Essential insight into NHS matters in the North West of England, with a particular focus on the devolution project in Greater Manchester. Contact me in confidence here.

In this week’s North by North West:

Hidden waiters

Official provider figures published by NHS Improvement show the national waiting list for elective surgery was around 3.9 million at the midway point of 2018-19.

But this excluded figures from five trusts (including St Helen’s and Knowsley) which have apparently been unable to submit their numbers due to shortcomings within their information systems.

The regulator estimates the waiting list would include another 400,000 patients if these trusts submitted their data.

Various trusts have appeared in the ‘non-reporting’ list over the years, including University Hospital of South Manchester Foundation Trust. Now merged (taken over), UHSM stopped reporting figures for several months in 2015 after discovering patients who had waited more than a year to be treated, but were not flagged within their systems.

Worryingly, it’s now emerged there have been similar problems at Manchester University FT, the mammoth acute trust born out of the merger of UHSM and Central Manchester University Hospitals FT.

At the end of 2017-18, the trust reported around 30 year long waiters, but three months later the number had shot up to 293.

MFT says this followed a review of its waiting lists and investigation of the IT systems, which discovered problems around “systems and processes” primarily within the general surgery and ear, nose and throat pathways.

Within the calendar year, the trust said it conducted 394 clinical case reviews (split across its sites) in response to the concerns, with no “significant harm” identified.

In other words – lots of “low harm”.

The trust told HSJ the delays were “clearly unacceptable” and it has “worked intensely” with commissioners and regulators to work out what happened. I’ve asked them to elaborate.

The trust managed to clear the bulk of these cases, with help from some outsourcing to private hospitals, in the second half of the year, with the number of year long waiters now back down below 30.

Lack of distinction

The devolution project for Greater Manchester received plenty of fanfare when it launched three years ago, but has since ticked over relatively quietly.

Arguably, this is an indicator of success. Unlike some other areas, the region has so far avoided major scandal or financial ruin.

But the absence of significant excitement or controversy can also be explained by its lack of distinction from the rest of the country.

As a new evaluation of devolution by Alliance Manchester Business School reminds us, the devolution deal has no statutory basis and national leaders continue to hold substantial influence over health and social care policies in Greater Manchester.

Local and national policies remain tightly aligned, while the statutory organisations still guard their own autonomy and remain subject to the same governance and performance regimes as everywhere else.

Other “integrated care systems” have also now emerged across England, along with regional directors and health authority type structures. Perhaps surprisingly, several other systems actually have more full time staff attached than the devolution partnership.

What has set Greater Manchester apart has been the integration of clinical commissioning group leadership with local government, and the fact that it’s benefited from a guaranteed transformation fund of £450m.

As we approach the latter years of that funding deal, we should start to get a better understanding of how well that money has been spent, and whether the limited devolution arrangements have borne any fruit.

A quantitative analysis from the same academics, due to be published this year, could be enlightening.

Back to the future

The shift back to an NHS structure that looks more like that of the pre-Lansley era of strategic health authorities could feel even more pronounced in the north west.

Bill McCarthy, who was confirmed as the new regional director before Christmas, will be familiar to those who were around before 2013. He was policy director at NHS England until 2014, having previously been chief executive of the Yorkshire and Humber Strategic Health Authority and a director general at the Department of Health.  

He has since been deputy vice-chancellor at the University of Bradford and chair of Bradford Teaching Hospitals FT, and has previously worked in local government too.

I understand Mr McCarthy is due to start next month, which should mean he’s involved in recruiting his regional team.

The north west is in some senses a special case within the new NHS structure, as there is already an SHA like leadership in place in Greater Manchester which will want to preserve its limited autonomy. Lancashire also has relatively strong county wide leadership in place, so it will be interesting to see how the new regional directorate slots in.

In this context the north west may have done well to get Mr McCarthy, who is strong on partnerships and doesn’t fit the old dominating regional director stereotype.

Blackpool pleasure

NHS England’s new funding formulas have worked out nicely for some bits of the north west, with Blackpool the main beneficiary.

The new formulas effectively give greater weight to lower life expectancy, but also include new adjustments for mental health and community care needs.

Blackpool was already 3 per cent behind its “fair share” target under the old distribution formula, but is now deemed to be underfunded by around 11 per cent.

Once this has been fed into the spreadsheet, and adjusted for pace of change and other tweaks, it will translate to a 12 per cent cash increase in 2019-20, equating to £32m.

As a whole, Lancashire and South Cumbria is now deemed to be around 0.8 per cent behind target, as opposed to 1 per cent above target. So, its funding will increase faster than other areas.

Greater Manchester will get a smaller share of the pie however, as it’s now deemed to be just 0.3 per cent below target, rather than 1.1 below. Stockport and Trafford will see their fair share target drop the most, with Wigan the only gainer.

Cheshire and Merseyside will also get a smaller share, with the new formula determining that its allocation is 1.3 per cent above target, compared to 1 per cent previously. The fair share targets for Eastern and Western Cheshire will fall the most, with Liverpool gaining.

Google Maps

It’s shaping up to be a testing couple of months for the Lancashire pathology collaboration, after a second evaluation process led to the same Lancaster University site being recommended as the preferred “hub”.

The preferred site is due to be included in a forthcoming outline business case, which must then be approved by the individual trust boards.

This is far from a foregone conclusion, however, as tricky questions will surely be asked about the method used to score the sites, especially on the “distance from geographical centre” measure.

Rather than determining the centre by current activity volumes (weighted heavily in the south), the collaboration has now told HSJ that a “find the halfway point” tool was used on Google Maps. Perhaps I’m naïve, but I imagined there would be a little more sophistication.