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

Making an NHS omelette

Last December, a senior Department of Health and Social Care official said trusts should not be “overly worried” about having income withheld to fund the new NHS Supply Chain’s operating costs.

Jim Craig told an audience at the Health Care Supply Association’s winter conference that the impact on trusts would be “quite small” and indicated savings would start to be felt in 2019-20.

However, 11 months later, a handful of trusts may beg to differ after finding they face making a net loss from the implementation of the new NHS Supply Chain model next financial year.

These trusts, of which HSJ understands there are around 20, could rack up losses between six and seven figures, depending on the model’s success.

Viewed through a national lens, the old proverb about breaking eggs to make an omelette springs to mind.

After all, less than 10 per cent of trusts are negatively affected, and their net losses are very small compared to their overall turnover.

But, from a trust’s point of view, losing a six figure sum could have a crucial impact on the organisation’s financial performance.

The sense of injustice may be magnified at some of the trusts, which – HSJ understands – ranked in the top quarter of NHS Improvement’s recently updated procurement league table, which measures procurement efficiency.

Ultimately, national chiefs hope the losses can be recouped. It is anticipated NHS Supply Chain will expand its market share and deliver hundreds of millions of pounds in savings overall.

But, in the short term, the model looks set to create another burden for local finance directors of the negatively affected trusts. 

Grim tidings from the regulators

NHS Improvement and the Care Quality Commission would probably rather draw a veil over what happened at North Middlesex University Hospital from 2014-2016.

As the NHSI commissioned Deloitte review made clear, the combined regulatory might of themselves, the CQC, Health Education England and the General Medical Council failed to react quickly enough to a dangerous accident and emergency department.

This was a situation that saw a patient discovered dead in a corridor and 15 out of 18 junior doctors reporting being asked to do things they did not know how to do.

Although Wellington House commissioned the report, it would not say which part of it had done so.

It also claimed it was only its desire for thoroughness in consulting with the other bodies that dropped the ball which saw the report released yesterday, 10 months after its completion.

If anything, the huge delay while NHSI consulted with the other (statutory) bodies points to just how inefficient inter agency working is.

The CQC in 2014 failed to spot an A&E that proved to be dangerous, rating it only “requires improvement”.

That is not a great sign of its effectiveness in protecting the public.

That the HEE chief executive had to write directly to the CQC chief executive two years later to get them to reinspect is even worse, especially for a system working under the most patient safety focussed health secretary ever – what will it be like under the “executive chairman”?

This all took place as the CQC was beginning its four year journey to working on a budget reduced by 12 per cent.

How does everyone else come out of the report?

The Trust Development Authority (now subsumed into NHSI) was underresourced but, more importantly, “lacked appetite” for the task. TDA medical director Kathy McLean is now NHSI’s medical director, and then regional chief operating officer Andrew Hines is now director of corporate development at Barts Health Trust.

Although directly responsible for regulating NMUH, the TDA/NHSI was eclipsed by NHS England, because of the “strong characters” there, the report said. The body’s NHS operations and delivery director Simon Weldon is now at Kettering General Hospital Foundation Trust, which needs the help.

It took HEE writing to the CQC to prompt a reinspection, but its previous warnings were not given the “weight” they should have been by the rest of the system. They were also perceived as being too ready to use the “nuclear” option of pulling out their trainees (something that would have brought north central London’s urgent care system to a halt).

Haringey Clinical Commissioning Group took an early lead at NMUH but later bore “undeserved” criticism, in Deloitte’s view, having been “forced into a role to compensate for weaknesses at NHSI”.

Since 2014, CCGs have got a lot smaller.

How assured should we be that these bodies will regulate dangerous services better in the future?

Deloitte said NHSI should reflect on whether it had enough money to “tackle structural issues at challenged trusts”, and on whether its approach encourages trusts to conceal their difficulties.

The evidence is not that NHSI is now better resourced or gentler (although the exec chairman has signalled a move towards firing fewer chief execs).

The closest the story has to a hero is HEE, which will soon report direct to NHSI.

But that’s okay as long as it retains its ability to prompt the rest of the system into action, right?

Well, NHSI has rejected the main recommendation in the review – that an independent chair should be appointed in situations like this, someone “not influence by pressures facing individuals and their respective organisations” – so that’s far from certain.