London Eye: It’s that can again

Dis-integration

So London Eye might have been too hasty in considering north central London the least advanced in terms of acute provider collaboration.

Earlier this month, it seemed reasonable to say the shared exec directors plan between Barts, and Barking, Havering, Redbridge – along with their single chair (Jacqui Smith, of Labour home secretary/Strictly Come Dancing in 2020/chairing-UHBirmingham-during-the-period-featured-in-Newsnight fame) – put north east London ahead of NCL.

Now they have backed away from the shared exec scheme, and the press office did not respond to HSJ when we asked about reports that this was prompted by a revolt among staff.

Then at the end of last week a statement issued by Barts (note, not a joint Barts/BHR statement) said, actually, yes that idea was being “paused” to better focus on developing other parts of the acute provider collaborative.

The APC includes not just BHR and Barts but also Homerton University Hospital Foundation Trust, which sits in the middle of NEL and in the top decile of most performance tables.

So why the back pedalling?

Sources describe resistance from senior medics at both ends of the patch.

At BHR, concern is said to centre on the fear that closer working means more work going into zone one, and a de-specialisation – with neurosurgery thought particularly vulnerable.

At Barts, a source said consultants were wary of greater integration, and there was a sense their BHR counterparts were “a bit feral”.

To be fair, there is some decent integration going on already. More elective work is being transferred between the different acutes in NEL, a famously tricky process but being achieved. Barts and BHR do have some joint consultant posts and three non-exec directors in common.

So there is progress (and still better progress on the other fundamental, urgent care. BHR’s turnaround of accident and emergency performance is one of the most significant developments in the capital’s acute sector in years).

But as another source put it: “What’s going on at King’s might make them risk averse about having one finance director across two financially troubled organisations.”

What is going on at King’s?

A senior leader told London Eye last year that asking integrated care boards/trusts/systems to submit knowingly fictitious financial plans undermined local management teams.

“We’re supposed to be modelling good values around honesty,” they said, and argued south west London’s insistence on sending through a deficit plan reflected principled management.

HSJ has reported on reality-adjacent plans butting up against reality across the country, but the unfolding finance issues at King’s College Hospital FT ask some important questions of the new systems, and their relationship to the centre.

For starters, KCH has always had an underlying deficit of around 10 per cent of turnover. This position has endured many different management teams, many different oversight systems.

Yes, £80m (thought to be the deficit which has just surfaced at KCH) is a lot of money, but in the KCH context (£1.6bn turnover), well, we’ve seen worse.

Denmark Hill erupts like a volcano fairly regularly. A few chairs back, in 2017, the late Bob Kerslake resigned saying: “There are undoubtedly things I and the trust could have done better – there always are – but fundamentally our problems lie in the way that the NHS is funded and organised. We desperately need a fundamental rethink. Until then, we are simply kicking the can down the road.”

You have to wonder about a central oversight system that lets KCH exit financial special measures in December 2022, then has this happen.

Here we are, seven years down the road, with the same can. Last time the finances erupted at KCH the tension was between them and the now abolished NHS Improvement.

Now the situation asks serious questions of the ICB and other trusts in the patch, considering everyone is supposed to be pooling budgets.

The management question is for NHS England and whether the whole of SEL gets triple-locked on spending, as has happened in south west London, or whether it’s just King’s which will be subject to this stringent approvals process.

Let’s not forget KCH was in the top 1 per cent of mortality performance in the covid years, and its intensive care teams led much of the region’s pandemic response – the high standard of most services there should not be forgotten.

Also worth remembering KCH is not the only London giant whose deficit has a tendency to resurface. St George’s chair Christopher Smallwood stepped down around the same time as Bob Kerslake, after one of its regular financial blackholes opened up, and said it was “working extrordinarily hard in impossible circumstances”, blaming politicians for “the damage their neglect is doing”.

To be fair, at that time, St George’s internal controls were slack to the point of prolapse. And the then-NHS Improvement boss, Sir Jim Mackey, said everyone had these pressures but an engaged management team would be “kicking windows out” to make the finances work. If the Treasury didn’t face such shenanigans dealing with NHS finances it might allow sensible measures like multiyear budgets. 

But then if the government funded health and social care like other European nations we could have a more grown-up system generally. In the meatime, finance directors do their best to protect frontline services from blithely ordered central savings targets.