This report outlines the results of our third regulation survey, which was carried out in January 2017. This follows on from similar surveys undertaken in 2014 and 2015. As in previous years, we undertook this survey to explore our members’ experience of regulation over the preceding 12 months, as well as their views on the future of regulation and to identify trends over time.
Over the last year, the regulatory environment for NHS providers has experienced an intense period of change, with the creation of NHS Improvement, the introduction of a single oversight framework for NHS trusts and foundation trusts and the announcement of a financial ‘reset’ which saw a new financial special measures regime being established.
Regulators have also sought to achieve greater alignment in the discharge of their respective functions on a range of measures, including by co-developing their assessments of leadership and use of resources by trusts. Moving forward, the regulatory landscape looks set to continue to evolve at pace – upon completion of its comprehensive inspection regime, the Care Quality Commission (CQC) is now firmly moving into the implementation phase of its recent five-year strategy, which will see important changes to how NHS trusts and foundation trusts are regulated from April 2017 onwards.
More widely, the provider sector has continued to deal with considerable pressure in the face of increasing demand and a tightening financial environment. While addressing these immediate challenges, NHS trusts are also working with local partners to transform health and care services to meet the changing needs of patients and ensure they are sustainable.
There is a prevailing view that sustainability and transformation plans (STPs), now moving from planning to implementation, have the potential to transform delivery of care in the direction set by the Five year forward view. NHS England has now published its Next steps on the five year forward view, setting out priorities for the NHS over the next two years and how STPs are evolving. This sets out the intention to introduce an additional layer of STP oversight that will look to align with NHS Improvement’s single oversight framework and NHS England’s clinical commissioning group improvement and assessment framework.
This all creates an environment where a proportionate and risk-based regulatory system has never been more important – autonomous boards are best placed to respond to a challenging financial and operational context, while additional regulatory intervention and increased regulatory burden risks being counterproductive and overload providers at a time when they are managing rising demand, trying to restore performance against operational targets and achieve financial balance and transforming services.
The current context brings into sharp relief the delicate balance that regulators must strike between adopting a more supportive approach to improvement with increased intervention while facing pressure to support the sector in overcoming the challenges it faces.
The current context brings into sharp relief the delicate balance that regulators must strike between adopting a more supportive approach to improvement with increased intervention while facing pressure to support the sector in overcoming the challenges it faces.
The results of this year’s survey show a perception among trusts that the regulatory environment may be starting to move in the right direction and that the regulators’ efforts to ensure better alignment and consistent messages are starting to gain a welcome momentum. However, the findings also indicate that the provider sector has experienced additional regulatory requirements and reporting.
The weight of regulation and oversight still impacts heavily on individual trusts and the time and resources that regulation absorbs often stretch their capacity. Respondents to the survey described a situation in which autonomy is increasingly confined and a tightening of the regulatory grip, without necessarily there being a recognition that many of the challenges the sector is facing are driven by system wide factors.
Where we refer to the regulators we mean the Care Quality Commission (CQC) and NHS Improvement (formed from Monitor and the NHS Trust Development Authority (TDA)).
summary of key findings
Key findings emerging from this year’s survey are outlined below.
- This year’s survey reveals a perception that the regulatory environment may be starting to move in the right direction, with 44% of respondents considering the overall regulatory framework to be working ‘fairly’ or ‘very well’ – an increase on the 29% recorded in our last survey in 2015. A greater proportion (up from 36% to 44%) indicated that regulators are getting better at coordinating their approaches but more is needed to achieve a more streamlined regulatory framework despite progress made. Respondents stressed that demands placed on trusts when it comes to complying with regulatory requirements have not reduced and that the overall burden is in fact increasing.
- While regulators’ efforts to ensure better alignment and duplication are starting to gain a welcome momentum, the task ahead remains large. Worryingly, a third of respondents continue to report that the regulatory framework is working either ‘fairly’ or ‘very poorly’. In addition, the majority of respondents do not feel that the overall regulatory system delivers value for money – 56% of respondents felt it provides either ‘poor’ or ‘very poor' value.
- The survey highlights that the regulatory burden that NHS trusts and foundation trusts experience remains excessive. Overall, two thirds of respondents (68%) felt that the regulatory burden had increased over the last 12 months and the same proportion also felt that the number of ad hoc requests from regulators had also grown. This is the third of our surveys in which trusts have reported increases in the demands asked of them by regulators. Respondents felt the burden of the additional regulatory demands over the past 12 months was tied to operational and financial challenges.
- An effective regulatory system must be commensurate to the degree of risk posed, however survey findings show that this remains a major concern. More than half of respondents (55%) do not feel that the current reporting requirements are proportionate to risk, a position that has hardly shifted since 2015. Overall, this response is more widespread among foundation trusts (62%) than among NHS trusts (36%). There was also a view that action by the regulators is not assisting them in better managing the risks they face.
- NHS provider boards need to be confident that their autonomy will be upheld, with appropriate accountability in place. Findings on whether NHS Improvement strikes the right balance between autonomy and support and respects board accountabilities paint a generally positive but mixed picture, with foundation trusts less optimistic about this than NHS trusts. Overall however, when asked about the impact of the merger of Monitor and the NHS Trust Development Authority, there were recurring concerns among respondents from foundation trusts regarding the dilution of their autonomy. Respondents repeatedly voiced concerns about ‘a move to trust regulatory approach for foundation trusts’.
- Changes in the regulatory framework will take time to bed in before their full impact can be seen. Many respondents commented that it was too early to provide a definitive view on how the single oversight framework is operating. While respondents cited examples of good support, views were split with acute providers more positive about the support offer than non-acute providers.
- There are further changes on the horizon in terms of the regulatory framework. Looking ahead to the CQC’s proposed move to a more targeted and responsive approach to inspecting and regulating trusts from April 2017, there is considerable scope to take on board concerns about the resource intensive nature of the current inspection regime that is again reflected in this year’s survey responses.
About the survey
This report outlines the results of an online survey of NHS Providers’ members – NHS foundation trusts and trusts – carried out in January 2017. We collected both qualitative and quantitative information covering experiences of the regulatory regime over the last 12 months, as well as to capture their feedback on topical issues.
The survey questions were shared with the CQC and NHS Improvement prior to the circulation of the survey. Each organisation had the opportunity to provide feedback on the questions, with suggested changes taken into account and reflected where possible.
There were 76 responses to the survey (22 NHS trusts and 54 NHS foundation trusts), representing 32 per cent of NHS of the provider sector. 41 per cent of respondents were trust chairs and chief executives, 47 per cent were company secretaries and 12 per cent were other board level directors. Just over a third (38 per cent) of respondents have received an ‘outstanding’ or ‘good’ rating from the CQC, with two thirds rated as ‘requires improvement’ or ‘inadequate’. 71 per cent of respondents are in segment 1 or 2 of the NHS Improvement’s Single Oversight Framework (maximum autonomy or targeted support), with the remaining 29 per cent in segments 3 and 4 (mandated support or special measures).
Please note that not all questions were answered by all respondents.