North by North West: Running rings around the ICB

Greater Manchester’s financial plight is leading to some pretty bleak decisions.

Compulsory redundancies are in the pipeline in several areas, while a “systematic” cut in activity sent to private providers will limit the ability to tackle the elective waiting list, which is among the worst in the country.

But perhaps most depressing are the cuts being made to preventative services – which in the long run are the very thing deemed critical to getting out of the current mess.

Around half of the integrated care board’s population health budget was already raided last year to prop up the bottom line. According to its latest board papers, the ICB is now considering another cut of 60 per cent in 2024-25. This would reduce the £17m budget to just £6.5m.

It would be hard to find a system that talks more about prevention’s importance than GM, and one senior leader told NxNW the “dreadful” situation was being blamed on the pressure coming from NHS England.

Addressing the underlying causes of ill health was the central theme of devolution, and a city more famous for footballing trebles frequently cites prevention as key to addressing its “triple deficit” – on finance, performance, and population health.

Carnall Farrar was commissioned to reinforce the same message recently, suggesting several hundred million pounds could be saved by 2028 through programmes that help reduce demand.

I’m not sure if consultants have an answer for the current predicament, however, in which ICB leaders have to deliver immediate improvements but lack the power or influence to deliver radical cuts to hospitals’ staffing budgets.

There’s lots of speculation about what’s gone wrong in GM, but by issuing enforcement undertakings to the ICB, NHSE is signalling that commissioners haven’t done enough to challenge providers.

What I often hear is the ICB lacks experience in how to deal with providers when it has limited direct powers to compel them to do anything.

Neither chair Sir Richard Leese, nor CEO Mark Fisher, had any prior NHS experience, while recently seconded chief financial officer Sam Simpson had never been responsible for overseeing multiple trusts’ finances (barring a short sustainability and transformation partnership spell when they had no official status).

Contrast this with Cheshire and Mersey ICB, which is led by former regional performance director Graham Urwin, and Lancashire and South Cumbria, which was chaired until recently by former national regulator David Flory. Both know NHS regulation inside out and have the contacts and influence that makes it easier to make things happen.

If we also recognise that GM probably has the two most powerful foundation trusts in the region (Manchester University FT and the Northern Care Alliance), this was always going to be a gargantuan task for a rookie ICB. Another source reckons providers have been “running rings” around the ICB.

Recent ICB board minutes hint at some of the dynamics, noting leaders held some “financial performance review meetings” with providers aimed at improving the “system deficit”. Yet the only outcome noted was a recognition that “further income was due to the providers from the ICB”.

As well as whipping the ICB into shape, it sounds like NHSE might need to start dealing directly with the providers. The regional team did not respond when asked about the population health cuts.

Official lines

According to NHSE and the ICB, Ms Simpson’s secondment to a strategic role in the regional directorate has nothing to do with GM’s financial collapse or enforcement undertakings. They say the move was purely driven by the need to provide some backfill in the North West team after regional director Nik Khashu was asked to fill a national role.

If we take that as read, it seems an odd decision. This is a crucial period to have the right people in system CFO roles at the moment, especially in a system that’s struggling as badly as GM.

Private concerns

GM’s plan to “systematically reduce” the volume of activity sent to private providers is likely to set hares running in the independent sector.

Ministers want ICBs to ensure patients are always presented with a genuine choice of providers at the point in which they are being referred to secondary care, but this is tricky to implement and enforce.

Given its financial difficulties, GM and other systems will want to make sure any activity where it’s possible to turn a profit under the tariff is kept within the NHS family.

Appraised appointment?

Talking of family, eyebrows were raised by a recent announcement by Gareth Wallis, medical director for system improvement and professional standards in the regional NHSE team.

In an email to colleagues earlier this month, he announced Lesley Atherton had been chosen as clinical appraisal lead for both GPs and local responsible officers in the North West, following a restructure. She had previously just been responsible for the former.

What the email didn’t mention is that Dr Wallis and Dr Atherton are husband and wife.

NHSE said there was a fair and competitive appointment process and Dr Wallis was not involved in any way.

Lessons from failed procurement

Regular readers will recall the mess Lancashire and South Cumbria got into with its system-wide electronic patient record procurement.

Leaders knew they had to run a competitive process to select a preferred provider, yet this was muddied by the fact East Lancashire Hospitals only recently purchased a new EPR (from Cerner), which was installed last year.

It would therefore have been convenient if the tender process, which ran last year, somehow came up with Cerner as the answer for the whole acute system. Perhaps they would say this, but sources at rival suppliers believe the process was coming up with a different answer, and so the decision was made to start the tender again with different specifications.

One source said the new tender documents are likely to be written in a way that emphasises the need for as little upheaval and additional costs as possible, which should favour Cerner. System leaders said the process, expected to launch again in the next year, will be fair and transparent.

Meanwhile, the ICB has issued a separate £60-£70k tender notice for a consultancy firm to carry out a “lessons learned” review on the process.