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

Two to tango

NHS Improvement chair Dido Harding told private providers the seven new regional directorates would become “fiefdoms… over my dead body”, as she sought to reassure them the NHS would become more open to using their services.  

She pledged a more collaborative culture would be fostered and said she accepted criticism from independent sector providers that the NHS was “shutting them out” of discussions and service provision.

In a critical assessment of the NHS’ current ability to work collaboratively with other NHS partners as well as independent, voluntary and council organisations, she said there was more collaboration in the “cut throat” world of telecoms than in the “supposedly caring health and social care sector”.

She warned it would take time to change the culture but insisted the wheels were in motion.

Even the most ardent of NHS defenders would struggle to argue its constituent parts are good at integrated working or that a more collaborative culture would be anything other than a good thing. 

There is, however, good reason why the NHS is often sceptical about private sector involvement – namely a lot of overselling and underdelivering, from the disastrous franchising of Hinchingbrooke Hospital to the ongoing debacle involving Capita’s failure to send out 48,000 cervical cancer screening letters.

These are, of course, exceptional examples.

The argument that the NHS must change its culture and approach to the private sector is a valid one. But private sector providers must also consider their approach to the NHS and why they are often greeted with such scepticism.

It takes two (or more) to tango and cultural change will be required on all sides.

King’s of the deficit

It will likely be a while before King’s College Hospital Foundation Trust comes out of financial special measures.

The trust’s finances have imploded pretty spectacularly over the past 18 months and the report commissioned from PwC does not give a lot of detail on just how NHS Improvement came to be quite so surprised by its repeated reforecasts.

Poor financial grip on issues like accruals – where lots of trusts get into trouble – was part of the issue but the root causes were more fundamental.

King’s made heroic assumptions about how much income it could generate, within and without the NHS. This started to edge out what you might actually think of as run rate savings.

Common wheezes are deleting vacant posts for a paper saving but not a cash one, or renegotiating multiyear contracts with a supplier that show a saving at the beginning before ramping back up again.

The question is not how things came to get so bad at King’s. It is how many other trusts are sitting on 2018-19 cash positions that are far, far worse than they’ve told anyone.

This is why the Treasury is uneasy about putting money the NHS’ way. How sure can it be a provider sector 60 per cent composed of legally independent foundation trusts aren’t all going to try and income their way out of trouble and bust the budget?

The other cause of the deficit? They hired a load of doctors and nurses.

What the public would hope a hospital would do, but again a problem for central NHS bodies who appear not to have known the trust was going big on recruitment (to hit waiting time targets and provide safe care) until the finances had comprehensively tanked.

What regulatory intervention saw the trust decide to spend £40m more on staff in 2017-18 than it did in 2015-16?

How much of the organisation’s £138.9m spend on purchasing healthcare from non-NHS providers was the outsourcing of big slugs of elective work?

These are questions to which we do not yet have answers.