Monitor will be a fair and pragmatic regulator

The challenges facing the NHS show no sign of diminishing. Treatment costs rise, patient expectations grow and a changing population demands new and different services. The NHS is not alone: health services in other developed countries face similar challenges.

Older woman in hospital bed

‘We are all acutely aware that patient expectations for the quality and accessibility of services are rising, just as cost pressures continue to grow’

As a result of the reforms recently introduced in England, Monitor has a range of new powers and responsibilities we believe will help us help the sector tackle these problems. We are currently developing our corporate strategy to set out how we will do this, but as those new powers come into force I wanted to outline the type of regulator we want to be.

As the sector regulator, our role is to establish and oversee a framework for all commissioners and providers of NHS-funded care; one that ensures a fair playing field for participants, but above all advances our core duty to protect and promote the interests of patients.

This means we will have to be proportionate and pragmatic in how we enforce the rules.

New structures and the right balance

The new structure for the NHS gives local players the independence to make decisions that are right for their communities. We must balance the need to let them get on and do this with as limited a regulatory burden as possible, against the desire for strong action when providers get into difficulty. Otherwise the system just isn’t working the way it should.

Getting the balance right will not be easy, and we will have to work closely with providers, commissioners and our national partners to learn from each other how best to serve patients in this changing world.

We are all acutely aware that patient expectations for the quality and accessibility of services are rising, just as cost pressures continue to grow. There is also increasing acknowledgement that the quality of care has to get better.

Further pressures to improve quality and access

What is perhaps less well understood is how far and how fast these pressures could increase. Our view is that if the NHS is to provide more and better care in any likely funding scenario, then very significant change in how care is delivered will be needed.

What can commissioners and providers do? They can make immediate progress by optimising current models of care. Providers of hospital and community care have achieved a lot in recent years by doing what they do better and more efficiently, although wage restraint has played a major part in this.

Reconfiguring care

Reconfiguring existing models to deliver care in the best setting for the patient will now also be essential. This could mean providing more care for elderly patients in the community rather than in hospitals, or consolidating the provision of specialist care in centres of excellence. Such moves should improve care quality and efficiency at the same time.

‘Set the bar too low for aspirant foundation trusts, we risk too many of them failing. Set too high, we may have no failures but no new FTs’

However, it is very likely that to improve patient care sustainably under any future funding scenario, commissioners and providers will have to develop and deploy models of care that have never been seen in England before. These are likely to focus strongly on prevention in the community; better integration of primary, secondary and mental health care along with social care; more imaginative use of new technologies; and a better understanding and deployment of “Lean” techniques across the sector.

The innovation challenge

We need to see more ground-breaking innovations in all these areas, though they are not necessarily easy to deliver. The Francis report is making staff on the frontline more risk averse. They are worried that regulation is going to get heavier.

Scarce funding also makes any kind of novel investments harder to justify, and there is obviously less evidence on their likely impact. These factors play to the familiar difficulties of making change happen in the NHS.

How will Monitor help? Our job is to use our powers to help providers and commissioners of health services deliver the best possible care for patients. In simple terms, these powers allow us to establish and enforce rules, apply incentives and make information available to ensure:

• public sector providers are well led, so they can deliver high-quality care on a sustainable basis;
• essential NHS services are maintained if any provider gets into serious difficulty;
• prices for NHS services reward high-quality, efficient providers and incentivise them to deliver care in ways that best meet patients’ needs; and
• procurement, choice and competition work in the best interests of patients.

How Monitor must adapt

As we prepare to consult on our strategy for doing this, one thing is already abundantly clear: Monitor must facilitate the change that is needed on the frontline, not obstruct it. This will require flexibility on our part. We must adapt our models for assessing and overseeing foundation trusts, finding ways to evaluate applicants that haven’t operated in their current configurations for long, or who have business models which are generally untested or otherwise high risk.

This is likely to mean placing more emphasis on the quality of a leadership team and their ability to deal with rapidly changing circumstances. It might also mean introducing a “probationary period” for new foundation trusts with particularly high-risk business models while they demonstrate they can deal with the challenges that come their way.

It also means we must adopt an approach to pricing that encourages new ways of delivering care.

The question of scale

In addition, we must support the development of the sector, helping the system answer some of its most difficult questions, such as the extent to which greater operational scale is desirable. We will promote debate and undertake research to get the evidence that’s often not there today.

We will also continue to work with others to make tools and good practice guidance for the sector available to use where it wants. As well as supporting institutions, we must support individuals. We must find ways to encourage the nurses, doctors, administrators, managers and many others who deliver care. We must have a bias to helping them do the right thing, not punishing them for doing the wrong thing.

Managing the risk of failure

While supporting change, we must also manage the risk of failure. If we set the bar for aspirant foundation trusts too low, we risk too many of them failing. Set too high, we may have no failures but no new FTs and no innovation either. We raised the quality bar in the light of the failings at Mid Staffordshire; now we must hold it steady, resisting demands to reflect the tougher financial setting.

Our goal is to make sure each foundation trust is capable of providing high-quality care on a sustainable basis. Every NHS provider should be able to meet that standard.

Board assurance

Of course, the composition of boards and their operating environment can change. We need reassurance that organisations continue to be in a position to sustain their performance.

We have proposed that boards should review their governance arrangements every three years and demonstrate they are maintaining high-quality strategic plans. We need to be able to spot where organisations are getting into serious difficulties they cannot fix themselves and step in quickly. 

Outcomes, not processes

Most controversial among our new powers is our role in making sure procurement, choice and competition work fairly in the best interests of patients. Some argue this is an agenda to privatise the NHS, or to pursue competition for the sake of it. It is neither.

‘We will be rigorous and evidence-based in all that we do, while keeping sight of the need for pragmatism’

However, I do believe we should try to make sure the best providers are the ones who get to deliver care to NHS patients, and that effective procurement, choice and competition have a role to play in achieving this. Nevertheless, we recognise that the NHS, and the institutions within it, are complex organisations with many interdependencies − we know we must proceed with care as we seek to improve it. This is particularly true for the better integration of care, where we will work with commissioners to help them deliver better services for patients within the rules.

Monitoring performance and indicators of risk thoroughly, while imposing as little burden on the sector as we can, means working with other bodies to rationalise the information we each ask for, focusing on what providers should be collecting anyway, and sharing data. At the same time, we should be as open and transparent as possible to explain what we do, how we do it and how it fits in with others.

We will publish guidelines as comprehensive as we can make them, but not so prescriptive as to discourage the innovation that we want to support. This means consulting before we decide on how we do things wherever possible.

Throughout, Monitor needs to maintain high standards of professionalism. We will be rigorous and evidence-based in all that we do, while keeping sight of the need for pragmatism. It is outcomes that matter to us, not processes. We have one simple principle guiding us: to do what is, overall, in the best interests of patients.

David Bennett is chief executive at Monitor