The must-read stories and debate in health policy and leadership.

Much of the NHS is deep underwater on finances, with little hope of reaching the surface.

But systems like Lancashire and South Cumbria must still show they are trying, after warning NHS England it expects to report a deficit of £200m this year – around £120m worse than planned.

In a recent letter to trusts seen by HSJ, Kevin Lavery, L&SC Integrated Care Board chief executive, wrote: “Starting from 2024-25, we are asking that you work to a planning assumption of a 10 per cent reduction in contract values, over and above organisational cost improvement plans. This is a planning figure and may be subject to change, especially if we negotiate a further level of deficit funding in 2024-25…

“I am asking you to consider what impact a 10 per cent overall system reduction would have to the services provided for our population and the way that services are delivered.”

He said this would include implications for “bringing forward any service reconfigurations and/or mergers, particularly for identified fragile services”, and proposals for the “decommission of services that generate no health gain, or their recommissions at a cost saving to the system”, as well as considerations “in terms of risk” and how that can be mitigated.

Implications for “workforce reductions” should also be considered, he wrote.

Over the last decade, the system’s four acute trusts have had annual efficiency plans averaging around 4 to 5 per cent, which have often been missed, so many in the system will likely take the new demand with a pinch of salt.

Practice makes imperfect

The proportion of the NHS budget spent on general practice is due to fall to its lowest point in at least eight years, according to national NHS spending figures. 

HSJ analysis of the data shows that the share accounted for by primary medical care was planned to fall to 8.4 per cent in 2023-24. 

That is nearly a percentage point lower than three years ago, when it hit a high point of 9.2 per cent, and lower than every other year back to 2015-16 when the figures begin.

Meanwhile, most other services saw their share of the spend gradually increase, except for “other” and NHS Continuing Healthcare. The proportion going to acute services has risen 3 percentage points since 2015 and remains by far the largest area of spend. 

This comes despite the NHS long-term plan in 2019 promising “a new guarantee that over the next five years, investment in primary medical and community services will grow faster than the overall NHS budget”, with a ringfenced fund of at least an extra £4.5bn a year by 2023-24.

That has been knocked off course by covid and the subsequent inflation/NHS funding squeeze. 

Also on today

2024 could be the year of the “neighbourhood” in the health system, for primary care at least, writes Dave West in The Integrator. And Julian Patterson says that it’s no coincidence that as accident and emergency targets have got softer, performance has got worse – but NHSE has a foolproof plan to turn things round.