Regulation provides objective and independent judgement
An increased role for ICSs in the oversight of trusts may mean that the partners within an ICS will be held to mutual account for the outcome of decisions they themselves have made. Conflicts of interest need to be avoided. The NHS England and NHS Improvement merger set out in the bill introduces further risks here that need to be managed through the development of safeguards which prevent and give trusts a means of challenging decisions made by their ICB.
Regulation should be risk based and proportionate
The degree of oversight and intervention should be proportionate to the performance of the trust or system, and wider challenges in the system. Where systems are playing an increased role in oversight it will be important that this does not duplicate work being done by either CQC or NHS England and NHS Improvement national or regional teams. There should be a clear set of metrics and transparent criteria for triggering regulatory intervention. It is important that, as part of this, trusts and systems are empowered to drive their own improvement and that regulation/oversight enables them to do so. Where system-wide issues are identified as part of an ICS-level assessment, the impact on individual trusts should be proportionate to the level of risk as well as the degree to which the trust has influence over the issues in question.
Regulation and oversight arrangements should place minimal burden on providers and add value
The commitment from CQC and NHS England and NHS Improvement to continue to align approaches is welcome as this has been a longstanding concern for trusts prior to the introduction of ICSs as an additional oversight tier. As systems take on an increasing role in oversight there will be concerns around duplication and additional burden with NHS England and NHS Improvement regional teams particularly as ICSs continue to develop their capability and expertise in oversight. National bodies should articulate the clear purpose and value-add of regulation of ICSs and ensure that this adds to, rather than cuts across, existing provider level regulation, offering new insight into quality and performance rather than simply aggregating or repeating judgements already made at provider-level.
The context within which providers and systems operate should be taken into account in regulatory judgements
The shift towards regulation within and of systems provides a clear opportunity to take the wider system context into account when assessing trusts, including understanding how wider partners influence care pathways and performance in individual services. Trusts have noted that in the past, regulation and oversight has not aligned closely with the context in which they work, and this continues to be important particularly within the context of COVID-19. ICSs are at different stages of development/maturity and are still building capabilities which may have an impact on their performance. All of this context needs to be considered sensitively, but new proposals offer an opportunity for regulatory frameworks to fully consider the broad context within which providers operate.
Accountabilities should be clearly defined
New regulatory frameworks which attempt to create judgements about how ICSs are performing leave room for conflicting or confused accountabilities, and a risk that organisations will be held accountable for decisions made elsewhere in the system. There should be no ambiguity about where accountability sits for a range of potential issues, with clear routes of intervention, and a means of capturing improvement at the level it takes place.