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What does the single oversight framework mean for trusts?

Miriam Deakin, head of policy at NHS Providers, considers what the newly proposed single oversight framework means for trusts and how they can make it work.N

NHS Improvement (NHSI) closed its short consultation on a new single oversight framework (SOF)  for all NHS providers in early August.  In a context of unprecedented challenges, with a provider deficit of £2.45bn and a need to maintain quality, sustain workforce morale and a move to more integrated models of care which serve patients better, the new framework could play a vital role in helping providers balance an array of competing policy demands. We set out what the new framework means for trusts, and what NHSI will need to keep in mind to ensure its success. 

What is the SOF? 

The SOF replaces Monitor’s Risk Assessment Framework and the Trust Development Authority’s accountability framework, although the powers exercised through NHSI importantly relate directly back to those predecessor organisations. It seeks to create one coherent framework for NHS FTs and trusts which takes account of the challenges facing NHS providers – and importantly just applies to NHS providers rather than to the independent or voluntary sectors. NHSI and the CQC have clearly worked together on a number of the measures, although there is much more to do to integrate their two frameworks more helpfully for trusts. 

The framework will be used to divide the sector into four based on each trust’s performance against indicators of quality, finance and operational performance, as well as two further themes which will evaluate a trust’s contribution and capacity for collaborative working (enabling strategic change) and for leadership and improvement.  

The other important shift is a commitment within the framework to a much earlier offer of improvement support, and the chance to encourage a sector-led improvement movement. The segmentation will determine the approach that NHSI takes with trusts with regard to both oversight and support. 

Making it work 

Given the scale of challenge facing NHS providers and their colleagues in commissioning, primary care and social care, a new regulatory framework for trusts risks creating more confusion and an even heavier hand from the national bodies.  Our members, NHS trusts and FTs, identified a series of themes which NHSI should consider to ensure the new framework adds value: 

• Clarify the aims and understand the limitations of any regulatory approach: In the context of recent announcements, such as the introduction of financial special measures, there is a danger the SOF could be used to focus on financial management at the cost of other priorities. A public debate on funding, rather than a new regulatory tool, is required if we are to resolve the deep-seated financial issues facing the NHS
• Ensure coherency and objectivity in the approach to regulation and support with objective, evidence-based judgements, and closer alignment with the CQC: In addition, in the context of emerging sustainability and transformation plans, new care models and devo deals, it is essential for NHSI to take an iterative approach to developing the SOF and to work with trust boards, and other arm’s length bodies to support the development of local health economy governance structures
• Clarify the direction of travel for regulation and support, keeping firmly on the table the principles of risk-based, proportionate regulation, a return to earned autonomy and integration of the regulatory frameworks under one definition of ‘success’: As a sector, we should consider the merits of moving to a single regulator, and a separate improvement body over the longer term, but in the meantime NHSI needs to respect the different statutory bases of FTs and trusts, and avoid conflating the different functions of regulation, performance management and support
• Maintain the commitment to ‘earned autonomy’: The pillars that underpin the FT model – board autonomy and local accountability – are essential if strong local leadership is to thrive. Provider boards need to remain empowered to take difficult decisions in a tough financial climate, with due accountability not just to the regulator and Parliament (for FTs) but to their local communities
• Better reflect the requirements of mental health, community and ambulance sectors in the framework: This as an opportunity to work with providers to identify common measures with an emphasis on outcomes 

In summary 

Overall, NHSI has developed a pragmatic and swift response to the conundrum of overseeing and supporting two sets of NHS providers with different legislative bases, at a time of unprecedented challenge.  

However, the latitude the new approach appears to allow for intervention (as well as for support) risks moving decision-making much closer to the centre and away from provider boards and their communities. This is its greatest risk. While there will always be quarters of the sector which can release efficiencies or where performance needs addressing, in a context where numerous independent commentators have described the issues facing the NHS as ‘systemic’ rather than driven by poor leadership or management, NHSI needs to balance short-term operational requirements with a longer-term view.  

In the years ahead, the NHS will need to rely more on strong leaders and boards able to work collaboratively with partners, deliver more integrated care for their communities and sustain core quality standards. We should approach the dilution of board accountabilities with caution.

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