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

Whose bill is it anyway?

Wider agendas play out beyond our revelation that government and NHS England are at loggerheads over who will fund the pay uplift for NHS staff working in public health services.

Government currently feels NHS England – whose budget is now benefitting from the uplift announced last summer in the prime minister’s five-year deal – should cough up.

NHSE is declining to pay and is likely to be keen as ever to defend the boundaries of its ring fence: £50m spent here cannot be spent on other NHS priorities, coming from the government or elsewhere.

But wider agendas are also in the mix in this discussion over what is, in relative terms, a drop in the funding ocean for the NHS.

Parts of government, particularly the Treasury, were never very happy about granting the NHS funding deal in the first place, and will be keen to squeeze as much as possible from it. The news comes as the government’s mandate for the NHS, which is meant to set out what money NHSE gets and what it will do in return, has missed its publication deadline (NB: government is also repackaging this as part of an NHS “accountability framework”).

Then there is Brexit – draining political attention, and Whitehall resource, from pretty much everything else.

For NHSE, there is the issue of funding and control of these public health services, which are pretty clinical, close to the NHS, and involve staff normally considered part of the NHS. Many read the NHS long-term plan as making a pitch to take control of these back into the NHS from local government (which strongly resists the idea). At the very least, NHSE seeks to argue these services, which have been cut deeply in recent years, should be properly funded by national and local government. Tacitly, the argument is: “If you want us to fund these services – go the whole hog and give us formal responsibility for doing so.”

Matthew Winn, chair of the Community Network which represents NHS providers of these services, links the issues in an HSJ opinion piece today. The absence of funding compounds the recent cuts, which of course are shared across local councils’ other responsibilities, as their grants from the centre are slashed.

So there is a silver lining to this row in that it will fuel the wider debate – highlighting the lack of funding and the confusion over the split.

The cloud is that, while people will clearly get paid, for many in the affected providers – some independent sector organisations as well as trusts – it means more frustration, belt tightening, and falling into serious financial problems.

Ward vs trolley

Just before the bank holiday weekend, HSJ revealed moves by the regulators to end long waits in emergency departments for mental health patients.

In high-level, advanced discussions, NHS England and NHS Improvement have been considering telling acute providers they cannot keep patients in accident and emergency while they are waiting for admission to a mental health bed, or for a Mental Health Act assessment.

The discussions appear to have been triggered by the high number of recorded 12-hour breaches which are mental health patients. Readers may want to keep an eye on Lancashire where, due to particularly heightened problems, moves have already begun.

HSJ has heard very reliably that a letter to the system along these lines has been drafted, although we were assured one is not actually going to be sent.

The backlash from acute providers and clinicians could explain regulators’ apprehension to take the leap. A glance at the story’s comments section gives an idea how negatively those in the sector would react.

There are many valid reasons providers would not welcome this move. However, there is an argument that, for the mental health patient, waiting in a ward would be preferable to waiting in a loud, distressing A&E.

But several caveats would have to be put in place if more mental health patients were to be admitted into acute beds.

These would include additional mental health staffing to support those patients and controls to prevent patients being forgotten on these wards and never actually reaching an appropriate bed.

The knock-on effect any move would have on those needing to be admitted for physical health problems would also need to be considered.