The targets the NHS will have to hit this winter

The targets may yet be officially reconfigured to reflect the virulence of the second covid wave. More likely is an approach which gives flexibility to trusts under demonstrable pressure, while also setting thresholds for central intervention when organisations are either struggling to cope or where underperformance is not justified by pandemic pressures.

As NHS England chief executive Sir Simon Stevens told the BBC’s Today programme on Wednesday, there is unlikely to be a repeat of a nationally-mandated ban on electives. Decisions will continue to be left to local leaders as promised.

Getting as close as possible to the phase three targets will be important, but achieving the best possible combined outcome will be even more so.

Some trusts have done better on increasing activity than many (including sometimes the trust itself) thought possible and keeping up that momentum is deemed crucial. There is also a welcome and understandable desire to make sure trusts that fail to meet agreed activity levels are not penalised financially if they have done all they can to manage the pressure they are under.

Activity could well be measured at system level across groups of trusts. This will focus attention on mutual aid – which has been an important, but not always consistent factor in the NHS’ response to the pandemic.

That system-level approach might well also include the work that is done on the NHS’ behalf by the private sector. The national deal struck in the spring is being replaced in the near future by one which creates more local sensitivity and control. A reversion to centrally-controlled procurement is still possible as the covid pressure builds, but giving system leaders all the levers of activity in their area has the attraction of both incentivising the sharing of workload and removing one of the excuses for poor performance.

Stevens sets the record straight

This week’s round of media appearances by NHS England chief executive Sir Simon Stevens were partly a recognition that attention was turning from the government oversight of the pandemic response, to the NHS’ part in it.

Sir Simon has been content to let government lead on matters of public health, but now the second covid wave has started to impact NHS performance, he is keen to prevent the idea taking hold that the NHS was not well prepared for this year’s unique winter pressures or that it is closed for regular business because of the coronavirus surge.

He has been at pains to stress that the tide is rising everywhere – and that in capacity constrained areas like the south west the rapid increases in covid admissions currently being experienced, though relatively small in number, can impact on activity quickly and severely if unchecked.

However, this most politically savvy of public service leaders, is also aware there is considerable expectation in Westminster and Whitehall, not to mention the media, that “routine” services will be restored and maintained in those parts of the country less affected by the second wave, which effectively means most places south of Birmingham.

Sir Simon has, long before the pandemic, stressed the importance of the NHS building and maintaining credibility with government stakeholders, especially Number 10 and the Treasury. Trust chief executives whose organisation’s under-performance is not justified by covid can expect some difficult conversations.

Ask not what the NHS can do for you prime minister

The NHS England chief is likely to be just as robust with government about the need to not only meet the continuing extra costs created by covid, but also to provide the investment in diagnostics and other extra capacity needed to stop waiting lists ballooning beyond control.

When HSJ asked Boris Johnson yesterday if he would continue to honour the promise of giving the NHS what it needs to fight the pandemic, Sir Simon felt the need to step in to help the floundering prime minister.

In doing so, he pointed out that predictions of a 10 million strong NHS elective waiting list made during the summer were way off the mark thanks to the service’s success in recovering activity (as well as a huge drop in referrals of course). But it will not have been missed, however, by those who he is negotiating with in government that something approaching that remains a possibility unless they find a way to provide the funds needed in this month’s spending review.

Sir Simon also refused to say whether a four-week lockdown would be long enough to ease the pressure on the NHS. Only time would tell, he observed. The government knows he will be, therefore, asked the question again in December which gives them a big incentive to make sure Sir Simon is feeling confident about the future.

Whether a Brexit-distracted government at war with its own back-benchers can deliver is another matter entirely.