System regulation can help or hinder collaboration

System regulation can encourage cross-system innovation, dismantle organisational silos, empower local organisations to deliver care in a more joined up way, and drive population health approaches with other system partners so that citizens are active agents in improving their health.

The opportunities

This year will see a wide-ranging health and care bill introduced into legislation that brings major changes to how health and care are organised. Importantly, it gives the CQC the power to assess integrated care systems (ICSs), with a key consideration being how well partners are working within the system to deliver care. This provision adds accountability mechanisms to the legislation’s duty to collaborate placed on all system partners, which will greatly improve continuity for those receiving care.

...the opportunity to regulate differently and support integration cannot be missed

The potential of these mechanisms will be limited by how robustly this is measured.  This will not be an easy task for regulators who have historically focused on individual organisations and who do not have direct lines of accountability for all organisations within the ICS, such as voluntary sector organisations. But, the opportunity to regulate differently and support integration cannot be missed. Regulators will also need to ensure their frameworks adequately cover the integrated care partnership, which will be responsible for delivering on key ICS priorities.

The government’s integration white paper elaborates on the role of regulators in assessing the strength of integration within an ICS. It stipulates a single leader at place level, responsible for planning local health and social care services with some agreed outcomes to be locally defined at place level. Regulators will need to ensure their regulatory regimes account for these local metrics, along with some new centrally defined national metrics. The upshot of this policy will be even closer working between the integrated care board (ICB) and local care partners, demanding closer interrogation by regulators of the quality of partnership working.

our members ... regularly share concerns about overly burdensome regulation and oversight and their desire for a more lean, light and agile regulatory framework

Secondly, conversations with regulators over the past year have shown they share this vision for a more cohesive approach to avoid creating additional layers of regulation for systems. This aligns with our members, who regularly share concerns about overly burdensome regulation and oversight and their desire for a more lean, light and agile regulatory framework.

Based on these conversations, the NHS Confederation has developed a set of principles to guide year one of system regulation.

Principles to guide system transformation

Co-design must be built into regulatory frameworks at all levels.

There will always be a role for inspection and intervention. However, this should be proportionate and predominantly owned by the system, for example by allowing system leaders to define the metrics they are assessed on and supporting peer review processes driven by ICS leaders. There are some encouraging signs that NHS England (NHSE) and the CQC are treating system leaders as partners and co-designers in processes of improvement, but they will need to work hard to build trust to unlock the full potential of integration and collaboration.

Cultural and behaviour change will be key to successful collaboration.

This will demand not only assessing the progress of ICSs and other system partners against quantifiable collaboration metrics, but regulators interrogating the cultures of their own workforce. Our members are often frustrated by discrepancies between messaging from ‘above’ and the behaviours of CQC inspection and NHSE regional teams ‘on the ground.’ System working will only thrive if there is mutual trust, confidence and respect. Regulators must therefore ensure their staff have the requisite seniority and training to inspect and support complex systems. Embedding new cultures and behaviours will take time but will be worthwhile and necessary.

Regulatory activity must be streamlined.

ICSs, provider and partner organisations should have clarity on what regulators need from them and what they are being assessed on. Metrics should be aligned and driven by the system as far as possible. Smarter use of data such as reports from patients and staff will allow earlier intervention, enable sharing of best practice and importantly minimise the bureaucratic burden placed on provider organisations, systems and service users.

Our focus in 2022

In 2022 the NHS Confederation will focus on:

1. Facilitating feedback loops between regulators and system leaders to ensure our members interests and concerns are reflected in the way they are regulated.

2. Working with regulators and members to develop a strong and clear case for the role of peer review alongside existing regulatory activity. ICB-level peer review could potentially offer a more robust assessment of culture, partnership working and leadership; 2022 will be a crucial time for testing and piloting such mechanisms.
3. Supporting regulators to finesse their frameworks for system regulation. We intend to meet towards the end of the year to consider progress against our principles.
4. Working with the government and regulators to develop clarity on accountabilities.

The potential benefits of creating a regulatory environment where distributive leadership, peer learning, partnership working and innovation are supported and rewarded, and where systems can drive their own improvement, are momentous.

And the stakes are high: system regulation could help or hinder collaboration.

Annie Bliss is a policy associate at the NHS Confederation. You can follow Annie on Twitter @anniebliss0

You can also read Danny Mortimer's article, which appeared in HSJ (18 March): A More Agile Approach to Regulation is Needed as we Embed System Working