This report outlines the findings from our fifth regulation survey, which was carried out in May and June 2019. The annual regulation survey explores NHS trusts and foundation trusts’ experiences of regulation over the preceding 12 months and their views on the future of regulation, and trends over time.


The boundaries between organisations with regulatory and oversight roles such as NHS England and NHS Improvement are blurring. Locally too, traditional organisational responsibilities are changing, as providers, commissioners and their partners are asked to plan and deliver services collectively through local system partnerships. In this context, trusts are navigating a complex, evolving, and sometimes conflicting, regulatory framework.


NHS England and NHS Improvement have recognised that, as they expect local systems move towards greater integration, they must likewise commit to closer working. While the statutory framework means a formal merger between the two organisations is not currently possible, the two leadership teams have come together as the NHS Executive Group and a new integrated NHS England and NHS Improvement regional structure has been introduced. Seven NHS England and NHS Improvement regional teams, each led by a regional director (RD), are now responsible for the quality, financial and operational performance of all NHS organisations in their region, including both providers and commissioners. The regional teams are also playing a role in supporting the development of sustainability and transformation partnerships (STPs) and integrated care systems (ICSs).


CQC introduced its next phase inspection model in 2017, which was being implemented at the time of last year's survey. This year's survey offers an opportunity to understand how CQC's new approach to regulation and inspection is bedding in, in practice. CQC is also exploring how it can reflect the move to system working in its approach to regulation - last year, CQC completed its programme of local system reviews, which looked at how health and social care services are working together to support and care for people aged 65 and over. CQC also continues to develop its approach to working with STPs and ICSs.


As this report highlights, the changes taking place nationally and regionally represent a real opportunity for the regulators and national bodies to streamline their approaches and consider the culture, behaviours and processes that underpin the way in which they carry out their regulatory duties. There are indications that trusts are optimistic about potential impact of changes to the regulatory landscape. However, our findings show that turning national ambitions into tangible benefits at the frontline is challenging. As the regulators continue to adapt and implement new ways of working, it is more important that ever that they focus on ensuring regulation is proportionate, coordinated and offers value for money.


We are grateful to those trust leaders who responded to this survey and to the national bodies for working with us to develop the survey questions. We look forward to exploring the findings with the national bodies and regulators in the coming months.



About the survey


This survey was sent to all trust chairs, chief executives, company secretaries, finance directors, chief operating officers, strategy directors, medical directors and nursing directors in May 2019. In previous years we have surveyed chairs, chief executives and company secretaries only - this year we opened the survey to a wider group of trust leaders to reflect the changing nature of regulation and oversight in the NHS and seek a broader range of views.  


This is the fifth time we have run this survey. As in previous years, it covers NHS trusts and foundation trust's experiences of the regulatory regime over the past 12 months and looks forward to how the regulatory system is evolving and the impact this is having in practice. We have adapted some questions in this year's survey to reflect the changes in the regulatory landscape, but wherever possible, trends have been monitored over time to identify key changes in provider views on regulation.


We received responses from 116 NHS providers, representing over half (51%) of the sector. All regions and trust types were represented in the survey sample. Of the respondents:

  • 69% were in segments 1 or 2 of the NHS Improvement single oversight framework, with the remaining 31% in segments 3 and 4
  • six trusts were in quality special measures at the time of responding, three were in financial special measures, and two were in both quality and financial special measures.


Where we refer to the regulators and national bodies, we mean CQC, NHS Improvement and NHS England, as these are the main bodies our members interact with on a regular basis.


Due to a small sample size for some categories when splitting the data by trust type, they have been grouped for analysis into acute (acute, acute and community, specialist) and non-acute (ambulance, community, mental health).