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

Given the desperate nature of NHS finances, you can’t really blame trust chiefs for trying their luck with elaborate accounting tricks.

With “control totals” and “provider sustainability funding”, trusts are encouraged to spend time fiddling with their balance sheets to help make the headline numbers look better.

A complex transaction undertaken between University Hospitals of Derby and Burton Foundation Trust and its charity arm was the latest to test the auditors.

It involved the trust selling long-term leases for its buildings to its charity, and then renting them back from the charity on shorter-term deals.

For the charity to afford the £210m premium payment for the long-term leases, it has taken out a loan financing facility with the trust. The charity’s rental income from the short-term leases then funds the interest payments on the loan, as well as its other activities.

Meanwhile, the “book value” of the assets on the trust’s balance sheet was around half the sale price. So, the trust expected to benefit from a £102m “profit on disposal”, thereby boosting performance against its financial control total by the same amount, and triggering around £60m of incentive and bonus payments as a reward.

The trust said all this was supported and agreed by NHS Improvement, the Charity Commission, the trust board and council of governors.

Although the deal went ahead, the accounting treatment that gave rise to the financial boost was ultimately rejected by external auditors, which scuppered the £60m.

So the trust and its charity are now left with an intricate loan and lease-hold arrangement which appear to serve no purpose. They said they are working to “agree next steps”.

Give peace a chance

Being a medical consultant is an important, consuming and difficult job.

That needs to be acknowledged before pointing out that at any given time across the NHS there seem to be lots of acrimonious disputes between senior clinicians and management, or between senior clinicians and other senior clinicians.

Whatever the rights and wrongs in the case involving Jayaprakash Gosalakkal this week, the terrible working relationships in the Leicester paediatrics unit is well-trodden ground.

There is no doubt that patients suffer when service lines are so fractious that clinicians refuse to work with one another.

The litany of complaints and countercomplaints in cases like these are familiar: grievance procedures within the trust, grievance procedures at the private hospital they work at, disciplinary procedures, referrals to the Care Quality Commission, referrals to the General Medical Council, referrals to counter fraud authorities and sometimes referrals to the police.

These conflicts eat up years of clinical and management time, cost millions in legal fees and have a difficult-to-calculate effect on patients as lists are cancelled (sometimes at short notice) and locums hired.

How many of these conflicts, like the one described in the Gosalakkal court papers, are going on at any given time?

Hard to say, as they mostly surface through employment tribunals or other legal proceedings. The Royal Colleges, often called in to investigate and adjudicate, might have an idea, as might Practitioner Performance Advice (formerly the National Clinical Advisory Service) but these bodies are far from open about the numbers.

Is there something in the way the NHS is organised that allows these issues to fester? Or exacerbates them?