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

Breaking the cycle

System leaders are laying the ground for getting performance back on track. This follows years of promising to deliver ambitious targets in year, only to fall short – a cycle which has cost them serious credibility with the government.

The NHS last hit the 95 per cent target in July 2015, and system leaders have promised to get this back on course in each of the last two years. Next Steps on the Five Year Forward View, published in March 2017, pledged most trusts would be fully compliant at 95 per cent by March 2018, and the whole system by the end of 2018.

This has failed. The “rolled forward” trajectory in the 2018-19 planning guidance – aiming to get the system heading in the right direction “within the course of 2019” – is now also unlikely.

There’s been a similar pattern with elective and cancer waiting times.

Yet news today suggests the NHS long-term plan, expected in the near future, might finally break the cycle. An NHS Improvement statement – published alongside its quarter two report today – said: “The long-term plan for the NHS will signal a reset on performance over the next five years…”

That doesn’t rule out unrealistic improvement targets within the five years coming later, but it is a strong signal that some more long-term thinking is going on.

Takesies backsies

As real efficiency savings – in terms anyone outside the NHS would understand – get harder to make, trusts have had to look elsewhere.

It has long been a baffling part of the NHS finance world that “cost improvement plans” could include income. But they do, and it forms an increasingly large proportion of the “savings” across the provider sector.

In most cases this is NHS income, ie: “Let’s do more work than commissioners want us to. Their demand management plans never work anyway.”

This worked fine when there was more money around. But, as NHS England got tougher with clinical commissioning groups, this became more difficult.

NHS England is fiercely retentive about the details of the arbitration processes these conflicts entailed (partly because it encouraged more trusts to challenge, it accidentally revealed. Also, the process highlights the let’s-play-shop nature of the NHS quasi-internal quasi-market).

So could some of the answer be for NHS trusts to do more private work?

Private hospital care is a £5bn industry that depends on your own consultants anyway, so why not try and grab some of that back?

Maybe real income is better than a bogus saving?

The shinier, big name providers have been doing this for some time. As the most recent annual accounts data shows, the top 10 earners from private patients are still all in London. It’s an industry with a turnover of more than a quarter of a billion in the capital, it has big-name medics and can be combined with a shopping trip for the wealthy from around the world (there is also the lucrative embassy trade in London, although try and get your money upfront from Libya).

The news from the rest of England is not as good. Private earning outside the capital largely stagnated in 2017-18.

It isn’t exactly clear why this was, but there is a train of thought that smaller trusts, where there is only one private operator competing, could do a line of low complexity private work quite successfully.

Overall, there is just not that much scope for the NHS to do this. As interesting as it would be to have a private unit do work the NHS will no longer fund or offer richer new parents a sideroom in the maternity unit, it’s not going to dig trusts out of their funding holes.

And considering the main problem is staffing, private work could get harder to justify rather than easier.

Commendable as it is that Basildon and Thurrock University Hospital Foundation Trust trebled its private earnings year on year (they would not explain how, so it could just be a change in where they recorded income) it might sit uneasily alongside figures for NHS treatment showing an increase in waiting times for NHS patients.

Private patients jumping the queue for treatment is a queasier position for the NHS when its own waiting times are rising.

That said, it might still be less contentious than increasing car parking charges.