The reliance on regulation to drive performance is set to continue, albeit with some subtle but important changes.
Changes to Monitor's risk assessment framework underline the emphasis on stronger financial control, while the addition of a new measure of 'use of resources' to hospital inspections carried out by the Care Quality Commission reinforces the shift in the cost–quality equation. Bringing together the functions previously held by Monitor and the NHS Trust Development Authority under a new body – NHS Improvement – and moves to extend regulatory interventions and look at performance across local areas instead of just focusing on individual organisations are positive.
Although the majority of national targets remain in place, there has also been a subtle shift towards using a wider range of metrics to measure performance, in line with the emphasis on ‘intelligent transparency’. The Secretary of State has explicitly offered a deal – 'more transparency in return for fewer targets'. Two of the three 18-week referral-to-treatment waiting time targets have been abolished, addressing concerns about the perverse incentives created by these targets, and removing two targets the NHS was finding it increasingly difficult to meet.
- Changes to Monitor's risk assessment framework
Following a consultation exercise in June, Monitor has made changes to its risk assessment framework (RAF). The RAF sets out the metrics that foundation trusts are required to meet and the thresholds that determine when Monitor may intervene.
The changes, included in an updated RAF published in August, are designed to strengthen the regulatory regime and encourage financial efficiency by enabling Monitor to intervene earlier where a foundation trust is in financial difficulty.
The changes are:
- re-introduction of a measure that tracks foundation trust deficits and another that monitors foundation trusts’ variance from their financial plans
- a new financial sustainability risk rating, which combines the two metrics above with the existing Continuity of Service risk rating
- inclusion of a value-for-money governance measure in the existing governance rating (the accounting officer memorandum has also being updated to strengthen the requirement on accountable officers to consider value for money)
- a new requirement on all foundation trusts to submit financial information on a monthly basis
- Success regime
The NHS five year forward view highlighted the need for national bodies to take a new approach to those health economies facing long-standing and deep-rooted difficulties. NHS England, the NHS Trust Development Authority and Monitor (working closely with the Care Quality Commission) have introduced a ‘success regime’ targeted at the most challenged health economies.
The regime aims to bring together key stakeholders within the local health economy and work across local organisations to help create the right conditions for success. This will include support for diagnosing deep-rooted, systemic (rather than organisational) challenges, and help with identifying and implementing the changes required to address these – including considering whether adopting one of the new care models could form part of the system.
North Cumbria, Essex, and North, East and West Devon have been identified as the first three areas to go through the regime.
- NHS Improvement
Monitor and the NHS Trust Development Authority are to become a jointly led organisation under a new operating name, NHS Improvement. Work to bring the two organisations together will begin under the current chief executives, but the jointly led organisation will have new leadership. Two new appointments have already been announced: Ed Smith, currently NHS England's Deputy Chairman and Chair of the Audit Committee, has been appointed as the new chair; and Ara Darzi as a new non-executive director. The intention is that a new chief executive will be in post by the end of September.
The new jointly led organisation will encompass all functions of the NHS Trust Development Authority and Monitor, placing oversight responsibility for all providers in the hands of single organisation. These changes will give all providers access to the same support and will mean that, when relevant, they are subject to the same intervention. Although it is not yet clear how this arrangement will work in practice, this approach avoids further structural and legislative change for which many in the NHS will be grateful.
- CQC inspections
In early June the government announced that from 2016, inspections by the Care Quality Commission (CQC) will include a new ‘use of resources’ domain. The aim is to ensure that the work of the CQC reflects wider system priorities by encouraging NHS organisations to focus on providing safe, high-quality care that is also efficient and sustainable. This ‘enhanced approach’ will also help to share learning about effective use of resources across the NHS.
CQC plans to work with Monitor, the NHS Trust Development Authority and NHS England to develop a set of measures before putting these out for public consultation. The intention is to pilot the approach with NHS trusts and foundation trusts from April 2016, with further consideration given to how it may be rolled out to the other sectors regulated by the CQC at a later date.
In August the CQC announced the launch of its ‘Quality of care in a place’ pilots, which will focus on the quality and coordination of health and social care across local organisations within two areas, Greater Manchester and North Lincolnshire. The pilots will draw on information from inspections and other intelligence to provide a picture of quality of care across an area, with a particular focus on older people and those in need of mental health care.
For each area the CQC will report on the quality of services, areas for improvement, and examples of good joint working. Findings from the pilots will feed into the CQC’s new five year strategy, due to be launched in April 2016.
- New performance measures
The Department of Health and NHS England are planning to introduce a set of indicators to measure performance across local health economies, with a new focus on commissioners’ accountability for local services.
The exact scope and content of these measures is still being developed – advice on this will be provided by Chris Ham and The King’s Fund – but the intention is that they will take the system closer to outcomes-based assessments, seeking to measure all aspects of patient care by focusing on local systems rather than individual organisations.
Reviewing commissioners’ performance may also be a feature of the CQC’s two ‘Quality of care in a place’ pilots, although the details of these have not been finalised.
The Secretary of State has also announced a review of metrics used to assess quality of care in general practice. This work will be led by the Health Foundation, working with NHS England, the Care Quality Commission, the Department of Health and a range of stakeholders, drawing on best practice within the NHS and from abroad.
Alongside this work, the government also announced new support for practices in difficulty. A £10 million programme of support for struggling practices will be developed by NHS England and NHS Clinical Commissioners.
- Changes to waiting times targets
Following his review of waiting time measures, National Medical Director Sir Bruce Keogh has made a number of recommendations regarding the measurement of NHS standards.
Perhaps the most notable of these is the recommendation to abolish two of the three headline targets relating to 18-week referral-to-treatment time – the admitted and non-admitted targets – on the basis that these create perverse incentives to treat patients who have been waiting for less time ahead of those who have been waiting for treatment for longer than 18 weeks. This change will mean that the ‘still waiting’ target, which focuses on all patients waiting longer than 18 weeks for treatment, is the primary measure. Financial sanctions against trusts that breach this target will also be increased.
The review also recommended that further work is undertaken in line with the wider work of the Keogh urgent and emergency care review. This includes expanding the ambulance pilot currently taking place in the South West, which is focused on improving the classification of non-urgent calls on the basis of emerging findings from the review. It also includes work to explore how to reflect non-acute services within access targets, as part of the implementation of redesigned urgent and emergency care services.
To address the confusion faced by providers when having to report on different standards at different times, a final recommendation is for reporting arrangements to be standardised so that performance statistics for A&E, referral-to-treatment, cancer, diagnostics, ambulances, 111 and delayed transfers of care are all published on the same day each month.
NHS England has confirmed that it will accept all of Sir Bruce’s recommendations in full.