What NHS England isn’t telling you, and more indispensable insight for commissioners, by Dave West.

Limiting the NHS offer

In its terse response to last week’s budget, NHS England promised a “difficult debate about what it is possible to deliver for patients with the money available”, and that it would kick this off at its board meeting on Thursday.

Some see this is as a misstep – a further foray into territory that should be left to Parliament. For others, it’s a noble and necessary move to fight for the NHS and lead when the politicians will not. A third group may see it as a dramatic presentation of decisions about affordability and value that are nothing new for those running the health service.

Certainly, it was not a complete about-turn for the independent national commissioning board. Over the past year, NHS England has moved to formally delay the introduction of approved, cost effective drugs, and began the capped expenditure process to provoke “thinking the unthinkable”. Its default reaction to local access restrictions (aka rationing) has changed from condemnation to endorsing them as “difficult choices about what can be afforded within the funds parliament has made available”.

A decisive point came in the spring when, catching government on the hop, NHS England astonishingly secured its permission to publicly declare elective waiting lists were not a priority and would grow.

Although all this highlighted the NHS’s financial squeeze and inevitable trade-offs, in the first instance it was mostly the result of an intense determination to try to stay within budget (something the commissioning side has largely achieved).

The NHS England board this week needs to do similar: drive home the message that ugly trade-offs will be unavoidable, take some unpopular decisions to help balance its books, and pave the way for more.

Its options will take the NHS further in all the areas already broached.

Measures discussed locally in the capped expenditure process could be nationalised – for example with more central coordination of access restrictions and waiting times. Royal colleges have already identified interventions with little or no benefit, and there is some NICE evidence in this area too, but so far little national action has been taken.

The programme already under way for cutting some prescriptions can be extended to new – more contentious – medicines; and the introduction of expensive new drugs slowed further both nationally and locally. Another swipe at community pharmacy contracts is likely too.

But at the centre of the debate will be the government’s delivery priorities for the NHS. Simon Stevens’ pre-budget speech offered the “difficult choices” of growing the waiting list further, staffing retrenchment, and compromising ambitions on cancer and mental health - the latter a clear prime ministerial priority.

A longstanding conundrum of NHS savings is that services most in need of expansion – prevention and social support, and particularly mental health– are the first to suffer cuts. They are less driven by demand at the front door and rely on discrete new funding pots, ripe for raiding.

Trying to escape this, NHS England’s deal in the spring prioritised mental health, cancer and primary care at the expense of planned surgery. NHS England could argue this was the best course and will need to continue; but that might require a change to NHS constitution standards, which government has made clear it won’t wear.

More technical options include cutting contingency and risk funds (which would presumably make the Treasury a little shaky) and making steeper cuts to management costs (undoubtedly on the table but subject to ongoing wrangling).

The above are largely commissioning budgets and policies. Simon Stevens and colleagues, with NHS Improvement’s new bosses, will also have to decide how to approach the business of providers. Most NHS costs are ultimately committed in the £80bn trust and foundation trust sector, where there are also huge choices and trade-offs.

Uncharted waters

Government/NHS rows over the budget and delivery asks are nothing new.

Where there is uncharted waters is in the move by the independent national commissioning board – the closest thing we have to an NHS head office – to make the trade-offs a matter of high profile public debate. I suspect it is also unprecedented for the closest thing we have to a national NHS chief executive to be openly saying it is impossible to deliver totemic targets; and so blatantly at loggerheads with government.

National Voices, the umbrella group for many patient and public organisations, said in a stark warning on Friday that making “significant reductions to the NHS offer… is properly a matter for ministers and Parliament” – though, it acknowledged, NHS England may be right to step in to avoid a “wave of piecemeal, short-termist rationing decisions”.

NHS England’s first chief executive, Sir David Nicholson, who had the foresight to start webcasting its public board meetings, perfect for occasions like this week, suggested its role was “not to tell the public what they can’t have but present the government with options and choices… and do it openly and transparently”.

The board’s post-budget statement was in the name of chair Sir Malcolm Grant, which could be a sign that, with the mud already flying in Mr Stevens’ direction, more of the noise will be made by Sir Malcolm in the run up to his term on the board ending next autumn.

If NHS England’s stand up row with government ultimately succeeds – changing enough minds in Parliament and government to get NHS funding back on an even keel – it could potentially be the making of the independent board.

But it has angered many civil servants and politicians in Whitehall, and if the chance arises then the episode could equally lend them another argument for reining the independent NHS back to the Department of Health.