Accountability and oversight

The health and care system needs a simple and effective system operating model, where every part of the system is clear on its purpose, what it is accountable for, and to whom. Due to the integrated nature of IHOs, there is a heightened risk of overlapping responsibilities and shared decision-making arrangements leading to blurred lines of accountability. 

If the host provider is ultimately to be held accountable, then careful thought must be given to how this is managed alongside accountability for the provider's own service delivery responsibilities, including metrics assessed by the NOF and CQC assessments. This is essential to avoid creating an overly complex or burdensome reporting system and to prevent competition between organisational interests and system-wide goals.

The host provider will also need clear lines of accountability given the level of financial risk they will hold on behalf of their local population. This includes clarity from the government and ICBs about the outcomes they are expected to deliver. Over time, there should be a shift from process compliance to a small number of high-impact and measurable health indicators that are linked to population health. 

IHO oversight is likely to be tied to the existing oversight and regulatory regime, as opposed to a new legislative framework. As an extension of the advanced FTs, IHO host providers will presumably remain under the NHS provider licence. Some healthcare leaders questioned the ability of effectively overseeing IHO host providers from the centre, especially given current provider performance challenges.

DHSC will need to decide whether there will need to be a deauthorisation process or contract transferral process for advanced FTs and IHO host providers that experience major performance or financial issues, or which fail against other criteria. When a local health system is designed around a provider, it is not a simple matter to move to a different arrangement if things go wrong.

Clear lines of oversight

ICBs and regions

According to the 10YHP, IHOs will be overseen ‘in a proportionate, rules-based way by their NHS region.’ Meanwhile, the strategic commissioning framework confirms that ICBs will provide ‘robust oversight’ of host providers through their contractual relationship. This includes holding them to account against the outcomes they have commissioned them to achieve for their population, as is the case for other providers including those holding neighbourhood contracts. The IHO contract should also include a regime for dealing with failure, including step-in arrangements with sub-contractors when the main IHO contract fails. There needs to be sufficient clarity and distinction between ICBs’ contract management role and NHS England/DHSC’s regulatory and performance management functions to avoid duplication and hindering IHO progress. 

It is not year clear that regional teams have the capacity and capability to discharge this function, given the extensive range of other functions also set out in the model region blueprint. Unlike the model ICB blueprint, the model region does not clearly specify what functions are new, existing or will be stopped or transferred elsewhere, begging the question: will they have capacity to oversee and support systems developing IHOs?

The CQC

It is unclear what role the CQC will play in assessing IHO host providers and sub-contractors of care, rather than just providers. Given they are still undergoing a major recovery and transformation process, concerns will likely remain about whether the CQC is yet in a position to take on this new responsibility or develop a novel way of assessing this different way of working. But robust regulation will be essential to ensure IHO host providers are effectively discharging their functions.