In 2018, what should the leaders and staff of the NHS do to perform well again, asks Andy Cowper 

There’s a justifiably little known dirty joke in which one of the two protagonists is over describing their sexual performance with a new partner. At the end of the first speaker’s act of rhetorical self love, the other speaker interjects, “yes, but what do you do for an encore?”

That’s the opening question of 2018 for the NHS: what does the system do for an encore?

Many people working up and down the service from the front line to the back room feel as if they’re (metaphorically) getting shafted badly, inexpertly and without love or desire. There is no plan; the system is going through the motions with no technique worthy of the name, and people feel as if they’re getting screwed.

The service needs £4 billion a year to stay upright; Chancellor Philip “Spreadsheet” Hammond came up with £1.6 billion more for 2018-19 and £350 million for winter.

When the nears disappear

Spreadsheet Phil and the Treasury Munchkins are quite clear what they’re doing for an encore: they’re going to wait out the near permanent near universal near crisis in the NHS, until all the “nears” disappear, and then throw in some more money. Late, too little: it’ll be wasted… but they’re either too stupid to realise or too cynical or frightened to care. 

But what can you, the committed leaders and staff of the NHS, do for an encore in 2018?

The first thing you can do is keep clear records of any communications you get that tell you to do the wrong thing for safety and quality in the pursuit of financial balance. Make sure that it’s not a verbal order. Get it in writing. The civil service calls this a ‘letter of direction’.

The second thing you can do is make sure you don’t get isolated. The pressures in the system at the moment are relentless and intense. It is a stupid way to expect a system to work - and as you know, in many places it’s just not working.

Do not get isolated. Get support, and give it to others when you can. Many people in the service do brilliant jobs of acting as shock absorbers, but the wear and tear of this is considerable. Don’t forget that.

To market, to market to buy a fat pig

The third thing you can do is co-operate. The Five Year Forward View, vanguards, sustainability and transformation partnerships and accountable care organisations/accountable care systems add up to a policy Liverpool Care Pathway for the competition elements of dear old Lord Lansley’s reforms. Monitor’s remit to prevent anti-competitive behaviour is nowhere to be found, other than in the Competition and Markets Authority, and even they are starting to see that markets don’t work when nobody’s got any money.

Some of you have already started this. Others of you know you need to, but don’t know how or have no tradition. Well, you’re going to have to invent one. Co-operating with your commissioners, with local government, with the third sector, what the hell, go crazy, even with regulators. Nobody’s got the bandwidth or the plan to stop you. 

The money is Donald

As I wrote above, things will have to reach the point of an undeniable care quality scandal before the finances will be fixed. It’s probably going to have to involve a celebrity or their relative, as Robert Winston’s mum’s bad trolley wait at Charing Cross drove the New Labour opening of the financial taps.

For now, the money is going to remain Donald Ducked. All the signs are that the Month Nine financial figures will see further explicit distress in both the commissioner and provider sectors.

What if anything can you be doing about that? 

There’s not much. The non-recurrent things like land sales are a distress sale: never the best approach. And unless you go into the fraud business, you can’t sell the same piece of land or building twice.

Failing to pay your suppliers just means your cash position looks less bad and the debt still has to be recorded in year. It won’t save anyone, and it really annoys your suppliers.

There might be some productivity improvements available in things like procurement (remember the co-operate thing?) and pharmacy, but there are obvious capacity and capability issues in a system running as hot as the NHS is now. 

The shifting of where we put deficits is A Thing. Deficits used to be put in commissioners in times of big real terms annual financial growth. When the money ran out, providers’ surpluses had to be raided, so tariff was cut and the two part tariff was made up. Sorting out the problems around the two part tariff would help providers at commissioners’ expense (on money they don’t even have).

A 6 per cent solution of nonsense on stilts

There is definitely some lobbying and publicising to be done of the loan interest rates. It is stupid enough that underfunding and over demand means the NHS is having to get loans from the Department of Health at 1.5 per cent; but the 6 per cent DH currently charges to providers in financial special measures is similar to the “double jeopardy” financial system of the late 1990s and early 2000s is fiscal nonsense on stilts.

The NHS is currently paying the DH about £200 million a year on its capital and revenue loans. That is simply bloody stupid.

Spreadsheet Phil and The Treasury Munchkins need to wrap their heads around the fact that once pretty much the whole NHS system is in financial trouble, it’s their problem. It’s the bank debt fallacy, writ large: owe the bank £10,000 and it’s your problem; owe the bank £10,000,000 and it’s their problem. 

A bail out in drag

Phil and the Munchies also need to realise that all these loans to the NHS are not real in the sense that they are not going to be repaid in full. Ever. They are just a bail out in drag.

There are practical issues with the extra money for now (£350 mn winter money for Q4) and the £1.6 bn for next year. There are some numbers floating around from the Spending Review calculations which show that non-elective growth was supposed to be negative: it’s currently running at about 2.7 per cent, with the financial consequences for commissioners and budgets you’d expect.

As for next year, if the new money is targeted on referral-to-treatment waiting times (18 weeks elective, 62 days for cancer et al) but the problems with delayed transfers of care have not been sorted, then the extra money will be wasted and the system logjam will continue.

Moral and morale arguments

There is a moral argument for ensuring that the elective capacity in the system can be used for patients’ benefit: there is also a morale argument. The staff teams want to be doing their jobs, getting patients seen and treated: that is why they trained and what they come to work to do.

Addressing DTOCs will mean getting more social care packages in place: Leeds have been working on a match funding basis with their local council to improve this. The trick is not to get into cost shunting: equal match funding is allowing Leeds to get elective patients through. It’s not costing them nothing, but it’s making their hospital flow work and there is some elective tariff revenue.

There are some reasons to be optimistic: providers and consistently delivering recurrent efficiencies in excess of the 2 per cent that both government and independent analysts have deemed reasonable (the Carter agenda, GIRFT, etc).

There are some reasons to be pessimistic, too: the Treasury Munchkins are not reasonable people.

Best wishes for 2018, and good luck to you all. 

Watch your backs - and watch each others’ backs.