Trusts are broadly supportive of the direction of travel for regulators to take into account wider system factors when overseeing and assessing performance. Our most recent regulation survey report, Reconsidering the approach to regulation, found that trust leaders are supportive of CQC's strategic ambition to assess the system-wide context and, similarly, support NHS England and NHS Improvement's intention to develop models of oversight to enable system working and hold ICSs to account for the collective performance of constituent organisations. This reflects the increasing reality that ICSs' decisions may influence outcomes and operational and financial performance, particularly as they take on more functions related to the commissioning and funding of services. Support from trusts for the direction of travel increased between 2019 and 2020, which is likely a reflection of their ongoing work to collaborate with partners across the system and integrate care as well as in anticipation of legislative change.
Regulation is an important driver of behaviours and can therefore incentivise and encourage trusts to work more collaboratively within their system(s) to deliver care. Trusts therefore feel that an enabling framework will help to drive further progress and deliver on the opportunities and benefits of system working. They are also supportive of regulation and oversight which reflects the value of partnership at ICS and place level. For example, there is a real opportunity to more effectively explore population health challenges and tackle inequalities in access and outcomes through acknowledging the system wide effort that is needed to address health inequalities meaningfully.
Refreshing regulatory frameworks also offers an opportunity for regulators, and the trusts they assess, to ensure they are gathering data from the wider range of sources, including perspectives of patients, the public and engaging with governors of NHS foundation trusts. The shift to a system lens can strengthen targeted engagement with experts by experience across a broader spectrum of services.
There have also been long-standing issues when provider-level regulation has fallen short of reflecting the external operational pressures influencing an individual organisation's performance. The changes to regulation and oversight to reflect the context of system working, and the intention to hold ICSs to account for their decisions therefore offer an opportunity to address these concerns and ensure trusts are not held to account for the consequences of decisions that have been taken elsewhere. This shift will, however, bring with it an increase in the complexity of regulating health and care services and monitoring performance. There are many unanswered questions about how the regulators can meaningfully determine the contributions being made to quality and performance at each level of scale, to ensure that providers and systems are only being held to account for decisions and outcomes they have control over.