NHS regulation ‘the tide has turned, but the sea is still stormy’

Cristina HRDespite recent improvements in how trusts experience regulation, there is much more to do to support trusts in navigating the complex regulatory landscape, writes Cristina Sarb, policy advisor on regulation for NHS Providers. 

The health and social care landscape has changed significantly over the last 18 months. As our ‘State of the Provider Sector’ report outlined – the financial position of the NHS has deteriorated and providers are under increased pressure to find savings and meet ‘control totals’. Support programmes in areas like A&E have been created as standards fall against key targets. Focus is now shifting to collaboration rather than competition to help overcome these challenges. 

The regulatory environment has also seen big changes. NHS Improvement was established and the new single oversight framework (SOF) was introduced. The CQC has pressed ahead with adapting its approach to regulating and inspecting trusts, following the completion of its round of comprehensive inspections. Most recently the Next Steps on the Five Year Forward View provides an indication of what lies ahead, with national bodies now exploring how they will oversee sustainability and transformation partnerships (STPs). 

With this in mind, we asked our member trusts to tell us about their experience of regulation over the last year. We received responses from 76 member trusts – a 32% response rate – across all sectors. 

Getting better, but… 

The findings show encouraging results in some areas – it is positive, for instance, to see that more trusts feel that the regulators are getting better at co-ordinating their approaches to overseeing trusts, an increase from 36% in 2015 to 44% in this year’s survey. 

'There is definitely a direction of travel of improvement'

But alongside this cautious optimism, there are also persistently worrying trends that the regulators need to address. Trusts welcome the role that robust, risk-based regulation and inspection plays in giving confidence to patients about the quality of care and providing the public with the assurances that NHS organisations are open and accountable for delivering high standards of care. 

While the fundamental role of regulation is accepted, crucially two-thirds of respondents – 68%– told us that the regulatory burden they experience had increased over the last 12 months. The same proportion also felt that the number of ad hoc requests from regulators had also grown. 

Survey respondents variously characterised this as being ‘vast’, ‘massive’, ‘overwhelming’ and requiring extra resources. Taken with the increases that trusts have reported in previous surveys, it all adds up to a significant increase in the regulatory burden. As one respondent put it, their trust experienced: 

“Lots of last minute ‘urgent’ requests that interfere with other duties. Lots of time taken away from trying to improve services. Multiple reporting of the same information to different bodies. No real, effective support from national bodies to address national issues.” 

Recent months have made it clear that the NHS cannot escape difficult choices about what it can deliver within the resources at its disposal. Against these pressures, the rise in regulatory burden is even more worrying.  

In practice, trusts are concerned that meeting the needs of the regulators can sometimes detract from the task of managing increased patient demand and meeting key targets for patient care and balancing budgets, as well as detract from their capacity to fully engage in transforming services. 

More concerning still, the majority of respondents (56%) do not feel that the overall regulatory system delivers value for money. Regulators need to demonstrate they are becoming more efficient and sustainable for the future given the level of fees they charge or resource they require. 

Alongside this, 55% of respondents do not feel that the amount of inspections or requests for information are proportionate to risk they face. This has hardly shifted since our last survey in 2015.  With performance heavily influenced by local or national systemic factors which are often beyond an individual trust’s direct control, regulation alone and particularly its focus on individual providers, can only go so far. 

In the words of one respondent, “the tide has turned, but the sea is still stormy”. While there are opportunities to build on improvements that have been made, there is also much more to do to support trusts in navigating the complex regulatory landscape and ensuring they can stay focused on delivering safe, high-quality and compassionate care. 

Looking ahead 

As the NHS Improvement’s Single Oversight Framework remains at an early stage and the CQC begins to roll out its new inspection approach, trusts need a period of stability to allow changes to bed in. 

At the same time, the national bodies are beginning to explore oversight at an STP footprint level as plans move towards implementation and some evolves to become accountable care systems. As this happens, we need to make sure that any local health economy oversight or regulation is aligned to the current framework for overseeing providers and their equivalents for other parts of the system.


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