At the time of last year’s survey, NHS Improvement had recently been formed from the merger of Monitor and the NHS Trust Development Agency. We sought to understand trusts’ initial experiences of the first formal segmentation process, which determines the approach that NHS Improvement takes with trusts with regard to both oversight and support. Through the SOF - which applies equally to NHS trusts and foundation trusts - NHS Improvement sought to reposition its approach with a greater emphasis on support and on enabling sector-led improvement. This approach has continued, and become embedded, over the last year.
In 2017, NHS Improvement asked trusts to deliver more demanding savings through ambitious cost improvement programmes (CIP) in order to meet financial control totals. For the second year, NHS Improvement, in discussion with trusts, set control totals, with trusts’ access to sustainability and transformation funding contingent upon meeting their control total and performance targets.
In this year’s survey, we gathered trusts’ views on a range of aspects relating to NHS Improvement’s role, including the segmentation process under the SOF, the support offer and trusts’ experiences of the balance between organisational autonomy and regulatory oversight and intervention.
For the second year, NHS Improvement, in discussion with trusts, set control totals, with trusts’ access to sustainability and transformation funding contingent upon meeting their control total and performance targets.
Trusts’ perspectives on the Single Oversight Framework
Nearly two thirds (62%) of respondents to this years’ survey were allocated to segments 1 or 2, with the remaining placed in the lower segments. Last year, the majority (88%) of trusts told us that the segment to which their trust had been allocated matched their expectation prior to allocation.
This year, now that the SOF and segmentation process have had more opportunity to bed in, we sought trusts’ views on how the SOF is applied by NHS Improvement. The results suggest that providers consider the SOF as more of a performance management tool than a support tool. This view was more commonly held by acute providers compared to non-acute providers.
We also asked trusts’ about how well they felt they understood the decision-making for their segmentation under the SOF. The results indicate that the application of the SOF is working well and is understood by trusts. Three quarters of providers (76%) said they understood the decision making process well, and of these, 26% suggest they understand it 'very well'. Non-acute trusts report feeling more confident that they understand the decision-making well (87%) compared to acute trusts (70%).
Perspectives on the support offer
Since last year’s survey, NHS Improvement has become more established and trusts have become more familiar with its role and support offer. In light of this, this year we asked respondents to reflect on the value of the support they have received and the extent to which they felt the support had been appropriately tailored to their trust.
It is important that NHS Improvement’s support offer has a positive impact on financial position of trusts given NHS Improvement’s focus on helping the sector to achieve financial balance. Therefore, it is disappointing that our survey found that although some trusts value the support there is still considerable room for improvement. We asked trusts to rate the value that NHS Improvement’s support adds to the financial position of their organisation on a scale of 1 to 5, where 1 represented 'no value' and 5 represented 'high value'. Trusts gave an average score of 2.6 and the most common rating was 3.
"Would welcome help that is more about medium to longer term financial restructuring, rather than short-term incremental improvements."
"I am not sure that the current regulatory activity is focused on supporting organisations to deliver the highest quality care and for providing assurance to the public. I am concerned that NHS Improvement is very heavily focused on achieving the national control total as its primary aim."
It is important that NHS Improvement’s support offer has a positive impact on financial position of trusts given NHS Improvement’s focus on helping the sector to achieve financial balance.
We also asked trusts about the extent to which they agreed that the support their trust has received from NHS Improvement has been appropriately tailored to their sector (acute, community, ambulance, mental health). Over half (51%) agreed that it had been appropriately tailored. Among non-acute trusts, 20% disagreed that the support had been appropriately tailored, compared to 15% of acute trusts.
Over the last year, a number of initiatives and support tools, such as the model hospital and assessments of trusts’ use of resources have been rolled out within the acute sector only. It is crucial that trusts across all sectors have the opportunity to access and take advantage of improvement tools, otherwise well-intentioned initiatives may inadvertently lead to polarisation of the sector and a disparity in the improvements experienced by people using services.
"Not sure there is much focus on [support for] mental health or community. [NHS Improvement is] consumed by acute sector woes."
"There is a definite disparity in the parity of esteem of mental health organisations as opposed to acute."
"I think our new local and sub regional NHS Improvement and NHS England team are trying to operate a tailored oversight and support."
Balance between autonomy and support
Striking the right balance between provider autonomy and regulatory assurance is essential for trust boards to feel empowered to drive their own improvement. The results this year suggest that there is a danger that this balance is not being achieved. Over the last year, the proportion of trusts that believe NHS Improvement strikes a good balance between respecting trusts’ autonomy and support has declined. Less than half (47%) agreed there was a good balance, down from 58% who agreed with this in 2017. Views were more positive among non-acute trusts (57% of whom agreed it was balanced) compared to acute trusts (41% of whom agreed).
Feedback from respondents highlighted that among some trusts there is a perception that NHS Improvement’s priority is on ensuring the provider sector achieves financial balance. Control totals will have been in operation for three years by the end of 2018/19. There is a danger that what was conceived as a short-term solution becomes a long-term feature of the regulatory system that risks undermining trusts’ autonomy and does not align with the move to system collaboration.
"Believe we are given autonomy where appropriate for our low risk and high quality."
"All too often a ‘crisis’ results in a huge over- reaction and autonomy disappears very quickly."
"The NHS Improvement team strike a reasonable balance, but the deployment of regulatory intervention takes place within a framework that doesn't leave much room for genuine autonomy."
"[NHS Improvement] say they understand why we have been unable to sign our control total that required an in year CIP of 11% but have made no changes next year where the CIP remains the same."