This report sets out the findings of NHS Providers' eighth annual regulation survey, which explores NHS trusts' and foundation trusts' experiences of regulation. We asked respondents to reflect on their experience of regulation during 2022/23, with a specific focus on the roles of CQC and NHSE.
This year's survey was carried out between April and May 2023, against a backdrop of severe challenges relating to performance, finances, ongoing industrial action, and staff burnout.
This year also marks the first anniversary of the establishment of integrated care systems (ICSs) in law. The Hewitt Review recently reflected on how the oversight and governance of ICSs could enable them to succeed, balancing greater autonomy and robust accountability. Meanwhile, the CQC and NHSE have been adapting their own regulatory approaches within a new system environment, by making changes to their assessment, oversight and operating frameworks.
The provider context
Following a period marked by Covid-19 and its legacy, 2022/23 was one of the most challenging on record for the NHS. The health service, and care quality, have come under pressure due to increasing demand and care backlogs in all sectors, staff shortages and staff burnout, difficulties with the flow of patients through the system, and industrial action.
This combination of operational and workforce challenges has come at a time when providers, and their partners, have been adapting to statutory system working, and to new regulatory requirements. Trusts' optimism about the improvements system working can offer therefore sit alongside their concerns over additional bureaucracy and undesirable complexity. While there remains considerable support in the provider sector for more flexible, supportive and risk-based regulation, this is mixed with frustration about a regulatory culture which continues to feel 'top-down' variable inspection quality, and a lack of appreciation for the context within which trusts and staff operate.
We are grateful to all the trust leaders who responded to our survey, whose views are reflected in this report. We are also grateful to CQC and NHSE for their feedback on our proposed survey questions, and for their commitment to engaging with us and our members constructively in refining their regulatory approaches.
The regulatory context
Care Quality Commission
Since the publication of its new strategy for the changing world of health and social care in 2021, CQC has been developing its new approach to regulation. The regulator has been working with providers, stakeholders and members of the public to co-create, test and pilot aspects of that new approach, including its new provider portal, which is expected to become operational this summer.
CQC has also been refining its new single assessment framework, which will apply across providers, systems and local authorities, and is currently scheduled to become operational later this year. CQC’s four ratings and five key questions will remain central to the new framework, but they will be underpinned by a set of new quality statements, and six new evidence categories.
CQC’s new powers to review and assess ICSs and local authorities, under the Health and Care Act 2022, became effective in April 2023. In preparation for these, the regulator has published updates and new interim guidance on its approach to local authority and integrated care system assessments. CQC will begin by reviewing data and published documentary evidence across all local authorities and ICSs, to form a national view of performance. It has also committed to a small number of pilot assessments to test the new single assessment framework with local authorities and ICSs.
The delivery of CQC’s ambitious programme of transformation, and the move to a “smarter”, more dynamic and flexible style of regulation, has also involved changes to its executive team and operational teams. Instead of being split by sector, CQC’s operational teams will now work across four geographic areas or ‘networks’, with local teams featuring a mix of expertise and experience of different types of health and social care services.
We have been keen to understand trusts’ views of these significant changes in approach, and to grasp their experience of CQC regulation within a period of extreme operational challenge.
NHS England
In June 2022 NHSE published its NHS oversight framework for 2022/23, reflecting updated priorities for the NHS, the establishment of ICBs, and the formal merging of NHS Improvement into NHS England. It also accounted for NHSE’s duty to undertake an annual performance assessment of ICBs under the Health and Care Act 2022.
In October 2022 NHSE published its new operating framework, which signalled an intended shift in culture, mindset and approach spanning the whole NHS. It aimed to provide clarity on the respective roles and accountabilities of providers, ICBs and the NHSE national and regional teams, and committed to the principles of collaboration and subsidiarity.
We have been keen to explore how NHSE has been living up to these commitments and to hear our members’ views on the implementation of its oversight and operating frameworks over the past year.
Integrated care systems and integrated care boards
ICSs were put on a statutory footing on 1 July 2022, following the passage of the Health and Care Act 2022 the previous April. Working through their two statutory parts, ICBs and integrated care partnerships (ICPs), ICSs have four key aims:
- Improving outcomes in population health and health care.
- Tackling inequalities in outcomes, experience and access.
- Enhancing productivity and value for money.
- Helping the NHS to support broader social and economic development.
ICBs were established as statutory bodies, with the function of arranging health services for their populations. We have therefore included some questions on ICBs in this year’s survey, given their responsibilities for the oversight and performance management of NHS services alongside NHSE, which retains statutory accountability for the oversight of both ICBs and NHS providers. The driving principle, as described in the NHS oversight framework, is for NHSE to discharge its duties in collaboration with ICBs, asking them to oversee and seek to resolve local issues before escalation.
In this year’s survey we asked trust leaders about their perceptions and experiences of working with ICBs, and about how ICBs have been discharging their functions in their first year of operation.