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:

  • The multiple challenges faced by Lancashire Teaching Hospitals look insurmountable
  • A review of funding formulas will be watched nervously by commissioners
  • Advanced health economies reject terms for “system control total”

Cracks appear

Emergency pressures left hospitals across England creaking at the seams this winter, with some now showing cracks.

Many of the staff at Lancashire Teaching Hospitals Foundation Trust, which runs hospitals in Preston and Chorley, are now exhausted and have had enough.

Towards the end of last month, I hear consultants at Preston accident and emergency wrote to trust leaders over unsafe staffing levels and dangerous levels of overcrowding in the department.

Then two weeks ago, the Lancashire Evening Post reported how nursing staff at Chorley A&E had also written to the board about having to work shifts of up to 17 hours due to the pressures, and were threatening to start leaving at the end of their shifts if the situation remains unresolved in a month.

This all sounds like enough for the trust board and operations team to have to deal with. But the sense of crisis intensified after the entire senior operations team handed in their resignations.

Operations director Suzanne Hargreaves announced her departure suddenly last week, citing the intolerable pressures she and other staff were having to endure.

Meanwhile, divisional directors Alison Haughton (surgery), Lisa Hulme (medicine) and Nina Russell (support services) have all accepted jobs elsewhere in the last fortnight, which the trust said was a coincidence.

With these senior departures and significant staff unrest, the difficulties facing the FT look daunting.

It is expected to report a £40m deficit for 2017-18, around £20m worse than planned, while performance against the four hour A&E target was around 80 per cent in the three months to March.

Elective performance has been around 83 per cent (against the 91 per cent target), while the trust had one of the highest rates of cancelled operations over the winter and has consistently struggled on cancer waits.

Amid all this, the board is trying to progress with long overdue, highly controversial reconfiguration of its two hospitals, which even without the operational and performance problems would be enough to cause a major headache.

There can’t be many trusts facing challenges of this quantity and scale.

Unspent surpluses

The quiet announcement of a review of NHS funding formulas is worth some consideration for commissioners in the North West.

With allocations beyond 2018-19 still only “indicative”, a low profile paper published by NHS England will spark some nervousness among clinical commissioning groups that are allocated additional funds for their deprived populations.

The report noted how health inequalities are increasing, and effectively questioned how the extra resources are being used.

The answer, judging by the large cumulative surpluses built up in places like Salford, Manchester, Liverpool and East Lancashire, is they’ve partly remained unspent and used to offset overspends in other areas.

This has not been a local decision, of course, but a result of NHSE’s requirement to deliver a 1 per cent surplus each year.

While plenty of CCGs in England have failed to meet this requirement and overspent their allocations, many of those given additional money for deprivation and unmet need have consistently met their requirements

The unspent cash still belongs to the CCGs but is held at the centre and only released when the national bottom line allows.

So, when it comes to making greater progress on reducing health inequalities, NHSE could make a start by releasing this cash. For Salford, Manchester, Liverpool and East Lancashire, their combined cumulative surpluses reached more than £60m at the end of 2016-17 (and will now be even higher). Imagine the difference this could make if it was ploughed into prevention services.

Risk and reward

Greater Manchester and the Fylde Coast were among the “advanced” health economies to reject NHSE’s terms for signing up to system wide financial control totals for 2018-19.

The options put forward by NHSE offered too much risk and no reward, and negotiations are still ongoing around an alternative solution.

As a devolution area with a dedicated system management team, Greater Manchester will be particularly keen to sign up to a regional target and put some of its “provider sustainability funding” at risk, but will want to be offered something extra if the target is met.

Meanwhile, NHS Improvement has changed the rules in relation to sustainability funding for shadow “integrated care systems” in 2017-18. The plan had been to pay out “bonus” payments according to achievement of their system control total, but the payments will now be made based on individual trust targets.

Four senior resignations at struggling hospital trust