The budget brings war and peace to the NHS

The chancellor’s speech made it very clear that the social care cash should “deliver immediate benefit to the NHS”. The purpose of the funding boost was confirmed later to HSJ when a very senior government source stated bluntly “the NHS is our number one priority”.

Surprising then that there appears to be little control over how local government will spend the money.

Full flexibility

The Local Government Association issued a bullish statement which is worth quoting at length: “Councils must have full flexibility over how they use this funding to ensure it helps people live independently in their communities and surrounded by their families and friends and to provide support to older people and those with mental health conditions, learning and physical disabilities. Adult social care is vital in its own right, as well as easing the pressure on the NHS.”

The government has the stick of the “tough accountability framework” and an associated penalty regime it is developing for 2018-19 to encourage what it would see as the right kind of behaviour

In other words – ”reducing delayed transfers of care is not the only measure of success for this funding”.

Overall the government would beg to differ – but was nervous about attaching strings to the cash in case it slowed up the commissioning of new social care packages.

Instead local NHS organisations – especially hospitals – will be asked whether action by their local authority is helping them free up beds and be encouraged to get “lippy” if it is not.

What happens then is a moot point – but the government has the stick of the “tough accountability framework” and an associated penalty regime it is developing for 2018-19 to encourage what it would see as the right kind of behaviour.

All of this is likely to encourage a fraught atmosphere between all but the closest NHS and social care partners. The former know their claims that the DTOCs problem is the fault of social care will be weakened by the government’s largesse; while council social service departments, tasting their first drop of fresh water after years of drought, may not, understandably, be in a sharing mood.

Proving credibility

In short the tension is between the NHS’s need to prove its credibility ahead of 2017’s second budget in November – the centre’s letter to trust chief executives issued today asks them to achieve 90 per cent accident and emergency performance by the autumn – and the cultural aversion of local authorities to jump to the tune of central government priorities.

The government is growing increasingly impatient that STPs are taking too long to deliver and will want some strong guarantees that any capital outlay will bring rapid results

But while at a local level the whiff of cordite may grow stronger, in Whitehall there are signs of the May/Hammond government have reached an accommodation with the service’s leadership.

While Mr Hammond twice used the controversial £10bn figure to boast of the government’s support for the NHS, he also did a very rare thing indeed for a Chancellor and presented a hostage to fortune.

“At the Autumn Budget I will announce a multiyear capital programme to support implementation of approved high quality STPs”, he said, nailing his colours to the Five Year Forward View mast almost as firmly as George Osborne.

Mr Hammond even found £130m of capital for Sustainability and Transformation Plans in the next financial year, despite Mr Stevens warning as late as last Friday that he was not hopeful of any immediate capital injection.

But let us not assume all is sweetness and light. The government is growing increasingly impatient that STPs are taking too long to deliver and will want some strong guarantees that any capital outlay will bring rapid results.

This could lead to clashes with NHS England whose desire may be to mix some longer term bets in with the few bankers. There also seems a definite danger of “two speed STPs” beginning to develop as some bids make the grade and others fail the government’s “what do we get in return test.”