Through the latest NHS oversight framework for 2022/23 and its new operating framework, NHSE has made steps to clarify the expectations of trust and system oversight, and to provide further clarity on the respective roles and accountabilities of providers, ICBs and the NHSE national and regional teams. Importantly, in these documents the regulator has expressed a commitment to culture change and more collaborative ways of working.
Together with our members, we have fed back on the frameworks and on the importance of their fair and objective application. We now look forward to contributing to the oversight framework’s next review and consultation, and to monitoring the progress and impact of the operating framework.
The NHS oversight framework
In our survey we asked members about their views on the oversight framework for 2022/23 and on NHSE's support, as experienced by their trust (see figure 8 below).
Well over half of respondents (56%) agreed (55%) or strongly agreed (1%) that NHSE's supporting oversight metrics for 2022/23 were the right ones to be measured against. And almost three in five (59%) agreed (56%) or strongly agreed (3%) that the segmentation descriptions and associated support arrangements were clearly defined in the framework.
However there remains a strong tendency to view the framework as a performance management tool. Less than a third (31%) agreed that the NHS oversight framework was a support tool, while more than three quarters of respondents agreed (69%) or strongly agreed (8%) that it was a performance management tool. These views were even more pronounced than last year, demonstrating that a clear shift in culture, approach and local implementation would be required before NHSE regulation feels primarily supportive.
There was variation by sector:
- Ambulance trusts were the most likely to say that the oversight metrics were not adequate and to disagree with the statement that the oversight framework is a support tool. Ambulance trusts were also the least likely to think that NHSE’s support adds value to the performance of their trust, and that it had been appropriately tailored to their sector All respondents from ambulance trusts also agreed with the definition of the oversight framework as a performance management tool.
- Community trusts were the most likely to view the framework as a support tool (57% agreed), and to think that NHSE support had been appropriately tailored to their sector (43% agreed).
NHS England's operating framework
The operating framework, published in October 2022, aimed to provide clarity in relation to oversight, set out the vision of the new NHSE, embed the principles of collaboration, and lay the foundations of an improved culture. We wanted to test to what extent these aims have been achieved, and asked members about these different aspects for the first time this year (see figure 9 below).
Over a third of respondents (36%) agreed (35%) or strongly agreed (1%) that NHSE's oversight and regulation enabled trusts to collaborate in a system context. Over a quarter disagreed (27%).
On all other areas the majority disagreed that the positive intentions of the operating framework had been realised to date. Over one in three (41%) disagreed that the operating framework had provided clarity on the respective roles of ICBs and NHSE regional and national teams, while just under a third agreed (32%). More disagreed than agreed that the operating framework had ensured proportionate and streamlined oversight by ICBs and NHSE, and that it had contributed to a positive shift in culture and behaviours in NHSE. The largest majority of almost six in 10 respondents (59%) disagreed that the framework had enabled ICBs to develop the right culture and behaviours thus far, with just 7% agreeing.
There was variation by trust type and once again, ambulance trusts held the most negative views in relation to several statements on the framework. All from this sector (100%) disagreed that the framework had contributed to proportionate and streamlined oversight and performance management. All respondents from the ambulance sector also disagreed that it had enabled positive shift in culture in NHSE and that it had enabled ICBs to develop the right culture and behaviours.
When commenting on NHSE's regulation and oversight, trust leaders brought up a range of issues, such as the overlap of functions between NHSE and ICBs, or the sense that the regulator was removed from the reality in which trusts operate – for example, a perceived requirement for systems to agree unrealistic financial plans.
What seemed to remain a commonly held view, despite some positive relationships with regional teams and some encouraging direction of travel set from the top, was that the culture and behaviours displayed by NHSE were still not where they should be.
"The oversight framework talks about collaboration and support, but we still hear NHS England colleagues talk about "choices and consequences" and give a sense of "if you were any good at your jobs, the position would be different". There are still too many people in NHSE that believe that bullying people is the way to improve performance."