Reinventing FTs and creating IHOs: autonomy, accountability and flexibility
Provider autonomy, freedom and flexibility in practice
High autonomy requires:
- Clarity about providers’ responsibilities;
- Consistency about the scope of their freedom to act;
- Transparent, fair use of regulatory powers.
History suggests that positive intentions to free NHS institutions from undue bureaucracy and unwarranted intervention from the centre tend to fail. Others[xiv] have written about this extensively but there are two factors that are particularly relevant here, which our members have raised with us.
Command and control
Firstly, the prevailing culture of command and control, whether enacted through central routine performance management, published guidance, or direct political intervention, must be addressed.
The idea that new FTs could be autonomous and accountable is laudable in theory. In practice, existing FTs have been de facto micro-managed with guidance (rather than by law) by NHSE, and the definition of "guidance" has increasingly meant "FTs must do this" as opposed to using statutory regulation.
The expectation of intervention hampers innovation and reduces risk appetite, and is therefore likely to stifle progress.
If there’s a permanent risk of a downgrade to a model with greater oversight by DHSC…new FTs may be reluctant to innovate and take risks (eg in their delivery models)...
...Freedom can only be used if boards think it is there to stay, otherwise boards may simply align themselves with all the expectations from the centre and nothing will have changed.
With NHSE’s abolition and powers shifting to DHSC and new powers of influence over the NHS potentially being given to strategic authority mayors[xv], there is also an increased risk of political interference. Clear boundaries are needed to protect provider autonomy.
We need to be clear about what trusts have freedom to do. We cannot decide as a mental health trust that we will not run in-patient services for people with the need for admission...
...But we might have freedom to change the way we provide the service. Do we have the right to amalgamate sites on which we provide care? That is something that may be welcome but has political implications.
How is the local accountability maintained with some control by local communities but no direct political interference by local politicians?
Limited freedoms
Secondly, within a constrained fiscal environment, proposed financial freedoms may be symbolic rather than practical and therefore unlikely to incentivise improvement:
- Capital investment remains subject to the capital departmental expenditure limit (CDEL), which requires central management and limits flexibility.
- The plan promises capital allocations for maintenance based on need, not provider discretion.
- Many providers are working hard to break even, and may not have large surpluses to reinvest.
The FT label carries historical associations with individualism and competition, but autonomy need not mean inward focus. Statutory duties to cooperate and consider system-wide impacts can be vital checks on excessive independence and should be embedded in relevant drivers of behaviours (eg funding flows, oversight framework). Policies[xvi] which may reinforce competition should be approached with caution. Well-run organisations will in any case seek integration wherever that makes sense for their populations and/or for the effectiveness of their organisations.
Too much talk of freedom can make organisations concentrate on themselves as sovereign bodies. Which of course at one level is true and at another level is nonsense – we cannot do what we want to do all the time!
We also need to think about what does freedom and accountability etc mean to peer organisations working in partnership… Freedoms are of course not absolute.