Closing wards and services, blocking choice of private providers, systematically extending waiting times, and stopping some treatments are all being considered under a national programme targeted at the health economies with the highest overspends.
The controversial measures are currently being discussed privately by national NHS England and NHS Improvement officials, with senior local NHS leaders, as part of the new “capped expenditure process”. The principle of the process, introduced this year, is to “cap” NHS spending in the targeted areas so that they meet ”control total” budgets in 2017-18.
NHS leaders from areas covered by the CEP have been told to examine “difficult decisions” and “think the unthinkable”, including modelling changes which are normally avoided as they are too unpleasant, unpopular or controversial. HSJ has spoken to senior officials in most of the areas.
One chief executive said it was the most extreme and difficult NHS finance process they had experienced, and that the some of the options - if pursued - would “challenge the value base” of NHS leaders.
Ideas under consideration across several areas include:
- Limiting the number of operations carried out by non-NHS providers so the funding stays within the NHS. Considerations differ between areas but include both limiting patients’ choice of providers, and reducing work which is outsourced by NHS trusts. In some cases it would require the NHS to find the capacity to carry out more operations.
- Systematically drawing out waiting times for planned care, including explicit consideration of breaching NHS constitution standards. Some plan to target delays at specialties/areas where waits are currently lower than average.
- Stopping NHS funding for some treatments, including extending limits on IVF, adding to lists of “low value” treatments, and seeking to delay or avoid funding some treatments newly approved by the National Institute of Health and Care Excellence.
- Closing wards and theatres and reducing staffing, while seeking to maintain enough emergency care capacity to deal with winter pressures.
- Closing or downgrading services, with some considering changes to flagship departments like emergency and maternity - though these would normally take too long to deliver savings this year.
- Selling estate and other “property related transactions”.
- Stopping prescriptions for some items, as suggested by NHS Clinical Commissioners earlier this year.
Leaders in the areas have been told to first consider whether they can make further efficiencies by normal means, such as reducing follow-up appointments or unnecessary referrals. But all of those HSJ spoke to - covering more than half the areas involved - said they were also putting forward new “difficult decisions”.
Meetings to discuss the CEP proposals with regional and national officials, including NHSE and NHSI finance chiefs Paul Baumann and Bob Alexander, took place throughout last month. No proposals have yet been formally approved or rejected, sources said.
Decisions are expected after the general election, and some of the officials involved have been told they will be put to the new ministerial team. There is no expectation of details being made public until after the election.
About 14 health economies - most of which are sustainability and transformation partnership areas - are subject to the process. They were chosen because they were expecting to fall substantially short of their “control total” financial targets in 2017-18.
- Bristol, South Gloucestershire and North Somerset;
- Cambridgeshire and Peterborough;
- Cheshire (Eastern, Vale Royal and South)
- Morecambe Bay;
- North Central London;
- North Lincolnshire;
- North West London;
- South East London;
- Surrey and Sussex;
- Vale of York and Scarborough and Ryedale.
The programme comes amid the longest ever sustained squeeze on the NHS budget, and with lower spending growth in 2017-18 than last year. These areas report gaps between plans and targets running into hundreds of millions of pounds, but NHSE and NHSI have not made public the total national gap.
Several sources complained that the national process - which is likely to require some 2017-18 contracts to be reopened - had run more than two months into the financial year, rather than being completed earlier.
Many also said that, while they had put forward “difficult decisions”, there were no sensible options which would save significant sums during 2017-18, without storing up problems for the future.
There is also debate over whether it is fair to target health economies based on their “control totals” - which require some to have surpluses and are based partly on past performance - rather than looking at absolute surplus or deficit.
An NHS England spokeswoman said: “Within their fair share of the NHS budget, local doctors and hospitals are planning how best to deliver services to patients focussing on the priorities of the public, including modern cancer care, expanded mental health and convenient GP services.
“While many options will have been considered locally, the choices of which options to pursue are still to be evaluated and agreed and would require national sign-off in due course.”