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

The man from the Treasury

You can take the man out of the Treasury, but not, it seems, vice versa.

In his first major intervention since becoming the finance director of NHS England/Improvement, former head of public spending at the Treasury Julian Kelly has written to trusts telling them to restrain their capital spending.

As the NHS tries to make the most of the year of relative financial plenty ahead of it to improve performance and deliver service change, long delayed or awaited capital projects have been included in trust plans. Unfortunately, it appears they have read the runes poorly – now is not the time to get building.

Mr Kelly writes: “The most recent provider plans, somewhat understandably, include a significant increase in forecast capital expenditure compared to last year funded by trust cash balances as well as emergency loan requests. This level of capital spend would lead to the NHS unacceptably breaching its capital spending limit…”

The reference to the spending limit was picked up by savvy commentator Stephen Black in comments below the story.

“What’s broken here”, he writes, “is that the NHS budget for capital is not, and has not been for some years, based on any thinking about what the NHS needs to achieve in the long term. It is purely a short-term fiddle to enable DHSC and NHSE to make their annual financial position look less catastrophically poor.”

Connor Ellis, another knowledgeable observer on the NHS’ use of capital, notes: “The irony is private sector capital (which is the only other option if real NHS capital becomes scarce) is virtually at an all-time low, [and] makes this a double whammy.”

Unfortunately, it is actually a triple whammy as Mr Kelly makes it clear he expects to be sending another letter soon, as “the current gap is sufficiently large that we suspect there will still be further work to do”.

Put those plans back on the shelf.

Six-hour target

With NHS England set to trial replacement metrics for the four-hour accident and emergency target, the organisation’s emergency care clinical lead’s suggestion that there should be “zero tolerance” to patients spending longer than six hours in A&E was notable.

NHSE’s emergency care clinical chief Cliff Mann told a King’s Fund conference he was “very keen on having a zero per cent tolerance of people being in an emergency department beyond six hours” because there were no clinical reasons for such a long wait.

But does this mean he wants to scrap the four-hour target and replace it with a six-hour standard instead?

No. He was also keen to stress that a “one size fits all” approach to A&E was no longer viable due to the large variation in case mix seen by different departments.

Could a six-hour backstop be part of a basket of measures used? That would seem more plausible.

Many senior figures in both the clinical and management communities argue one target alone is not enough to performance manage the complexity of A&E and systemwide flow which four-hour performance is currently used as a proxy for. You can read more about why in this week’s Performance Watch.