The Integrator: Could NHSE ‘throw in the towel’?

The short to medium-term financial outlook for health and social care has just got even worse.

As a result of the mini-budget and its disastrous fallout it now looks very unlikely that budgets will be topped up to account for rising prices. Instead government departments must make a rushed attempt to find yet more “efficiencies”. 

More importantly, the government’s backed itself into such a fiscal corner it seems unthinkable it will be able to announce a proper medium/long-term settlement or funded workforce plan before the 2024 (or 2023) general election.

Political fracture

Reader Steven Duckworth points out that what is really happening here is a big political realigment.

It appears to entail a fracture in the centre-right political consensus which since 2010 has seen the NHS get new funding deals — albeit pretty piecemeal ones — every few years as Cameron, May and Johnson sought to convince people they were not the enemy of the NHS: Not enough growth to stop persistent decline in standards, but enough to get what Sir David Nicholson called “managed decline”, rather than total collapse, and to buy just a glimmer of hope for the future.

We don’t yet know what prime minister Liz Truss and health and social care secretary Therese Coffey really think about the NHS. They’re clearly further to the right than their predecessors and they’ve threatened an NHS funding raid purportedly to help social care. More and more in their party (and a few others) are publicly questioning the NHS funding model.

In truth, if services need to prepare to live off chicken feed for the foreseeable future, a radical plan is indeed needed: Not about the funding model, but about how to keep some kind of viable minimum level of service going, rather than simply “muddling through”.

Throwing in the towel

What does it mean for the leadership of the NHS and NHS England?

On the one hand it’s in a grim place. No workable funding; and growing suggestions that with no means to recover performance or outcomes the government will look to point the finger at the service, particularly managers, and NHSE, with a media drum beat to support it.

And Truss and Coffey do not seem shy in imposing more demands on the service. Within two weeks of taking office they announced, with no real warning to NHS national leaders, a two-week GP appointment “expectation”, dreamed up a mystery unfunded £500m discharge funding pot, and revived the four-hour A&E target. Ms Coffey is said to want departmental officials to be all over NHS performance issues, via NHSE, on a day-to-day basis.

“What is the point of NHSE if it can’t stop this sort of thing?” one ICS boss asked as they grappled with local GP leaders angry at the bombshell two-week headlines and handbrake turn in policy.

The NHS, and Wellington House in particular, could end up taking orders, making cuts, and absorbing criticism with no way to deliver.

NHSE will continue to highlight, as it shows at its board meeting today, the trade-offs government is forcing it to make between services and balancing tightening budgets, but is anyone listening? 

Hypothetically, could the independent NHSE go further and decide to throw in the towel altogether? Its leaders could effectively hand ministers back their full responsibility and accountability for the NHS, ensuring voters are clear about where the buck stops for tax and spend decisions.

(Interestingly, Conservative adviser Bill Morgan, who saw the dysfunctional relationship from the department’s point of view over the summer, has argued NHSE should physically move back into the department.)

Structurally, another round of cuts will strengthen the case for stripping out even more management layers — be that national, regional, ICSs (just born) or merging more trusts.

Then again

The politics remains highly unstable. Have Truss and Coffey yet truly understood the consequences, for service users and voters, of selling off their “party of the NHS” mantle?

The Tory nosedive in the polls, and shortest odds on a Labour government for a long time, might give an independent NHS a stronger negotiating hand, and NHSE’s independence still offers a little insulation from all that turbulence.

Labour’s Wes Streeting seems to be anti-restructure, although whether a Labour government would decide to spend enough money in its early years to decisively improve health and care is an open question.

Leaving BOB

James Kent has become the first integrated care board chief executive to leave, three months after the role became formal.

He abruptly departed the Buckinghamshire, Oxfordshire and West Berkshire system on secondment to advise NHSE.

Is there anything that others can learn from the situation?

Local sources point to a clash between Dr Kent and the chair of the ICB, Javed Khan, who took up the role early this year. Dr Kent was previously an experienced and senior management consultant in the sector, and a health adviser in 10 Downing Street, but had not held any senior NHS leadership positions.

The ICS appears to have had a tough time with relationships in recent years, including turnover on its own exec team and difficulties agreeing ICB representation with members.

It was formed under duress by merger of two successful early systems (Bucks and West Berks) with Oxfordshire, which has often been a tricky patch. That made it closer in size and shape to the large northern ICSs than to some counties in the South West which were allowed to “go it alone” as ICSs. Up north they are doing OK so far, but BOB has struggled to get off the ground.

BOB offered one of the most colourful examples yet of the what can happen when you meld councils with the NHS, when the Conservative Bucks County Council leader told a conference relationships had “never been worse” due to the arrival of the ICS, as he had “never felt more disrespected or marginalised” by “an NHS steamroller literally coming down on us with a heavy hand”.

After news of Dr Kent’s departure, the same councillor tweeted: “We have enjoyed a close and very strong relationship with James both before and following Covid. He will be sorely missed.” Talk about Tory U-turns.

*Correction at 10am on 7 October: The chair of BOB ICB is not Alan Burns, as we incorrectly stated, but Javed Khan. Apologies.