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Re-directing the NHS supertanker?


It may only be five weeks since the general election, but there has already been a veritable blizzard of announcements coming from the Department of Health and national NHS organisations. So many in fact, that it is no mean feat to step back to make sense of it all.

There seem to be three main categories. First, there is a set of actions focused on denting rising NHS deficits in what many expect to be a dismal year. This includes implementing controls on agency spending, management consultancy and pay for senior staff, and now recommendations from Lord Carter’s report on efficiency. Some of these – particularly the last – will have more impact in subsequent years but may begin to deliver savings this year too. Behind all these actions sits the party line that, according to NHS England Chief Executive Simon Stevens at the NHS Confederation annual conference last week, there is ‘no likelihood that the NHS will receive additional infusions of cash this year’. We will no doubt hear more on action to reduce deficits if they continue to rise and the government sticks to its ’no more money’ line.

With a more complex relationship to money but a direct link to serious service pressures in acute trusts are the abolition of two of the three indicators of the iconic 18-week waiting time targets and the end of the National Institute for Health and Care Excellence’s work on safe staffing in the NHS. The latter is replaced by work overseen by Jane Cummings, Chief Nursing Officer at NHS England. With waiting times a key indicator of the health of the NHS and safe staffing so core to the quality agenda of the previous government (and current Secretary of State) it remains to be seen how any conflict between them and money will be handled.

Second, there are more changes to the architecture of the NHS. As the financial challenge does not end this year, many of these also relate to efficiency and money but are unlikely to have any impact on the ground in 2015/16. They include the Care Quality Commission’s intention to include ’use of resources’ in its provider assessment, changes to Monitor’s risk assessment framework, and work with three troubled health economies under a new ‘success’ regime. However, there will also be closer working between Monitor and the NHS Trust Development Authority and work on new CCG/local health economy indicators, which will be overseen by The King’s Fund’s Chris Ham. These latter changes have less to do with balancing the books and more to do with perceived gaps and overlaps in the existing architecture of the NHS.

Lastly, the system continues to plough ahead with the vision put forward in the NHS five year forward view (Forward View). Actions here include two new tranches of vanguard sites to take forward the new care models, one covering work between providers (previously focusing on sustainable smaller hospitals but now potentially more broad) and the other covering urgent and emergency care. There has also been a statement on the overall governance of the Forward View, with responsibilities lodged more clearly with specific organisations and individuals.

What should we take from all this? Perhaps most clear is the emphasis on money. After a number of years in which the phrase 'quality trumps finance' has provided at least a partial explanation behind the relentless and deep deterioration in provider finances, we are now witnessing an attempt to re-direct the NHS back towards money.

At the same time, NHS leaders are trying not to lose sight of the direction of travel for 2020 set out in the Forward View. However, we cannot underestimate how challenging this will be for 2015/16: it would have been hard enough if reducing deficits had formed the cornerstone of the NHS planning round that is just being completed, but it did not. Now the financial year has started and little of the new architecture is in place. If these new measures lead to staff reductions and declining performance then it will be an early test of the government’s determination to adhere to its spending plans at the same time as pushing through the changes needed for the Forward View. That these may be uncomfortable bed fellows was underlined by the recent near simultaneous re-commitment to prevention and public health from NHS leaders just as the Chancellor removed £200 million from this year’s public health budgets.

No doubt there is more to come. Last week felt like it marked much more than a busy week for policy-makers and officials – more like a sea change for the system.