Over the past year CQC and NHSE have continued with their programmes of transformation, while ICBs have taken on a more prominent and formalised oversight role within systems.
In an increasingly difficult operating environment, providers describe a regulatory system that is often too burdensome, duplicative, and detached from the pressures they are facing. They often question whether the regulatory system is helping them meet the challenges they face.
Respondents to our survey commented on the trade-offs between strict financial and headcount requirements, and the impact they can have on staffing numbers, the ability to meet performance standards, and the quality and safety of care.
"The current focus on finance and headcount is going to have a significant impact on quality and safe staffing which is at odds with CQC regulation and providers having to balance the risk."
"Increasing unrealistic levels of performance, outcome and staffing required [from national bodies and the government]. Increased oversight is [giving] false assurance as more attention and cost is driven into 'counting the bean' and presenting it nicely rather than being supported to deliver real change."
As pressure increases in the system, the leadership behaviours displayed by the regulators were not always in line with their own commitments in this respect, nor with their expectations of providers.
"Some people's behaviours are dreadful. No doubt a direct result of top down pressure."
"I think that there is a growing dissonance with the financial drive that is bringing back command [and] control and poor leadership behaviours."
Many member comments referred to an increasing disconnect between the reporting requirements of regulators and the operating environment of the health service – in particular, the extent to which there is recognition of the risks that organisations carry, including ones which are beyond their control.
"All health care is inherently risky but the regulators think that risk can be eliminated. We need to learn to manage risk better not seek to avoid it."
"Insufficient recognition of risks that organisations carry that are beyond their control. Too quick to quote other organisations that may be better placed on a specific metric without adequate understanding/analysis of the variables that are influencing respective positions. Too prone to taking simplistic high level view and apportioning fault based on that approach."
Trust leaders tend to report that regulators are not demonstrating an understanding of the pressures they are facing:
"There is now a significant disconnect between the regulatory theory (and capability) from another era compared with the operational reality on the ground – they are light years away from understanding the real world challenges trusts are facing. We would all love to meet every standard for every patient but that simply isn't possible... I have yet to see any meaningful process which recognises this key point..."
They remained more sceptical about CQC’s understanding, in comparison with NHSE's. The percentage of respondents who thought CQC’s understanding of the pressures was fairly good (38%) or very good (3%) was similar to last year (42%), but remained well below the results for 2019 and 2018 (52% and 62%, respectively).
"The CQC in particular do not appear to understand the environment in which trusts operate."
Around three quarters of respondents (74%) said that NHSE had a very good (13%) or fairly good (61%) understanding of the pressures that NHS providers are facing. This figure is above last year’s findings, when 70% described their understanding as good, and has returned to levels observed in 2019 (73%) and 2018 (74%).
