The recent resignation of a major London trust’s chair leads to some tough questions for the national regulators and the provider sector about the ongoing healthcare mess, notes Andy Cowper

When the former head of the civil service resigns publicly as the chair of a major London NHS trust, you’re looking at more than a little local difficulty.

When Sir Bob Kerslake (who knows the running of government and the national media about as well as any) uses the Monday morning national media to say “I have concluded that the government and its regulator, NHS Improvement, are simply not facing up to the enormous challenges that the NHS is currently facing.

“This is especially true in London where the demands of a rapidly growing population are not being matched by the extra resources we need”, you’re into A Whole World Of Interesting Things.

The takeover effect

Sir Bob’s resignation letter – sorry, national media article – notes that “the hospital has struggled financially since it took on responsibility for another hospital, the Princess Royal University hospital in Bromley, in 2013”.

Here we got almost instant corroboration from the very regulator Sir Bob had just criticised, as HSJ itself rush released an interview with NHSI’s outgone chief executive Jim Mackey, who noted that he was frustrated in his efforts to help King’s College Hospital Foundation Trust improve its position because the organisation “hasn’t hit a single number that they’ve put to us in the two years I’ve been involved in NHSI… they have been various forms of escalation that haven’t improved their position, and that’s going to have to be addressed.

“We’ve been round the loop lots of times about what has to happen in King’s because the numbers are huge. And honestly, I don’t think they have in my time hit a single set of their reforecasted numbers.

“And honestly, I don’t think they (King’s College) have in my time hit a single set of their reforecasted numbers”

“The team at NHSI that was involved in that was incredibly reasonable. More reasonable than you would expect about trying to reset a reasonable ask, and then get them to get into it and get ahead of it. And even then, they don’t manage to get there”.

Mmmmm. You have to wonder why NHS Improvement chair Dido Harding is alleged to have asked Sir Bob to consider his position on Friday.

So what’s happened here, over and above a healthcare system, that’s just running out of money and running into the brown stuff, as this column has chronicled for some time?

Gimme some truth

There is a wholly reasonable challenge that former NHSI chief executive Jim Mackey has made above in regard to the failure to deliver on the finance numbers.

That is more than slightly negated, however, by the generally acknowledged sheer improbability of the great majority of the system control totals on which system leaders have insisted. And indeed by Jim’s valedictory speech to the NHS Providers conference, which was a classic of the “who’s been in charge round here these past few years?” genre which the NHS loves so well.

The White Queen in the Alice In Wonderland books insisted on her ability to believe six impossible things before breakfast.

That said, the system control totals are beginning to pose an interesting pair of questions to both national regulators and the provider sector.

These ask the former NHS Improvement and NHS England teams, “why did you bully trusts and clinical commissioning groups into accepting unrealistic plans?”

And they ask trusts and CCGs, “why did you ‘comply and lie’ with your plans and forecasts?”

Questions and times

These are not easy questions of course. Because these are not easy times.

‘Nice customs curtsey to great Kings’

But there are pertinent points to make about Kings, which are locally distinctive.

For one thing, big London trusts have always made their own political weather - and probably always will as long as Parliament remains in Westminster.

For another, it wouldn’t hurt the system to understand some of the following.

It would be easy and tempting to blame Kings’ former managers, but that is not the entire the story. Insiders knew that the merger plans were a major case of PRUHdence without a purpose

The end of the Project Diamond money started a funding crisis, with what many perceive to have been politically driven health funding decisions.

We know already that the post 2000s funding boost has left the system with A Lot of sub specialisation; with sub optimal primary care; with a transient management workforce and so with reliance on interim management.

Add to this what many (Kerslake included) perceive as arrogant regulators, and a sense of clinical administration being something transient and temporarily driven, you’re looking at an environment that’s virtually made to make mistakes.

But nor is it that alone: human capital factors have big impact on city institutions: administrative and management roles in London are relatively low paid jobs in London’s over heated economy.

And whilst talent exists, there is an over reliance on temporary, transient labour and a long history of complex political relations between The Big Smoke’s commissioners, providers and regulators.

Put simply, the NHS has unbelievably talented clinical specialists living and working in London. But many front line staff in the capital think that basic operational content and delivery of standard health services is lacking.

It would be easy and tempting to blame Kings’ former managers, but that is not the entire the story. Insiders knew that the merger plans were a major case of PRUHdence without a purpose. Acquiring a trust with no seriously functioning IT or reporting plans, and with seriously deficient real estate, is not a good look: indeed, it’s likely to be dangerous.

This is A Bad Lesson for the system to learn at a time when there are not a few providers under water and in need of rescue.

Equally, many providers are familiar with the sense of CCGs running out of money, and the failure of many actors to recognise the need for local health economies to act as a system.

Oh, and you probably wouldn’t want to have been outsourcing HR at around the same time you were acquiring another in trouble trust. 

To put icing and hundreds and thousands on the cake of chaos, the absence of any willingness to commission any more emergency care left the region’s providers just squabbling every night. There could be some sharp questions to ask of the national system leaders responsible for that area, in both the commissioning and provider areas.

The mess is ongoing. Kings is not unique. Its mounting financial problems are at least an issue on which the system is and was sighted

Kings Commercial is also worth some consideration. A sensible person might wonder whether hospitals report less money due to giving their services to commercial arms and then not paying profit back in to the NHS core business.

The mess is ongoing. Kings is not unique. Its mounting financial problems are at least an issue on which the system is and was sighted. 

Other problems are steadily emerging – problems of finance and quality. It would be nice to feel the system leadership were sighted on these problems. But I am not sure that is the case.

There have been clear incentives for these problems to remain unseen, and guess what? They have remained unseen. They will not remain so. The clock is ticking. It always does.