1. Context
In recent years, the NHS has achieved improvements in care and delivered efficiencies during a time of increasing financial pressure caused by slowing growth in the NHS budget and rising demand. The need to respond effectively to this continuing increase in demand during a period of limited funding growth was the key impetus for the NHS Five Year Forward View (5YFV).
Part of the national response to the ambitious and stretching tasks highlighted in the 5YFV was to create NHS Improvement, reflecting that NHS trusts and foundation trusts face similar challenges. On 1 April 2016, NHS Improvement became the operational name that brings together Monitor, the NHS Trust Development Authority (TDA), Patient Safety, the Advancing Change Team and Intensive Support Teams. The specific legal duties and powers of Monitor and TDA persist.1 We will build on the best of what these organisations did but with a change of emphasis to one primarily focused on helping NHS trusts and foundation trusts to improve. We will provide strategic leadership, oversight and practical support for the trust sector.
We will support NHS trusts and foundation trusts2 to give patients consistently safe, effective, compassionate care within local health systems that are financially and clinically sustainable. We will work alongside providers, building deep and lasting relationships, harnessing and spreading good practice, connecting people, and enabling sector-led improvement and innovation. We will stimulate an improvement movement in the provider sector, helping providers build improvement capability, so they are equipped and empowered to help themselves and, crucially, each other. Our aim is to help providers attain, and maintain, Care Quality Commission (CQC) ratings of ‘Good’ or ‘Outstanding’.
The challenges facing the system require a joined-up approach and increased partnership between national bodies. We are committed to working more closely with the CQC, NHS England and other partners, at national, regional and local levels.
2. This consultation
This document sets out the approach NHS Improvement proposes to take in overseeing providers using a Single Oversight Framework for both NHS trusts and foundation trusts and shaping the support we provide. It describes our proposed approach to:
- the main areas of focus of our oversight
- how we will collect the information we require from providers
- how we will identify potential concerns with a provider’s performance
- how we will segment the provider sector according to the level of challenge each provider faces.
The purpose of this framework is to identify where providers may benefit from, or require, improvement support across a range of areas (see below). This will inform the way we work with each provider. This framework does not detail the improvement support we will provide as in each case this will be individually tailored to address what a provider needs help with. We ask a number of specific questions on our proposed approach through the document, and these are collected together in Section 8 and at the survey website (see below for link).
We are still considering our approach to oversight in a number of areas, including how well a provider is managing strategic change, and we are using this exercise to invite views on how we should proceed.
The Single Oversight Framework will replace Monitor’s risk assessment framework and TDA’s Accountability Framework. It is a ‘Single’ Oversight Framework because it applies to both NHS trusts and foundation trusts. As far as possible, we will combine and build on the previous approaches of Monitor and TDA, but adapt them to reflect and enable our primary improvement role. Any changes from these frameworks are intended to be as much as possible incremental in nature. The changes we are making are intended to reflect the challenges providers face and initiatives to support them. All other related policies and statements, unless indicated, remain unchanged.
The Single Oversight Framework set out in this document reflects the continuing statutory duties and powers of Monitor with respect to NHS foundation trusts and of TDA with respect to NHS trusts (whereby the TDA exercised functions via directions from the Secretary of State).
Alignment with CQC
CQC sets out what good and outstanding care looks like, asking five key questions of all care services: Are they safe, are they effective, are they caring, are they responsive to people’s needs, and are they well-led? These questions will be supplemented by a forthcoming assessment of the use of resources being jointly developed by CQC and NHS Improvement.
NHS Improvement will support providers in attaining and/or maintaining a CQC ‘good’ or ‘outstanding’ rating, covering the areas listed above. We will do this by focusing on five themes. As set out in the next section, these five themes are linked to CQC’s key questions, but are not identical to those questions. This is because: CQC’s questions do not yet incorporate use of resources; we have a particular role in supporting improvement in performance against the NHS Constitution standards for patients; and because our approach to improvement incorporates the strategic changes within local health economies that will be needed to assure high-quality services in the longer term.
We will continue to work with CQC to align our approaches more fully as we move towards a single combined assessment of quality and use of resources. We welcome views on this as part of the consultation.
Lord Carter’s report, Operational productivity and performance in English NHS acute hospitals: Unwarranted variations3, recommended the development of an integrated performance framework to ensure there is a single set of metrics and approach to reporting, reducing the reporting burden in order to allow providers to focus on improving quality and efficiency. In line with this recommendation, we are working with the CQC and with the provider sector to ensure that we draw on a single, shared set of metrics both to review performance and to decide where to target support or oversight.
