Steps towards system oversight

NHS England and NHS Improvement’s new oversight framework is a good statement of intent, but changes very little in the short term. The framework continues the ongoing alignment between the two bodies that have been acting as a single organisation since April. It also makes a move towards addressing one of NHS practitioners’ biggest concerns over the move to integrated working – how can we work as systems if you continue to regulate us as separate organisations?

At this point, the NHS remains well short of a regulatory system that is focused on systems not organisations. This is understandable. Systems have no statutory basis and so NHS England and NHS Improvement’s respective regulatory focus has to be on clinical commissioning groups and providers. Their formal powers to intervene to improve local performance is firmly at the organisational level.

This position would only change with the creation of new system-level bodies, and the appetite for further structural change is minimal both inside the NHS and at the political level.

So, the changes have to be looked at in this context. On the one hand, the ‘new’ oversight framework looks like little more than a stitching together of the metrics used in the pre-existing sector-specific oversight frameworks – the single oversight framework for providers and the improvement and assessment framework for CCGs.

There are a few new oversight metrics. For example, metrics have been introduced on the overall size of the waiting list and patients waiting over 52 weeks for CCGs, and a set of staff survey metrics for providers. But there are no major departures in terms of what is being looked at and the focus is firmly on organisations.

On the other hand, it demonstrates that the powers-that-be do recognise the importance of moving regulation to a system level alongside the continued development of sustainability and transformation partnerships and integrated care systems.

And there are some small, but important changes of emphasis. NHS England and NHS Improvement say they intend to work ‘with and through’ system leaders wherever possible to tackle problems and to provide greater autonomy for systems with ‘evidenced capability for collective working’.

At the heart of the new framework will be quarterly system review meetings – bringing the regulators’ regional teams together with system leaders. These meetings and performance data will inform decisions about what support might be needed.

Organisational-level information flows remain in place, in part so that the centre can spot where good system performance might otherwise mask emerging problems at the local level.

So there is a hint of a greater system focus and there is a promise for this to increase in subsequent years. Recognising that the 2019/20 approach – which has been published without consultation and nearly half-way through the year – effectively combines current approaches, NHS England and NHS Improvement say they will use this year to develop proposals for a new framework starting from 2020 onwards.

Crucially, the document introducing the new framework says the design of the 2020 framework will involve partners at key stages. This will include a consideration of the purpose of the framework and the balance between organisational and system oversight.

It will be important that these changes are subject to full consultation and that finance practitioners – as those arguably most aware of the importance of governance and regulation and how it works – are at the heart of this process.