Ben Clover casts his eye over what is going on in England’s biggest health economy

The worst?

So Croydon has the worst-managed finances of anywhere in the English NHS?

That’s what the “NHS reset” information out from NHS England and NHS Improvement last week seemed to say, with not only the main provider being put in “financial special measures” but also Croydon CCG.

Nowhere else has, as yet, had both.

So what happened? NHS England say the CCG’s performance in the first quarter of 2016-17 is what got it lumped in with Enfield and the other seven special measures CCGs.

The commissioner’s month two position was £2m overspent on plan with its acute providers but didn’t seem that dramatic. Is this a hard line from NHS England now? I can understand that if this endures and a CCG became £24m overspent, it would be a big deal, but I wouldn’t have thought it prompted being put in special measures (which, in practice, means receiving directions from NHS England).

Croydon has long been under-capitated but that position is slowly changing. The borough also had an accounting scandal a few years ago.

The CCG wanted to agree a £9.9m deficit plan for 2016-17 but is being pushed by NHS England to get this down to £4.2m.

The total historic deficit will be between £47.9m and £53.6m.

So what are the real-world things that are having such an effect on the abstract world of NHS finance?

The CCG blames out-of-area referrals for inpatient mental health patients for one thing – it links £2.7m to this in recent minutes. Other run-rate issues have been prompted by new facilities which Croydon Health Services Trust has built to try to cope better with demand.

London Eye wonders how fair it is to dump both the commissioner and provider into special measures when the former has only recently moved to within 5 per cent of the allocation it should get. Ditto the provider trust, just as NHS Improvement tells trusts they don’t have to hit key performance targets (CHST’s A&E performance has recently improved to very nearly hitting the 95 per cent target, from having been a long way off).

Then again – the trust is predicting a deficit of £40m for 2016-17, worse than last year, and terrible on a turnover of £274m.

Everyone knows that south west London might soon be making another deeply unpopular attempt to close services across the patch. A trust in Croydon’s position might therefore see the benefit in building up staff (and at a big loss) to prepare for that.

It might also want to tie itself more closely into community services, something the Croydon trust has had a breakthrough with.

Like Hackney and Lewisham, Croydon is one of those large London boroughs where the acute runs the community services and people wonder if some sort of accountable care organisations is possible.

Work is ongoing to pursue that, and the trust is also now preferred bidder to run urgent care services outside of hospital across the borough.

It bid jointly with AT Medics and the Croydon GP Collaborative. The service is currently provided by Virgin Health, whose contract expires in March 2017.

Uncertainty for patients in south west London

St George’s University Hospitals Foundation Trust’s run of misfortune/incompetence continues with a major waiting times problem.

It has had to admit that it doesn’t know whether thousands of patients were treated, or properly treated, after a failure of its information systems.

The trust has already reviewed cases of people who had not been treated and has not yet said whether patients came to harm and, if so, how much.

Scarily, the south west London trust, home of England’s smallest medical school, has admitted it doesn’t know how much it doesn’t know (or in it’s own words: “The inability of the trust to use its patient administration system as a reliable source of information is a significant problem in designing a solution going forward. Quantification of the full scale of the problem is difficult at this stage.”) It does know that solving the problem will be “expensive”.

St George’s is a trust with a chequered history of senior appointments, which was unable to figure out how much work it had punted out to the private sector, and whose wrongful authorisation as a foundation trust brought ignominy on all concerned.

So, fingers crossed it handled the core business of keeping patients safe better than any of the above muck ups might suggest.

And full credit to the team at St George’s, which is making big strides in turning A&E performance around.

London Eye features a look at what’s going on in England’s biggest health economy. London has the best and worst regarded hospital trusts in the country. It has excellence and dysfunction in commissioning and primary care. I will cover all of this.

As always, if there’s context I’ve missed, things of greater note I should be writing about in relation to this area (or more generally) get in touch confidentially at