The integrated health organisation (IHO) model represents the most significant structural ambition in the 10-Year Health Plan. 

At its core, it is a deceptively simple idea: give a highly capable provider a whole population budget for a defined geography to align the financial incentives across the care system, rebalance resources and move care out of hospital. The policy aims to solve NHS challenges at source rather than managing the consequences, letting the logic of integration do what decades of fragmented commissioning could not. 

But the hard work lies in turning a compelling concept into a functioning contract across multiple organisations with competing duties and objectives, which means grappling with questions of accountability, capability, risk and collaboration that have no straightforward answers. 

With NHS England actively working with the first two candidate systems, Northumbria Healthcare NHS Foundation Trust and Northamptonshire Healthcare NHS Foundation Trust, the IHO is now a live programme with real organisations, real populations and real lessons beginning to emerge.

It was against that backdrop that NHS ConfedExpo's session, ‘Integrated health organisations unlocked: early lessons from the first candidates’, brought together Miranda Carter, Director of System Architecture at NHS England; David Williams, Group Director of Strategy and Business Development at Leicestershire Partnership NHS Trust and Northamptonshire Healthcare NHS Foundation Trust; and Mark Major, CEO of Northamptonshire Carers, under the chairmanship of Lord Victor Adebowale, Chair of The NHS Alliance. 

What followed was an honest, substantive conversation about where the model stands, what it demands and what the first wave of candidates are already learning.

IHOs moving from concept to contract

Miranda Carter set out the policy architecture with clarity. An IHO is a contract – not a new legal entity – through which an ICB commissions a highly capable provider to hold a whole population budget and take responsibility for designing and delivering integrated care for a geographically defined population.

The ambition is to achieve the "left shift" of moving care into communities by redesigning pathways, eliminating the fragmentation that has long undermined continuity of care, and creating incentives that allow savings generated in one part of the system to be reinvested where they are most needed.

The model is built on a layered architecture, running from neighbourhood to multi-neighbourhood to IHO scale, with the IHO co-ordinating the full provider delivery chain beneath it. Capable ICBs remain essential – not as operational managers, but as strategic commissioners holding the IHO to account. The IHO itself takes on much of the service transformation and delivery, while the neighbourhood tier provides the connection and delivery to communities.

NHS England is now working with both candidate systems through a designation process that examines capability, board readiness and population health understanding, with the 'Fit for the Future' framework providing the structure. Each system is already working through the question of which population they want to focus on first. 

On the question of whether this is a pilot or a permanent direction of travel, Miranda was unequivocal that this is not a pilot, and hinted at the prospect, as advocated for in our own work with The NHS Alliance that IHOs may in future not be limited to only the highest performing organisations.

No one else to blame – and that is the point

David Williams drew on his experience of having sat on both sides of the commissioner-provider divide. He described a dynamic familiar to anyone who has worked in NHS systems: the commissioner blaming the provider, the provider blaming the commissioner, and patients caught between competing accountabilities.

The IHO model aims to dissolve that dynamic by design. When you hold the system contract, there is no one else to point the finger at. That is uncomfortable, but it is also precisely the point. The easy wins in NHS transformation have long gone. What remains are the genuinely difficult challenges: the hot potatoes that require everyone to sit down together and solve problems as one system, without the luxury of a better specification or a new procurement round to hide behind.

David was also direct about the measurable benefits the model can deliver: better dementia waiting times, improved support pathways, reduced acute admissions. These are not aspirations – they are achievable outcomes. But realising them requires discipline in how systems engage. You cannot have fifty separate conversations. Priorities need to be clear and consolidated, and organisations need to be prepared to move together.

The voluntary sector: Essential partner, an not afterthought

Mark Major offered a timely reminder that population health can’t be delivered by the NHS alone. An ageing population and increase in people living with long-term conditions is driving a corresponding rise in unpaid carers, and those carers are increasingly the invisible infrastructure on which the health and care system depends.

Mark spoke to the genuine opportunity the IHO model creates for voluntary organisations: an earlier seat at the table, a real role in shaping the market, and a chance to co-produce services rather than simply receive sub-contracts. The sector has spent years attempting to build meaningful relationships with the NHS, often without success. He advised voluntary organisations to be ready when the opportunity comes.

David reinforced the point with operational substance. His trust has worked with voluntary partners to provide support the NHS could not or would not provide directly – on full-cost contracts, over five-year terms, to provide the continuity and cashflow stability that voluntary organisations need to plan and invest. That is a replicable model, and a meaningful signal of what genuine partnership looks like in practice.

Miranda acknowledged that the IHO authorisation process does require candidate systems to demonstrate understanding of the voluntary sector in their place, and committed to greater transparency about expectations. There is also a greater emphasis on showcasing what has already been done. As she noted, stakeholder engagement is a central component of what it means to be an excellent strategic commissioner.

Governance, oversight and the performance question in IHOs

One practical tension the panel touched on is the current authorisation threshold. Candidates must have successfully completed the relevant assurance process and sit in segment one or two of NHS England's oversight framework, meaning only the highest-rated organisations are currently eligible. 

Quarterly provider ratings can shift and the question of whether that creates an unnecessary structural barrier was live in the room. Miranda acknowledged that some systems see the IHO model as the right solution for their particular context and are looking carefully at what it would take to qualify.

Our view: Local ownership, national enablement

The discussion at ConfedExpo reinforced and deepened much of what Browne Jacobson and The NHS Confederation set out in our joint report, Towards Integrated Health Organisations: Considerations for Policy and NHS Leaders, published in November 2025. 

Based on interviews and a roundtable with more than 30 healthcare leaders across The NHS Alliance's primary care, community, mental health, acute and integrated care system networks, the report presents considerations for local leaders and the government across four components: contract, structure, governance, and behaviours and leadership.

At its core, an IHO involves a capitated contract for a whole population awarded by an ICB to a host provider, which holds the IHO contract on behalf of a group of providers, then delivers or sub-contracts services, aligning financial incentives between providers to reduce downstream demand. 

What the NHS ConfedExpo session made clear is the contract’s mechanics are only part of the story. Beyond hard mechanisms, the success of IHOs will depend on trust, relationships and shared purpose across partners, and leadership should be about convening, not controlling. David Williams' account of the commissioner-provider blame dynamic illustrated exactly why that cultural shift is so important – and so difficult.

On the performance and authorisation question, our report found that while IHOs are intended to improve allocative efficiency and financial performance, limiting IHO contracts to only “high-performing” foundation trusts risks exacerbating performance variation and inequalities. A clear pathway is needed for organisations with lower performance in some areas, but strong leadership capability and partnerships, to hold an IHO contract. This remains one of the most important design questions for national policy to answer.

We also argued that host providers, collaborative arrangements and expected outcomes should be agreed locally, rather than imposed from above, and that while the first wave of IHOs might be authorised centrally, they should in future be initiated by ICBs. The designation process Miranda described – with its emphasis on system readiness and locally determined population focus – is encouraging in that respect. But the next step must be ensuring that national policy actively enables rather than inadvertently undermines the model. As our report recommended, the NHS Oversight Framework's financial and performance metrics should incentivise the collaboration between organisations needed to deliver an IHO contract.

Barriers in competition should be addressed, in consultation with the Competition and Markets Authority, and legal changes should be made to better enable social care and public health services to be included in IHO contracts in future. As IHOs mature, the inclusion of those services will be essential to delivering genuine population health outcomes, and not an optional add-on.

What the NHS ConfedExpo session underscored, above all, is the IHO journey is underway and the organisations involved now are already generating the lessons that will shape the model for the whole system. The question is no longer whether IHOs will happen. It is whether the policy, regulatory and legal framework will keep pace with the ambition of the leaders stepping forward to make them work.

To discuss contents from the full report, Towards Integrated Health Organisations: Considerations for Policy and NHS Leaders, please contact our specialist lawyers on integrated healthcare systems for more information.