Introduction

The challenges facing the NHS, although not unique to England, are considerable. Demand for healthcare services continues to rise disproportionately compared to the rest of the economy, exacerbated by an ageing population, increasing co-morbidities and continuously evolving technology. Long-term conditions are also becoming the norm, with nearly half the population suffering from one, and this continues to eat away at a sizeable amount of healthcare expenditure. Common mental health conditions in younger demographics are also becoming more prevalent. Demand for services is rising faster than the healthcare system’s capacity to meet it. These trends are straining public finances, reducing economic productivity and widening health inequalities.

In turn, waiting lists are growing and staff morale is reducing, as evidenced by ever-increasing instances of industrial action and declining satisfaction in the latest NHS staff surveys. All the while, public expectations of the NHS increase, driven by medical advances. 

Ever-increasing healthcare spending is not a sustainable option. Instead, healthcare needs to be redesigned to increase overall system effectiveness. Shifting resources upstream towards earlier preventative and community care, managing demand and boosting allocative efficiency, can recover services, reduce waiting times and put the NHS on a sustainable footing. 

The 10 Year Health Plan (10YHP) seeks to do this by shifting care from hospital to community. To help achieve this, the plan intends to devolve to and empower local leaders with significant freedoms for the highest performers via a reinvented, 'advanced' NHS foundation trust (FT) model and establishment of integrated health organisation (IHO) contracts. Advanced FTs will operate on the same core philosophy as their predecessors, with enhanced autonomy, control of board composition, financial freedom and the ability to raise capital. The 10YHP states that the most advanced FTs – with a track record of meeting core standards, improving population health, forming partnerships and maintaining financial sustainability – can receive capitated contracts to become IHO host providers. 

The concept of IHOs draws on the international case studies of accountable care organisations (ACOs) and domestic experience. In countries such as the USA and Spain, ACOs are generally a single provider in charge of the health budget for a geographically defined population, tasked with delivering longer-term outcomes within a fixed budget. In England, the 2014 Five Year Forward View (FYFV) outlined multispecialty community providers (MCPs) and primary and acute care systems (PACS), although the long-term, positive sustainable impact of these models was limited. Though they offered different approaches, they shared ‘a focus on places and populations rather than organisations’, emphasising a collaborative approach to care. 

In the Health and Care Act 2022, integrated care boards drew inspiration from American ACOs, although differed as their primary responsibility was as commissioners, not providers. Despite not formally materialising, a diverse selection of integrated provider models has populated the provider landscape since 2012, and most providers are now working within a provider collaborative of some form, with all acute and mental health providers required to be part of at least one. In their joint report with NHS Providers, Browne Jacobson highlighted the utility of collaborative models in delivering safe, effective and sustainable services to their populations, as well as a beneficial response to challenges and risks. We are seeing a similar collaborative model developing in primary care.

This report, based on engagement across primary care, community, mental health, acute and ICB leaders from August to October 2025, explores the current state of play on integrated delivery models and next steps to move towards IHOs. The proposals set out in this report are based on the views of members of the NHS Confederation. This report is not a statement of national policy, rather it is a set of proposals intended to inform government policy and local practice. We would like to thank all the individuals we spoke to as part of this research, including our members and NHS England colleagues.

For a more detailed overview of the report’s aims and context, including examples of previous approaches to integrated care, please see the appendix.