Building a replicable framework for the NHS Provider Improvement Programme
NHS England’s Recovery Support Programme, now the NHS Provider Improvement Programme (NPIP), was established to deliver tailored support to NHS organisations facing persistent challenges in leadership, finance, performance, and quality. To address the increasing demand for national assistance, CF developed and tested a data-driven diagnostic in collaboration with the NPIP team, enabling a deeper understanding of the structural, strategic, and operational factors behind underperformance. This approach facilitated the identification of specific barriers to improvement and informed targeted support strategies, as demonstrated in the pilot with Mid and South Essex NHS Foundation Trust, where it helped uncover root causes and guide focused actions that positively impacted both patients and staff.
What was the challenge?
NPIP supports organisations at the highest NHS Oversight Framework (NOF) levels, meaning those NHS organisations facing the greatest challenges across leadership, finance, performance and quality. The programme needs to be able to provide support that responds to the different needs and root cause drivers of underperformance in each organisation.
This was compounded by the increasing number of organisations entering NOF levels 4 and new level 5, making it difficult for available capacity to meet demand, and provide the timely support these organisations and their patients need.
What did we do?
CF were commissioned to design and test a sharper diagnostic process to assess the drivers of underperformance and limitations and barriers to improvement, informing more targeted support packages.
We worked at pace to design a rapid, data-driven diagnostic, starting with a framework to guide systematic analysis of the key finance, quality, performance and leadership challenges in an organisation. Unlike previous diagnostic approaches that focus on symptoms, our framework systematically traces issues back to their root causes, identifying operational drivers (that can be addressed at an organisational level through efficiencies), strategic drivers (that need to be addressed at a system level through funding allocation or models of care and structural drivers (that are not within the control of the trust or system to change or require capital investment).
Over two weeks, we piloted this approach at Mid and South Essex NHS Foundation Trust (MSE). We used nationally reported data to inform an objective, desktop assessment, using sources such as Model Hospital and Hospital Episode Statistics to ensure the approach could be replicated for other organisations entering NOF levels 4 and 5 and to support future automation. We engaged the Federated Data Platform team to begin exploring automation and set out the indicative timeline and data ingestion requirements to support this.
All metrics were benchmarked against Model Hospital and NHS-recommended peers, as well as compared to a five-year historical baseline to understand the trajectory of improvement or deterioration. Where desktop analysis could not reliably prove or disprove a hypothesis, we set out key lines of enquiry for subsequent engagement.
The pilot highlighted the challenges facing MSE and helped identify the root cause issues driving these. We studied the interdependencies between the identified drivers to inform a hypothesis-led approach to identifying support and improvement actions tailored to local needs.
What was the impact?
Our approach delivered benefits for both MSE and the wider programme. MSE gained greater clarity around the root causes of longstanding issues and the actions needed to enable sustainable, transformational change. NHS England received a methodology to achieve more with less in terms of diagnostic analysis and ensure future support packages are focused on addressing drivers instead of symptoms.
Our findings were welcomed by MSE, with NHS England improvement leads advocating for our methodology to be incorporated into the wider standard approach for diagnosing and tailoring financial and performance improvement support packages for challenged organisations.
This methodology is now informing how NHS England supports the growing number of challenged organisations to identify barriers and limitations to improvement, helping ensure limited national resources are directed where they can make the greatest difference to patient care.
“We have used this piece of work in reference to many forums, and I have been advocating that this is something that should be done for all Trusts that are in deficit to understand themes of deficit. This approach is valuable to NHSE and should be followed through in all challenged organisations before jumping in with actions.”
Understanding the Drivers
of NHS Underperformance
A systematic approach to diagnosing why NHS organisations face challenges across performance, finance, quality, and leadership—distinguishing symptoms from root causes to enable targeted support.
Structural Drivers
Issues beyond the trust or system's control, often requiring capital investment or policy change. Examples include estate limitations, PFI obligations, and geographic constraints.
Strategic Drivers
Challenges requiring system-level intervention through changes to priorities, pathways, or funding allocation. Solutions involve ICB coordination and regional planning.
Operational Drivers
Issues that can be addressed at an organisational level through improved efficiency, better processes, and enhanced management grip. The focus of targeted improvement support.
