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

A good week for candour

Its been a good week for candour. Today, NHS Improvement finally admitted reality on provider deficits and the government’s pick for NHS England chair was pretty blunt on what has to change (see below).

But finance first, and when a new boss comes in, they will often emphasise the scale of the problems they inherit.

This helps ensure there are realistic expectations and makes it slightly easier to be perceived as a success.

So, it is probably no coincidence that NHSI’s long awaited acknowledgement of the underlying provider deficit has come under a new health secretary.

In its first quarterly report of 2018-19, NHSI admits the provider sector is carrying an underlying deficit of around £4.3bn, once the non-recurrent “provider sustainability fund” is discounted.

HSJ first highlighted the underlying deficit two years ago, following analysis by the Nuffield Trust think tank.

The Department of Health and Social Care has previously dismissed the warnings, saying “we do not recognise these claims”, while regulators have never acknowledged the situation publicly before (privately they did).

So, Matt Hancock now has a get out card if/when the long term funding plan starts to go awry. He can simply point to the fact that the NHS is starting from an underwater position, and just getting back to surface will quickly eat into the additional £20bn.

Meanwhile, NHS trusts have forecast a combined deficit of more than £500m this year, despite an earlier commitment from regulators that they would break even.

In February, following an additional allocation of funds from the DHSC, NHSI and NHS England said the provider sector would “plan and deliver a balanced income and expenditure position” in 2018-19.

The year to date position and the pattern of deterioration in previous years suggests that delivery will be challenging. Trusts have already reported a deficit of £814m after the first three months.


Prior on changing provider psychology

A lot of the NHS’s legislation, policy and financial incentives are antithetical to delivering integrated care and system working.

A commonly held view these days, but not one previously put quite so clearly by an NHS quango chief.

So Monday’s NHS England chair pre-appointment hearing with the Commons health committee was too good an opportunity to miss for the government’s nominee, Lord David Prior.

He made it clear that, in his current role as a foundation trust chair (University College London Hospitals), he would have received no thanks or credit from its main regulators – NHS Improvement and the Care Quality Commission – for reaching beyond its statutory duties: ie, trying to help with “the system”.

This means that if providers are to stop acting as “islands in the sea”, instead working to help their populations, neighbours, and wider patches, there is a need for “very, very fundamental” changes across the board.

Lord Prior said that for 25 years the NHS had encouraged trusts to “look out for themselves and not the system” and the “whole psychology” behind this has to change if integrated care systems were to work. He also said integrated providers needed to be NHS organisations. A pretty significant shot across the bows for independent providers.

Parts of what he envisages is already on the cards, but equally it it is far from a done deal.

Most people, NHS England and Improvement included, want a move off the payment by results tariff and provider control totals – but to what, and how fast?

National officials would like legislation. But there seems a slim chance of getting it through Parliament. And is there really consensus about clipping FTs’ wings?

In the meantime, everyone has a clear excuse not to work as a system.