The creation of NHS Improvement last year came at a critical time for the provider sector. Through the development and implementation of a new single oversight framework that applies equally to NHS trusts and foundation trusts, the newly-established organisation sought to recalibrate its approach with a greater emphasis on support and also enabling sector-led improvement. In this year’s survey, we sought to gather our members’ views on a range of aspects relating to the operation of the new oversight framework including the segmentation process, the support offer and trusts’ experience of the balance between organisational autonomy and regulatory oversight and intervention. An important caveat is that the findings provide a snapshot in time, with the framework still being at a relatively early stage of implementation. That said, these early findings provide a valuable insight into how the framework is starting to bed in.
Trusts’ perspectives on the segmentation process
The segmentation process determines the approach that NHS Improvement takes with trusts with regard to both oversight and support. The first formal segmentation took place in December 2016 with the majority of providers (60%) placed in segments 1 and 2. This is mirrored in our survey, with nearly three quarters of respondents to our survey (71%) allocated to segments 1 and 2, with the remaining placed in the lower segments. The survey asked respondents whether the segment to which their trust had been allocated under the oversight framework matched their expectation prior to the allocation. A majority (88%) agreed that this was the case. However, the need for greater clarity and transparency in relation to the process for making decisions about the overall segment was noted as an issue, along with an uncertainty around the steps trusts need to take to move between segments:
“Anticipated the segment but thought it would be for different reasons.” (Segment 2)
“We expected to be placed in segment 2 due to the financial metrics – however have found that the NHSI SoF is very unclear in explaining how different performance in different themes will translate into an overall rating.” (Segment 2)
“It is not very clear how NHSI have made this calculation. This needs to be made more transparent.” (Segment 2)
“Still not got the necessary definitions to know what we are being measured against and no one can explain the overall criteria / weighting which determines your actual segment.” (Segment 2)
“Lack of clarity about how you move between segments and what is expected for some of the metrics.” (Segment 3)
Early implementation experiences
The new oversight framework only became operational in October 2016 and will require time to bed down before its impact can be seen in full. In this year’s survey, we took the opportunity to ask respondents to describe their early experiences of implementation of the framework. As would be expected, the general perception was that it would be too early to definitively judge the impact it has had, though respondents were supportive of the direction of travel.
Some respondents expected the reporting burden associated with the oversight framework to increase in the year ahead, in part linked to the themes which are still under development. Views also differed across types of trusts, with trusts in the mental health and community sectors expressing a view that the framework remains insufficiently tailored to those sectors.
“Too early to say. The general direction is good and regulators working together is welcome but the devil is in the details.” (Segment 2)
“Too early to say although initial involvement has been positive.” (Segment 2)
“For the known elements it has been relatively straightforward to link to our existing performance reporting but for those in developed linked to STPs and new care models we wait to see how these may be judged.” (Segment 2)
“We feel the application of the framework is unclear for mental health trusts as these metrics are underdeveloped in comparison with acute trusts.” (Segment 2)
“Limited value for community services as there is a lack of Key Performance Indicators (KPIs) developed.” (Segment 2)
Perspectives on the support offer
Given the ambition through the new framework to move to a more supportive approach, we asked respondents for their views on the support their trust has received so far. Overall, respondents were positive with 54 per cent indicating that the support had been ‘very’ or ‘somewhat useful’ (figure 10a). Positive examples of where good support had been provided included support received through the emergency care improvement programme and from the intensive support teams and the implementation of ‘red to green’ initiatives.
“We have had some support in relation to finances and in some areas it reinforced what we were already doing (which is helpful) but in 1 or 2 areas it was good to get new tools and methodologies to introduce” (Segment 4)
However, as was the case for the overall views on the oversight framework, nearly a third of respondents (30 per cent) indicated that it was too early to express a view on the nature or value of support. In addition, the survey results reveal significant disparities between acute and non-acute providers – the considerably higher proportion of non-acute providers – 30 per cent – reporting that support was ‘not very’ or ‘not at all useful’, compared to only 4 per cent among acute providers (figure 10b), suggests a need for further work to be done to ensure that support offer is sector-appropriate. Views on the support offer varied considerably across England’s regions. Addressing the consistency and suitability of the support offer across sectors and across regions will be an important for the success of the oversight framework going forward. Comments highlighted that the support offer remains under development. Respondents felt more positive towards support received at a local level, but more hesitant about central initiatives.
“Limited support received but generally useful. Expect regional director appointments to add more value.” (Segment 3)
“Support comprises listening only at present.” (Segment 2)
“Local NHSI has been very supportive but appears at times to be at odds with more central and regional NHSI.” (Segment 3)
Figure 10a
Figure 10b
Balance between autonomy and support
A balance between provider autonomy and regulatory assurance is essential to ensure that provider boards remain empowered to drive their own improvement. Our previous survey highlighted the potential conflation of the roles of an improvement body and that of regulator as one of the concerns arising from the creation of NHS Improvement.
In this year’s survey, we took the opportunity to ask respondents about the extent to which they feel NHS Improvement strikes a good balance between autonomy and support in its approach, as well as the extent to which it respects provider boards’ local accountabilities. Overall the majority of respondents – 58% and 64% respectively – either agreed or tended to agree (figures 11a and 12a). However on both counts, views were less positive among respondents from foundation trusts (figures 11b and 11b) and this was also tempered by a sense of an erosion in the degree of autonomy than previously experienced, as illustrated by this respondent:
“While I still agree with this, it is less so than under the Monitor regime.” (Segment 2)
The introduction of control totals was identified by respondents as a specific example of where a policy is inconsistent with local accountabilities and the autonomy of the board. The shift towards a more directive approach at the expense of a risk-based approach to regulation dominated feedback from respondents when asked about the impact of Monitor and the TDA coming together to operate as NHS Improvement. While respondents reiterated agreement with the logic of merging the two bodies and recognised the benefits of having a more consistent approach across all trusts, a recurring concern related to the autonomy of foundation trusts being diluted and a culture of performance management becoming more prevailing. Importantly, respondents highlighted a change in style “to be more supportive, but more hands on”.
"It has changed the way the trust is overseen with more of a tendency to stray into managing than oversight and regulatory judgment.” (Segment 2)
“Some of the more interventionist approaches of the TDA seem to have leaked in to the approach to FTs. This may be because it's old wine in new bottles!” (Segment 2)
“Failed to realised foundation trusts are different and put us all in the same boat of more regulation – not helpful.” (Segment 2)
“Made it worse as the TDA culture of performance management as opposed to risk based regulation seems to be the emerging culture.” (Segment 2)
In terms of the creation of NHS Improvement, other respondents referred to “still some bedding in of cultures and approaches” with disparities in the ways of working between Monitor and TDA not yet reconciled. Some raised concerns about focusing on financial management at the expense of other priorities under the oversight framework:
”Messages from the NHSI senior team tend to be exclusively financial at the moment.” (Segment 2)
Furthermore, trust respondents in particular voiced specific concerns about the unclear future of the foundation trust pipeline: