arrange indicators and measures is acceptable, and that this is one possible structure that NHSE have chosen.

The section is structured around six ‘domains’:

• Strategy
• Quality
• People
• Access and targets
• Productivity
• Finance 

Suggested questions for boards are again included against each domain, and then each is broken down into further areas, each with suggested qualitative and quantitative measures that boards may want to use to monitor and gain assurance.

Further detail in relation to these indicators is included in supporting guidance (see below).

The supporting guidance should be read alongside The insightful provider board and provides additional commentary on the metrics selected in the main document, and advice on developing and interpreting the suggested measures, as well as some additional indicators for consideration. An example integrated performance report (IPR) is also included. 

The guidance for ICB boards follows a similar format to The insightful provider board. For ICBs, the board’s focus is framed squarely in the context of strategic planning to deliver health care that achieves the four core purposes of integrated care systems (ICSs): 

1. Improve population health and health care
2. Tackle inequalities in outcomes, experience and access
3. Enhance productivity and value for money
4. Help the NHS support broader social and economic development 

It is notable that this document emphasises ICBs’ role as strategic commissioners, and does not position them as performance managers in their systems. Nor does it contain any reference to NHSE exercising its regulatory functions ‘with and through’ ICBs, as set out in the 2022 NHS England operating framework. Instead, it focuses on the information and insight ICBs require into both their own performance as boards and the performance of the system itself, to understand progress towards achieving the four core aims.

Beginning with a section on the role of the ICB board, the guidance sets out what ICBs need to use information for to be effective: 

• planning, 
• managing resources,
• understanding the provider landscape and procuring accordingly,
• gaining assurance about care delivery, and
• considering risk and mitigations.

As organisations, ICBs must also be sure they are run well and operate effectively, including delivering on their statutory functions. ‘Active governance’ is advocated, including relevant policies and reporting structures, and clarity about where decision-making and accountability sits in terms of any delegated functions.

The guidance includes advice on ensuring information is meaningful, including top-level information ICBs might wish to consider. ICBs should seek to assure themselves about the usefulness and accuracy of the data they receive. There follows a reminder about how information can be presented to enable boards to draw insight, and as in the provider board guidance, the benefits of triangulation, effective board and committee practice, and the use of analytics are highlighted. A sample IPR is also included for ICBs. 

The third and most extensive section includes suggested indicators and measures against “six functional areas which underpin how ICBs deliver their purpose”: 

1. Strategy and planning
2. Leadership
3. Arranging for the provision of healthcare services (strategic commissioning)
4. Assuring performance, quality and delivery
5. Learning and transformation
6. Effective governance and people 

For each area, there are questions for consideration by ICB boards, and further explanations about the importance of effective insight. NHSE commits to amending the metrics annually based on ICB feedback.

Finally, ICB boards are given advice about putting the guidance into practice. Appendices include an indicative ICB board agenda and annual cycle, and an outline of ICB key statutory duties. 

Overall, we believe trust and ICB board members will find these overviews helpful. These publications will help board members to check their own reporting, monitoring and assurance-seeking, and make improvements where needed. 

The insightful provider board

We were grateful to have the opportunity input into these documents, and to see our recommendations have been taken into account.

As supportive guidance, both documents contain sound and established governance principles and practice, clearly and briefly articulated. This is timely given that ICBs are still relatively new organisations, and because of the rate of turnover in trust boards. Board members will benefit from thinking through and self-assessing their practice against the principles and suggested questions here, with their colleagues, NHS partners, and with input from their governance and data analytics professionals.

We also recognise and agree that the context in which boards operate has become more complex, and the data available more extensive: the potential for missing the wood for the trees has increased so this guidance is timely.

We would agree that the domains and areas suggested for provider board attention are those which mature, effective boards should be concerned with. The specific measures and indicators selected are generally appropriate in our view, and give boards a potentially helpful list of suggestions to review their current reporting and assurance-seeking practice against. As the document recognises, this is a guide, not a checklist.

However, we observe that the productivity metrics are arguably too acute-focused, and the suggested people indicators lack a sustained focus on equality, diversity and inclusion. We are pleased to read that “Finance should not be considered in a silo – it is a significant factor in how the trust prioritises resources and the impact this has on the services provided for patients and service users, and the wider finances of the system”. More national messaging along these lines would be welcome. 

Revised focus for ICBs

We are pleased that The insightful ICB board guidance reframes ICBs’ role to emphasise strategic leadership focused on achieving the four core aims of ICSs. ICBs’ ability to focus on longer-term aims is vital to shifting care closer to home, and towards a prevention-focused model – two of the government’s three ‘big shifts’. ICBs have previously been asked to focus on immediate operational and financial pressures (including through the NHS England operating framework) and this has made it harder for systems to focus on longer term transformation.

We need the added-value ICBs can bring if given the space to convene partners to collaboratively and strategically plan, problem-solve and join-up services across the NHS and with social care. This is the system leadership role that was envisaged for them in the 2022 Health and Care Act.

This will also hopefully remove duplication between ICBs and NHSE, which in turn will free up trust boards to focus on doing their part to deliver for the communities they serve, and work with partners in their systems to create the sustainable NHS that we all want to see.

These pieces of advisory guidance cannot bring about change on their own: the changes suggested here need to be reflected in NHSE’s revised oversight and assessment framework, while the 10 year plan must tackle the other barriers to successful system working and integration. If you have any questions regarding any of the material within this briefing, please contact Izzy Allen (Izzy.Allen@nhsproviders.org).