Will they or won’t they? The long-running, on again/off again relationship saga is a device familiar from far too many long-running television series to list here. I’m currently more interested in what the government’s response to the Morecambe Bay investigation, announced last month, had to say about Monitor and the NHS Trust Development Authority (TDA) coming together as NHS Improvement.

In June it was announced the two arm’s length bodies will come together, under the leadership of a single Chief Executive, to focus on provider support. All parties have steered clear of describing the move as a merger, but it appears to be so in all but name.

Either way, closer alignment makes sense. Each organisation oversees a large part of the NHS provider sector: the TDA takes care of NHS trusts, while Monitor does likewise for foundation trusts.

Until recently, the case against NHS Improvement was that most foundation trusts – with a few unhappy exceptions – had been successfully entrusted with freedom from central control, while a number of NHS trusts needed more hands on support. These were distinct roles, requiring different approaches and different people with particular backgrounds and skills.

Despite all the legal differences between foundation trusts and NHS trusts, neither tribe of provider trust has proved entirely immune from the challenges of quality and money. Of the 13 providers currently in special measures, for example, foundation trusts outnumber NHS trusts by eight to five. That’s roughly in proportion to the numbers of each type of trust, but hardly a ringing endorsement for FT policy. Balancing the books is already difficult for foundation trusts and NHS trusts alike, and looks likely to become increasingly tough going forward.

Monitor and TDA are increasingly working in more similar ways to help providers confront these and other issues: so why not bite the bullet with a full-on merger?

Professional regulation goes back centuries but, as documented by our Policy Navigator website, the short history of organisational regulation has been arguably much more turbulent. The 2009 merger of the Healthcare Commission, Commission for Social Care Inspection and the Mental Health Act Commission to create the Care Quality Commission (CQC) highlights the potential difficulties.

The ‘many challenges’, pressures’ and ‘short timescales’ involved in merging three regulators performing ostensibly similar functions (albeit for different sets of provider organisations) are clearly set out in Sir Robert Francis’ second inquiry into Stafford Hospital.

Intriguingly, documents disclosed by the Francis Inquiry revealed that Ministers considered having the existing regulators – the three regulators that became CQC, plus Monitor – work together to develop a unified regulatory model to be inherited by the new regulator after the merger. In other words, form would follow function not the other way around. The option wasn’t pursued: officials suggested the existing regulators – particularly Healthcare Commission and Monitor – may not cooperate effectively. That assessment was echoed, years later, by the findings of the Francis Inquiry.

The Institute for Government’s work on merging and demerging government departments (known in the trade, rather wonderfully, as ‘machinery of government’ changes) suggests the difficulties experienced during the CQC merger were not unusual. Monitor and the TDA are not government departments, of course, but there’s a clear read across. 

Bringing Monitor and TDA together as NHS Improvement under shared leadership and a single organisational brand could offer the best of both worlds, though the scale of the task facing the new  Chief Executive must not be underestimated. A cursory examination of the different functions and powers of Monitor and TDA means aligning the resources, objectives and approaches of the two organisations together won’t be quite as straightforward as it may initially appear. And shifting from being regulators, overseers and performance managers to being genuinely supportive of providers in challenging times will be even more important, and at least as difficult.

The government has also announced the new Chief Executive will take on and potentially extend the reach of NHS England’s patient safety function, while also having some role in hosting the new Independent Patient Safety Investigation Service (IPSIS). The need for IPSIS to be genuinely independent of political control will be tricky to accommodate within the organisations formally known as Monitor and TDA. Monitor’s reputation for being independent from government – sometimes rather spikily so – has been diminished ever since Alan Johnson forcefully took control of the system’s response to the Mid Staffs investigation. The need to uncross that particular Rubicon means the scale of the task not only becomes larger but also that getting it right is now mission-critical for the future of the NHS.

The hook of the ‘will they/won’t they’ dynamic on television is ultimately all about a good journey: reaching the destination too early is massively anti-climactic, taking too long risks people switching off. Risk is part and parcel of any significant organisational change, merger or not. But either way, success for NHS Improvement is ultimately about the quality of the journey the new Chief Executive will lead them on, not jumping ahead to the destination of a nice new structure chart.

Tim is Senior Policy Fellow at the Health Foundation www.twitter.com/TimGardnerTHF 

You might also like...

Press release

Today’s NHS data should be a wake-up call to the next prime minister

Press release

Health Foundation response to the monthly NHS performance statistics.

Press release

Boris Johnson didn’t ‘fix social care’ - the next PM must

Press release

Response from the Health Foundation on the Levelling-Up, Housing and Communities Committee report...


Party conference schedule 2022


The Health Foundation will be holding multiple fringe events and partnering with other organisations...

Kjell-bubble-diagramArtboard 101 copy

Get social

Follow us on Twitter
Kjell-bubble-diagramArtboard 101

Work with us

We look for talented and passionate individuals as everyone at the Health Foundation has an important role to play.

View current vacancies
Artboard 101 copy 2

The Q community

Q is an initiative connecting people with improvement expertise across the UK.

Find out more