The national regulators are exploring how they can assess the performance of ICSs in the future, take into consideration the system context when assessing individual organisations, and support ICSs as they increasingly take on a role in regulating and overseeing trusts.
Both bodies have now set out how they will balance individual organisational responsibility for quality and performance, with the influence and role of ICSs in care across a patch. There are a number of interrelated elements to this concept:
- how the national regulators will take into account wider system influences, including operational pressures elsewhere, when assessing individual trusts' performance
- how a measure of what good performance looks like will take into account new responsibilities placed on trusts to collaborate with system partners
- how ICSs will play an increasing role in the oversight of their component organisations
- how the national regulators will assess and intervene in the performance of ICSs themselves, on measures such as finances, operational targets, and quality of frontline care and outcomes.
NHS England and NHS Improvement
In anticipation of the legislative changes proposed in the Health and Care Bill, NHS England and NHS Improvement has implemented its SOF for 2021/22, including a new support programme to replace the old special measures regime, and a segmentation framework for ICSs, trusts and clinical commissioning groups (CCGs). Its intention is to work through ICSs wherever possible and to support ICSs and regional teams to work together to develop locally appropriate approaches, while taking the level of ICS maturity into account. Alongside the SOF, it has also published its supporting oversight metrics, detailing what trusts, clinical commissioning groups and ICSs are being assessed against in 2021/22. These align with the deliverables outlined in the 2021/22 planning guidance and ambitions set out in the NHS Long Term Plan (LTP). They assess:
- Quality, access and outcomes – metrics for trusts include operational measures such as overall waiting list size, 52 week waits, ambulance response times and quality indicators such as CQC ratings and mortality. At the ICS level additional metrics include cancer outcomes, neonatal outcomes and antimicrobial resistance.
- Preventing ill health and reducing health inequalities – indicators in this domain are primarily measured at ICS and CCG level including vaccination coverage and screening programme uptake. Trusts are assessed on some measures related to reducing health inequalities, including ethnicity and deprivation characteristics across service restoration and NHS LTP metrics.
- Leadership and capability – trusts, ICSs and CCGs are being assessed on quality of leadership, and on an aggregate score for NHS staff survey questions that measure perception of leadership culture.
- People – trusts, ICSs and CCGs are being assessed against the people promise index, health and wellbeing index, staff experience measures including bullying and harassment, satisfaction with flexible working patterns, staff retention and diversity of leadership.
- Finance and use of resources – assessment of performance against financial plan, underlying financial position, run rate expenditure, and overall trend in reported financial position will be made at CCG, trust and ICS level.
NHS England and NHS Improvement also intend for oversight arrangements to reflect an expectation for evidence of effective provider collaboration, and the failure of individual trusts to collaborate in a system context, may be treated as a breach of governance conditions. This signals a clear shift in how the national bodies see the relationship between the statutory duties trust boards have towards their organisation and their responsibilities towards system working.
CQC
CQC is also developing plans, as set out in its new strategy, to take the system context into account when it assesses the quality of individual providers alongside its intention to directly assess how systems are performing as a whole. When assessing individual health and care services, it intends to look at how they work together in an area, as one system, to deliver better and more coordinated care. CQC has also committed to identifying ways of supporting systems to drive improvement in their local areas, and to assess how well they ensure equal and fair access to care, good experience and good outcomes. A possible amendment in the Bill may provide it with the powers to assess systems, which may include ratings for ICSs, but is unlikely to include powers of intervention.
CQC has also made strategic changes to its regulatory approach, with the aim to be more responsive and flexible to manage change, risk and uncertainty, and ensure assessments reflect the most up-to date picture of quality. This reflects the current context of a rapidly changing health and care environment, builds on learning from regulation during COVID-19, and enables CQC to ensure its approach remains fit for purpose in the future.