With national policy centred on developing system working, the focus is shifting from oversight of individual organisations towards oversight of system performance, notes Ella Jackson

NHS regulation used to be one of the important fixed points in the NHS architecture – but things have changed. Regulation is in transition and where it sits and what it seeks to do has become a bit of a moving target.

And this year’s NHS Providers regulation survey reveals trusts are experiencing this as a clear tension between the reality of the current regulatory approach and ambitions for new oversight models which take more account of system working.

National policy is firmly centred on developing system working and collaboration – integrated care systems, primary care networks and new models of care are based on the philosophy that collaboration, rather than competition, is a better way for the health and care system to respond to today’s challenges. 

While there is a general consensus across the sector that this is the right direction of travel, it has interesting implications for the way frontline organisations are held to account for the services they provide and commission. The focus is shifting away from the oversight of individual organisations towards oversight of system performance.

The new NHS oversight framework is clear that NHS England and NHS Improvement intend for ICSs to play a greater role in the oversight process for organisations in their system. Local system leaders will be involved in conversations with providers and commissioners where NHSE/I have cause for concern.

Trust leaders tell us they are optimistic about the potential for new oversight frameworks to hold system partnerships to account for collective performance, and for the alignment of system oversight with regulatory requirements at an organisational level.


They are clear that the existing regulatory frameworks do not sufficiently reflect the context in which they are now providing care or their organisation’s contribution to the wider healthcare system. 

However it is also important to remember that trusts retain formal legal responsibility for frontline service delivery and, in the absence of legislative change, it will be a complex task for the national bodies and regulators to reconcile regulation and oversight at organisational level with national policy ambitions to place greater weight on collective responsibility at system levels.

For the second year in a row, trusts responding to our survey highlighted the tension between the current institutionally-focused regulatory model, and policy ambitions for local systems.

NHS Providers has long argued that any legislative and regulatory changes intended to support the move to integrated health and care systems must be fully scrutinised, including consultation and co-production with the NHS frontline.

They highlight the potential conflict of interest in a situation in which STPs/ICSs, which derive their decision making powers from the statutory bodies which comprise them, are holding those very organisations to account

Trusts tells us they would like further clarity on the roles and responsibilities of NHS England and NHS Improvement regional teams and those of local system leaders, as well as further clarity on the relationship between them.

They highlight the potential conflict of interest in a situation in which STPs/ICSs, which derive their decision making powers from the statutory bodies which comprise them, are holding those very organisations to account. 

Trust leaders also point to the risk of additional regulatory burden and duplication if both local systems and the national bodies seek to hold individual organisations to account. They also warn that that STPs/ICSs lack the infrastructure and expertise required to take on an assurance role and manage performance.

These issues need to be worked through, with the full involvement of the provider sector. 

Despite these challenges, over half of trusts who responded to our survey agreed it is possible to align system oversight with regulatory requirements at an organisational level.

Local system reviews

The feedback from trust leaders on Care Quality Commission’s local system reviews show there is appetite for oversight and support at a system level and that, if done effectively, this can support whole systems to work together to improve care.

Of those trusts that had participated in a local system review, the overwhelming majority (87 per cent) agreed the local system review had helped identify areas for improvement. A majority (60 per cent) also agreed the local system review had encouraged organisations in their system to work more collaboratively, and over half (57 per cent) said they are making improvements as a result of their local system review. 

Many trusts have told us that a focus on improvement – not regulation or performance management – allowed local system review areas to reflect honestly on progress and put aside differences arising from individual organisational needs, which institutionally-focused regulation can exacerbate.

They welcomed the holistic view across a whole system, recognising the impact of the wider system on the ability of individual organisations to deliver care and, ultimately, the focus on how services can work together to improve the experience of people using them.

Overall, there is optimism and appetite among NHS providers for models of regulation and oversight that reflect the move to system working. With due consideration and full engagement with the sector new oversight models will avoid duplication or confused accountabilities and add value to providers and their partners in fulfilling their core purpose to deliver high quality care.