Daily Insight: Speaking truth to (the new) power

The reputation of Steve Barclay – who was made health and social care secretary only on Wednesday – precedes him. And it is that he hates spending more on the NHS. He is towards the extreme end of the spectrum of right-wingers who believe the NHS is a cash-hungry inefficient blob.

So it was apt, if also bold, for NHS England to give a stark message on its finances in public at its board meeting on Thursday.

Its great fear is that government will award a pay settlement for NHS staff above 3 per cent, in light of sky-high inflation, but that the Treasury will say it must be paid for from within existing NHS budgets rather than with new money.

As chief financial officer Julian Kelly set out at the board meeting, financial plans were already tight. The NHS, since last year’s spending review revenue settlement, has already swallowed the impact of the rise in inflation since then – meaning it is effectively seeing the first real-terms cut since at best 1997 and probably since the 1950s, as Mr Kelly put it. It has also given up some budget to help the Department of Health and Social Care with covid testing costs.

Each 1 per cent pay growth above the 3 per cent it is funded for will, on paper, cost the NHS between £900m and £1bn.

Mr Kelly’s boss Amanda Pritchard made clear she supports a decent pay rise – both as an “an operational necessity” for retention and because of fairness – but that NHSE had to be clear and honest about the consequences.

Total clarity is rarely a strong point NHSE finances, but the CFO was certainly stark – indicating that cancer services and primary care would be likely victims if it were forced to make cuts, along with planned capital investments in community diagnostic centres (also central to plans for improved cancer waits and outcomes). In his board paper, elective recovery was also noted as a candidate.

Sadly one suspects that in reality the victims would be more Cinderella in mental health and community therapies, for example.

Mr Kelly also asserted that the NHS’s spending review settlement from last year is based on lower levels of covid circulating – whereas right now we’re looking at a never-ending wave of substantial omicron, with associated staff absence and infection control costs.

Richard Meddings, former banker and now NHSE chair, repeated his emerging mantra about the need for more “capacity” – particularly underlining the need to increase NHS staffing – and said he would be banging the drum on this in every board meeting until the general election (NB: HSJ’s assumed target date).

We’ll soon see how Mr Barclay – whose early briefings will be shaped by the DHSC, with the NHS largely kept at arm’s length – responds to all that.

The NHSE board did have some announcements which might come as warmer news to the new secretary of state.

It has kicked off discussions with staff about cutting at least 6,000 whole-time equivalent posts across NHSE (now also incorporating NHSI), NHS Digital and Health Education England – the latter two of which are due to merge into NHSE next April. Together, along with some posts transferred from Public Health England, the new beast would amount to around 20,000 roles if there were no reductions.

NHSE has also asked its non-executive director and former retail big-cheese Jeremy Townsend to carry out an “efficiency stocktake” across the service, covering procurement and other matters. Ms Pritchard and Mr Kelly were keen to stress that – contrary to the expressed views of Mr Barclay – the NHS’s starting point for this is an already very efficient baseline.

The ethical minefield the NHS can no longer ignore

Everyone broadly knows what inequality looks like when it comes to care access, but do we know what equality looks like? On first blush, it sounds simple enough: everyone should get equal access to services and those with the greatest clinical need be seen first.

Except, of course, it’s not that simple. While some patients can advocate for themselves and families, others cannot or are far less adept at it. While some patients have jobs which will allow them to take time out to go to an outpatient or GP appointment, some less fortunate, perhaps on “zero hours” contracts, may not be able to.

The list of these sorts of economic and social differences is endless, and the result is growing health inequalities.

Of course, many of these societal inequalities are not solely within the NHS’s gift to address. But there is broad consensus there is much the health service can do to start closing the inequalities gap in access to health services.

That is why University Hospitals Coventry and Warwickshire Trust’s “agile waiting list” project, which is developing a system that takes “social value judgements” such as the deprivation level of a patient’s postcode into account when scheduling elective appointments, is such a must-watch story.

We explore the issues in Recovery Watch here.

Clearly the clinical priority must dictate care but if the NHS is as serious about addressing health inequalities as its leaders say they are, then grappling with these highly sensitive ethical questions must be prioritised. Sadly, there will be no easy answers.