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NHS England has dusted off its old box of tricks as it looks to improve the integrated care system financial position in the final months of the year.

Most of the 42 ICSs continued to say they would break even by the end of the year despite running up large deficits in the year so far.

One way to address this apparent discrepancy is for NHSE to hold money back and then release it at the end of the year.

ICSs now talk in board papers of “incentives” to sticking to their financial targets. Kent and Medway revealed that hitting a revised deficit target would “unlock” extra cash from NHSE to bring the overspend down further.

Sources told HSJ that those who “were playing the game” – ie submitted a balanced financial plan, even when this seemed, erm, “ambitious” – were likely to be looked on favourably in this process.

One trust figure said there had been a lot of pressure to use the “usual financing and accountancy tricks” to bring down deficits. They added: “ICSs that have played along with NHSE have been quite likely to effectively get an additional sum of money.”

Heart attacks, strokes and strike fatigue

The ambulance strikes have been going on for two months and seem to be at an impasse. While more union branches have voted to take action, there is little sign of the government bringing forward a better offer.

Two areas are now dealing with strikes with minimal derogations by the GMB – only category 1 calls are guaranteed to be answered, potentially leaving non-strikers to deal with all of the category 2s which have been covered up to now.

In principle, that means suspected strokes and heart attacks may not get an ambulance response although it seems likely that GMB members will step in without a formal derogation if they think patients will suffer serious harm. The decisions are local, based on unhappiness with how derogations have worked so far.

This undoubtedly ups the ante – especially if the public get strike fatigue and start calling 999 in more normal numbers. But it means the game now has very high stakes for both sides, not just the government.

Public support for the unions has been consistently high but people suffering or dying may change this. And the government must fear a backlash from the public. It may come down to who blinks first.

Also on today

North by North West has used a freedom of information request to learn PwC’s 17 recommendations for strengthening financial governance and delivering savings at Liverpool University Hospitals Foundation Trust. And Jonathan Pearson-Stuttard writes that the UK’s problem with economic inactivity could be partly alleviated by better provision of data to ICSs.