The NHS has come full circle and started round again on its efforts to deal with trusts and commissioners that display clear signs of failure to deliver financial stability, or safe services of sufficient quality to satisfy the CQC inspectors.
Back in 2005-6, at the high point of New Labour’s embrace of the idea that competition, private contractors and markets could be the key to improving NHS services, and when 190 NHS organisations were carrying deficits, many of them for year after year, then Health Secretary Patricia Hewitt set up a National Programme Office to drive through “turnaround” measures.
A standard response would be to wheel in costly management consultants to lead “turnaround,” but options were limited for tackling large scale financial problems: as a King’s Fund study pointed out:
“The result all too often is that some reduction in the deficit is achieved at the cost of deterioration in the quality of patient services and distraction from achieving greater productivity improvement over the medium term.”
As the deficits continued and in the aftermath of the banking crisis, the 2009 Health Act introduced a ‘Failure Regime’ to deal with trusts that could not balance their books. It provided for the appointment of a trust special administrator, working to a tight timetable allowing little or no local consultation, to advise the Secretary of State on what action should be taken when a trust fails.
This was not used until 2012, when it was invoked to take special powers to dismember the floundering South London Hospitals Trust, which was swamped with debt from two disastrous PFI hospitals. This intervention resulted in the long (ultimately successful) battle against the trust special administrator’s plan to include major cutbacks in the neighbouring Lewisham Hospital Trust in a major reorganisation.
Then in October 2012 the Foundation Trust regulator Monitor for the first time intervened on safety grounds, and invoked its own failure regime to address the revelations of scandalous failures in quality of care in Mid Staffordshire Hospitals Foundation Trust.
Both of these interventions triggered major campaigns and had long term negative consequences. This may be why following on the Five Year Forward View in 2014, new NHS Chief Executive Simon Stevens argued in 2015 it would be a better idea to deal with failing trusts not with a failure regime but a “success regime,” which would address both financial and clinical failures.
It was to be new in combining intervention with support to the local system in trouble, and unlike previous ‘special measures’ it was not subject to a strict time limit. Three areas, North Cumbria, Essex, and North East and West Devon, were chosen as the first to be subjected to the success regime in June 2015. In Cumbria and Devon management consultants were brought in at great expense.
However six months later the success regime became entangled with the establishment of Sustainability and Transformation Plans, with the result that little of substance was achieved.
UNISON’s Eastern Region newspaper Eastern Eye in October 2016, noted the reluctance of the Essex success regime to engage with trade unions, while appointing a new ‘HR Transformation Manager’, tasked with developing a “flexible workforce that can work across organisations and geographical boundaries,” summed up:
“It may be a bit early to brand the success regime a failure: but its main successes so far are confined to creating new management titles and posts.”
Over four years later there is still little evidence that the success regime has delivered any benefit: but STPs have come and gone, and now Integrated Care Systems are the latest panacea for the under-funded, under-staffed NHS. ICSs (which as yet have no legal standing) are not covered by existing remedial measures, and separate systems have applied to trusts and CCGs. NHS England argues the new regime will cover providers and commissioners:
“Having these separate programmes no longer fits with the much more integrated approach to healthcare and it is now time to focus on an integrated system approach to improvement. “
So in place of the “success regime” NHS England/Improvement have now unveiled a new “oversight framework,” setting up a 4-segment system allowing intervention into failing trusts, CCGs or ICSs.
The new default setting is that all trusts, CCGs and ICSs will be put into segment 2: the best performing of them can request promotion to segment 1, where they will be subject to minimal oversight. Trusts in segment 1 will be exempt from limits on spending on consultancy and running costs, and “benefit from streamlined business case approval.” Similar “autonomy” will also be available to segment 1 ICSs and CCGs.
By contrast providers and commissioners with problems can be pushed down to segment 3, where they will be required to accept “formal intervention and mandated support,” while those with the most serious problems could find themselves dumped into segment 4, and subjected to “mandated intensive support … delivered through the nationally coordinated Recovery Support Programme.”
Grounds for relegating a trust to segment 3 include performance on key measures in the bottom quartile nationally – suggesting up to a quarter of trusts could be included; “a dramatic drop in performance, or sustained very poor (bottom decile) performance”; financial failure“ reporting a negative variance against the delivery of the agreed financial plan and/or it is not forecasting to meet plan at year end;” or for failures of quality highlighted by the CQC.
CCGs (until they are eventually abolished by new legislation) can also be pushed down into segment 3 if they do not agree “plans to achieve streamlined commissioning arrangements aligned to ICS boundaries by April 2022.”
The bottom segment 4 is for basket-case bodies faced with:
• longstanding and/or complex issues that are preventing agreed levels of improvement for ICSs, trusts or CCGs in segment 3 or
• a significant actual or forecast gap to the agreed financial plan or
• a catastrophic failure in leadership or governance that risks damaging the reputation of the NHS or for trusts:
• a recommendation by the CQC.
While some of these issues may well suggest the bodies concerned need help, the extent to which the underlying problems can be tackled in the current situation of an under-funded, under-staffed and overwhelmed NHS is questionable.
The new regime is claimed to be better than the previous success regime because it will be “system oriented”, “focus on the underlying drivers of the problems” and be “nationally led by a credible, experienced system improvement director (SID).”
This surely raises more doubts about the success regime than it gives assurances over the viability of the new system.
For the battered staff and management of the dozens of trusts likely to be consigned swiftly to segments 3 and 4 there seems to be a prospect of long term pain of intervention from regional and national level, with little hope of clambering back up the rankings.
After all, just as it’s impossible for everyone to perform above average, the harsh fact is that no matter how well all trusts perform, a quarter of them at any point will be in the bottom quartile. Perhaps somebody should point this out to NHS England?
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