Exclusive: Monitor sets up 'engine room' for reform

In an exclusive interview with HSJ, Monitor chief executive David Bennett said the new “provider sustainability” directorate would aim to bring in-house a large chunk of the work it buys in from consultancies such as McKinsey and PwC. It will be funded from the £30m budget the regulator currently has for external consultants.

In a bid to gain a deeper understanding of trusts’ operational problems and help improve performance, Monitor will seek to directly recruit people with backgrounds as provider operations directors and chief operating officers.

However, Mr Bennett insisted the move was “absolutely not” about the regulator taking responsibility for the performance management of foundation trusts.

“That’s what makes me most uncomfortable,” he told HSJ. “We don’t performance manage trusts even when they’re in breach of their licence. Performance management of FTs is a responsibility for the boards of those FTs… However, we think they need help doing it.”

The Monitor chief executive said NHS providers had “two massive challenges” over the next five years: the first was to “push hard” on improvement against performance and financial targets. The second was to work out how to reconfigure services using the new care models set out in the forward view. He expected the new directorate to play a key role in both areas.

On the performance improvement front, he said the unit would provide a source of expertise that trusts with operational problems could draw upon. 

While some of this would come from within Monitor, he expected the unit’s main role to be to make sure more capacity was available elsewhere in the NHS. This might come from sponsoring the expansion of units such as the emergency care intensive support team, or from encouraging trusts with particular aptitudes – for example, in managing agency spending – to build capacity to help others.

He rejected the idea that this was a “land grab” for the kind of performance improvement role played by the NHS Trust Development Authority – instead it was “more a catch up”.

“To some extent we’ve been driven to it, because it’s a weakness for us compared with the TDA,” he said. “The TDA is full of people with operational experience in the NHS, who are able to work with their trusts to help them drive improvement. We need more people like that working with our FTs.”

He admitted he had “absolutely” felt that weakness during this winter’s furore over accident and emergency.

On reconfiguration, the unit will aim to take on the work of “contingency planning teams”, which are sent into seriously struggling FTs to diagnose underlying structural problems and help to restructure services. Monitor currently spends more than £5m a year commissioning this work from consultants.

“It’s become increasingly clear that we’re going to need more of this over time, and therefore we need to be able to deploy it at larger scale, and we can’t afford to do it,” said Mr Bennett. 

“That’s why now is the time to bring it in house.”

He said he hoped this, in time, would establish the unit as the “engine room” for the “whole system interventions” in challenged health economies described in the forward view.

At the other end of the spectrum, it will be the conduit for Monitor’s involvement in the health economies chosen to be in the “vanguard” of new care models, coordinating the support they need on issues like pricing or choice and competition.

He acknowledged: “One of our challenges is that the sort of people that are able to do this sort of thing are currently employed in the consulting firms at vastly higher rates that we can pay.”

Despite this, he believed Monitor would be able to make an attractive offer to these candidates. “Having been a consultant for much of my career,” he said, “I can tell you there’s a real difference between being on the inside working with an organisation to help solve its problems versus being an adviser on the outside.”