Executive summary

The government’s 10-year health plan, Fit for the Future, aims to reinvigorate the provider landscape to support delivering better care to patients. The plan’s focus on the benefits of high autonomy and strong accountability for providers is welcome. But, the changes proposed to reinvent the FT model and introduce ‘new FTs’ risk introducing significant tensions that will need to be addressed. 

Enabling autonomy

Provider autonomy is best understood – and deployed – as a way of ensuring the service overall is well run. While the plan aims to create a more devolved NHS to better serve communities, it also positions freedoms and flexibilities as incentives and rewards for good performance.

As they implement a new approach to autonomy, national policymakers must focus on the factors that enable and safeguard autonomy. These include robust corporate governance, a presumption against political interference, and a default of strong local accountability instead of central control. 

Autonomous, accountable organisations have the capacity and capability to self-govern within an appropriate legal, regulatory and policy framework, free of ad hoc intervention and direction. To enable this, DHSC and NHSE will need to ensure providers are clear about their responsibilities. They will need to nurture a consistent approach about the scope of providers’ freedom to act. And, they will need to be clear about the powers of the Secretary of State or regulators, and when they will be used. This will be the test of the “rules-based” approach, which the 10YHP promises to return to. 

Performance or capability?

There is a risk associated with how the 10YHP proposes to award providers greater autonomy, based on their performance. This could result in autonomy being awarded to organisations that are delivering at a point in time, but may have fundamental problems in how they are run. Instead of focusing on performance, any system of earned autonomy should emphasise the capability of trust boards, and examine the factors that determine capability. These include: strategic leadership, culture and behaviours, corporate and clinical governance, responsiveness to patients, resource efficiency, and the board’s insight into organisational performance. Greater freedom to act should be awarded to organisations that can demonstrate they are well-led in these ways. Deauthorisation of FTs should only be considered in extreme circumstances where there is no viable regulatory alternative.

This is particularly relevant to the proposals for integrated health organisations (IHOs). The plan states that these will be the “very best” FTs, selected to manage a whole health budget for a population: it does not explicitly set out how trusts will be judged capable of taking on this expanded role. We recommend it would be most appropriate to establish IHOs based on organisational capability, an assessment of the wider provider landscape in the relevant geography, and the likely benefits of adopting an IHO approach, rather than point-in-time performance.  

Consolidating power at the centre

The plan makes clear that autonomous, accountable organisations are more likely to deliver reform and improvement, while at the same time creating the conditions for the strongest central control and direction of the NHS for at least two decades. 

If NHSE’s powers to regulate, improve, commission, fund and direct trusts and FTs return to the Secretary of State, this would concentrate power at the centre, and create a set of conflicts of interest by bringing together lines of accountability for regulatory, commissioning and provider performance management functions. While political accountability is appropriate in a national taxpayer funded health service, policymakers should bear in mind the need for checks and balances within the system to avoid undue political interference and to ensure robust decision making. As the forthcoming health bill is drafted, we would urge policymakers to consider how the roles of the Secretary of State, commissioners, regulators, FT boards, and governors were balanced in the original FT model, and take steps to avoid undue consolidation of power at the centre. 

Councils of governors

The plan states it will remove the requirement for FTs to have governors, which will require the removal of councils of governors’ statutory powers via primary legislation. This has been suggested without a clear plan or communicated timescales, and as a result has presented a practical challenge for governors and FT boards, which must continue to govern together while councils‘ future remains unclear. 

It is also a challenge for FT governance: the plan overlooks council of governors’ integral role in an FT, including making board appointments, bringing local accountability, and as a check and balance on provider boards, with powers that enable them to represent the interests of the wider public through the membership model. In the absence of governors, there are a range of options for independently making board appointments, ensuring local accountability and that the public interest is represented in new FTs. It is important that these options are carefully considered, with the aim of achieving a robust new governance framework that supports FT autonomy, in line with the aims of the 10YHP.  

Next steps 

As they implement the 10YHP, and draft legislation to underpin a new operating model for the NHS, policymakers and legislators will need to consider how organisational autonomy, and the robust governance it requires, can be achieved and safeguarded. They face a challenge, as there are clear risks that the legal, regulatory, and performance management implications of the 10YHP may enhance central control, rather than devolve it. 

Where tensions and contradictions in the specifics of the plan cannot be resolved, our hope is that it can be considered a blueprint – that can be refined and adapted as necessary so it can be effective in practice – rather than a final design.