News / NHS calls for more details on system oversight plan

A consultation, which closed last month, said the new oversight framework will assess integrated care systems (ICSs), trusts and clinical commissioning groups against five themes, including: finance and use of resources; quality of care, access and outcomes; preventing ill health and reducing inequalities; people; and leadership and capability.

A sixth theme for 2021/22 will focus on local strategic priorities, recognising the unique circumstances faced by each ICS, and the ‘renewed ambition’ to support greater collaboration, accelerate progress in overcoming the most critical challenges, and support broader social and economic development.

ICSs, trusts and CCGs will be allocated to one of four segments. Bodies in segment 1 will earn the right to have the lightest level of oversight, including the ability to request devolution of programme funding, removing the requirement to account for resource deployment in exchange for agreed outcomes. They will have greater control over the deployment of improvement resources made available through regional improvement hubs.

Trusts and CCGs in segment 1 will also:

• Be able to request access to funding to provide peer support to other organisations

• Be exempt from the consultancy controls or relevant running cost limits

• Benefit from streamlined business case approval.

Segmentation will be phased in during 2021/22 and reflect the approach to operational and financial planning set out in the planning guidance. Segmentation decisions will be based on the assessed support needed and, by default, organisations will be allocated to segment 2.

NHS organisations in need of significant support will be placed in segments 3 or 4 and be subject to enhanced oversight by the national regulators, and could face additional reporting requirements and financial controls.

Bodies will be considered for mandated support and moved to segment 3 if, for example, they are reporting a negative variance against an agreed financial plan or are forecasting they will not meet their plan at year-end. Those in segment 4 will have long-standing, complex needs and previously been in special measures.

The current system of special measures, including financial special measures, will be replaced by an integrated recovery support programme (RSP), which will apply to systems, trusts and clinical commissioning groups in segment 4.

An integrated approach was needed to fit the new landscape, the consultation said. The RSP will differ from the special measures programmes in several ways.
The RSP will focus on systems while also providing support to individual organisations. It will be led by an experienced system improvement director (SID), who will co-ordinate an expert multidisciplinary support team.

Assistance could include: financial recovery support (for example, specialist help to reduce agency use or implement cost controls); a governance or drivers of deficit review; or intensive support for emergency/elective care.

Legally, NHS England must assess CCG performance annually. Currently, this is via the NHS oversight framework, which examines leadership, financial management, and performance in priority areas. For 2020/21, the assessment will be simplified as a result of Covid-19. A narrative assessment, based on performance, leadership and finance, will replace the ratings system previously used for CCGs.

The consultation proposed the 2020/21 approach be adapted for 2021/22 to ensure greater flexibility, basing the annual performance assessment against the oversight metrics; specific key lines of enquiry, including breaking even and contributing to the reduction of system-level deficits; and an evaluation of how well the CCG works with others to improve quality and outcomes for patients. This will inform an end-of-year meeting with their regional team.

While welcoming a more system-focused support programme, the HFMA consultation response warned that it could lead to a greater need for resources in bodies that have not in the past needed support, but are located in a system that does need intervention. HFMA policy and communications director Emma Knowles said clarification was needed on a number of points.

‘For example, we need more details on what support will be provided from the SID and NHS England and NHS Improvement team. Will this be asking for information, providing challenge, providing more money, or providing advice on how to use data to make improvements? As a joint appointment: who will pay for the SID; who will employ the SID; how does the SID fit with the organisational board and the ICS board?’

In its response, NHS Providers warned that using quartiles as part of the allocation into segments could be arbitrary and ‘potentially unhelpful as it is relative to other trusts. This may lead to scenarios where, for example, a trust sitting just outside of the upper quartile is penalised for an effectively arbitrary banding. It would be useful to understand further how these criteria will be weighted against the additional judgements made to identify the correct segmentation for a trust.’

The provider body welcomed the commitment to use discretion and flexibility where possible in identifying the correct segment, particularly as finance metrics could affect many trusts – only half of trusts met their control total in 2019/20, for example, and could be pulled into segment 3 without a nuanced assessment of their performance and support needs.