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‘Fluid’ single oversight framework strengthens earned trust autonomy

The new ‘segmentation’ approach in NHS Improvement’s (NHSI’s) single oversight framework is “designed to be fluid” and, from today’s revised version of the document, will include greater autonomy for segment 1 trusts – whilst segment 4 providers will be exclusively those in special measures.

During a briefing with an NHSI spokesperson about the revised framework, which was modified after a consultation process that ended in August, NHE was told that the segmentation approach is meant to be as proactive and reactive as possible.

The approach will cut up both trusts and foundation trusts into four segments according to the level of issues a provider has – or the type of support needed, in the revised framework’s friendlier language – informed by a series of data, informed judgement and external information.

Today, it has been clarified that segment 4 will only be for providers in special measures, and segment 1 providers will receive greater emphasis on “earned autonomy”, meaning they will only be assessed quarterly and will “see less of NHSI”.

The document added: “In parallel with the development of the framework, we will consider the incentives for providers to be in segment 1. While some conditions are fixed across the sector (e.g. control totals), others could vary from segment to segment in accordance with the principle of earned autonomy.”

The revised framework also confirmed that agency spending will be officially included within the overall metrics that go into the finance score, reflecting “the emphasis that is on agency spend as part of overall cost controls”.

The spokesperson told NHE that the regulator does not yet have a breakdown of how many trusts are in each segment. They have carried out a “shadow segmentation” so far, but will only do a formal segmentation once the framework has gone live on 1 October. The ambition is currently to publish the shadow segmentation in early October.

Asked how providers would be able to move up the ranks in the segmentation system, the spokesperson said it is designed to be a fluid as possible.

“If tomorrow we found out that a trust was deemed inadequate by the CQC, then if that trust was in segment 1, we would almost immediately want to reflect that in the segment,” he explained. “We don’t have to have an annual re-segmentation because things happen in the health service and we want to be quick in that. Trusts will change segment as and when the information dictates it.

“The information will come through on a monthly basis with things like finance, maybe quarterly on things like mental health metrics, monthly on things like A&E performance – but it could be ad hoc if a trust suddenly has a big increase in costs, or if the CQC responds.

“We’ve designed the process as fluid as possible. We don’t want to be stuck to any fixed, rigid segmentation window. We want to have it as live as possible so patients can see what we are doing at a trust at the moment, and where the issues lie.”

As well as using information from the trusts themselves, such as for finance, NHSI will rely on third parties – especially the CQC, but also on whistleblowers, patient groups, coroners, etc. – for data monitoring. It will also take information from nationally published statistics, such as staff surveys, NHS England performance standards and never events figures.

“What we are going to try to do as much as possible is streamline that reporting with other bodies – so taking information from the CQC, from NHS England, and only having to go to trusts for information which is very specific and only available there, like financials,” the spokesperson added.

Judging against clear criteria?

When the draft framework came out in June, NHS Providers largely welcomed it, but reiterated the importance of having clear criteria against which to objectively judge a trust’s position.

Today, NHSI confirmed that there are a series of specific triggers and metrics that will inform each of the five themes – quality of care; finance and use of resources; operational performance; strategic change; and leadership and improvement capability – against which providers are judged.

But the organisation was not able to put a clear trigger in place for every criterion. “Some areas don’t lend themselves to that sort of approach. Like never events, for instance – there’s no threshold for what is acceptable in terms of never events,” he said.

In that case, he added, NHSI might keep an eye on a trust for a few months and, if there is a spike in never events, they will “phone up and talk to the trust” to discuss what is being done about the issue.

“That could be a change in reporting culture, it could be a new internal process – it might not necessarily be a quality issue,” the spokesperson argued, adding that they will also work with the CQC for information on intelligent monitoring of less quantifiable concerns, such as insight collected during inspections.

Moving away from regulation

Asked how these measurements and overall data collection differed from standard regulation and performance management – which NHSI wishes to move away from – the spokesperson said the new framework signals “a change of emphasis and a change in approach”.

The roles of the five themes, he said, is to proactively clarify what a good hospital should be doing, and from there use in-house capabilities to provide targeted support around areas of concern. This will be different from before where, under Monitor, for example, foundation trusts were only assessed when they were already in breach of a licence.

“We’re not a regulator per se, we’re an organisation with regulating functions, but our emphasis now is on oversight and support,” NHSI added. “And while we retain some of the things we have to do under statute, we want to use the language and the tone of the framework as a means to get that across.”