The sturm und drang surrounding November’s Budget – with the government claiming it had given the NHS enough cash to meet accident and emergency and elective targets and NHS England publicly disagreeing and saying “hard choices would have to be made” – suggested an imminent collision between Simon Stevens and his supposed political masters. But it appears Jeremy Hunt is back on speaking terms with the NHS England chief and has agreed a deal, which in the words of one senior figure very close to the discussions, is “a sensible compromise which commits the NHS to progress on key targets whilst recognising Rome isn’t built in a day”.
Indeed, it is not. As we know it takes five years (with the right vision). And 23 months into Mr Stevens’ mission to reinvent the NHS, a pattern is emerging.
A period of austerity, especially one now benighted by Brexit, was never likely to deliver the kind of game changing funding settlement needed to propel the Five Year Forward View to its conclusion.
In hindsight, Mr Stevens might have been clearer about that when George Osborne revealed his supposedly generous support for the Forward View back in 2015, therefore removing the plausible deniability adopted by the government when challenged on its NHS investment.
Ever since then however, the NHS England boss has been unambiguous about the gap between what the government wants the NHS to achieve and what it can deliver, and has embarked on a series of tactical engagements to get enough money to secure at least some progression. As a result, he has copped a lot of flak from the prime minister down.
There has been talk of resignation or sacking, but after a period of reflection the government always agrees to either up the cash or reduce the ask, and Mr Stevens heads out once again to tell the public what they should expect, while attempting to convince the service that the light in the tunnel gloom is not a speeding express train.
The year 2018-19 will be no different. The NHS England board paper released on Friday with the planning guidance makes much play of how the NHS can hope to do more because of the funding released in the Budget and, now also, mysteriously, some winnowed out from the Department of Health budget. But on page 4 you will find a table which shows that in 2019-20 NHS funding growth on a per age cost weighted capita basis still falls by 0.8 per cent. As Mr Stevens has already made clear, the NHS expects its Brexit bonus.
So, how successful is Mr Stevens’ trench warfare proving?
Well, very importantly the NHS is now not committed by the planning guidance to delivering access levels which the funding does not support.
This gives the service some chance to press on with the development of the renamed “integrated care systems” and other objectives - albeit at a more modest pace and with significantly lower levels of funding than was hoped.
Significantly, the backing for improved and better funded mental health services is holding up despite growing system pressures – a first for the NHS. The planning guidance also says all waiting times for cancer will be met.
Less positively, access to emergency and elective care will be only marginally better in March 2019 than 12 months earlier - despite this core business, along with deficit plugging, being the main recipients of the additional £2.14bn. Even that goal could be endangered by another tough winter and it is noteworthy that all sustainability and transformation partnerships are to be required to produce dedicated “winter demand and capacity plans” by the end of April.
The commitment by NHS Improvement to deliver financial balance in the provider sector next year appears, on the face of it, as unachievable as previous claims of this nature have proven to be. However, much is being made of clinical commissioning groups being required to be more realistic in their planning assumptions on non-elective activity and therefore NHS trusts being more appropriately rewarded for the efforts of their overworked emergency departments.
Nevertheless, trust control totals look like being even more of a bone of contention this year. New NHS Improvement chief executive Ian Dalton is likely to be more determined that trusts stick to what they agree, while NHS Providers is already urging the regulator “to think carefully about whether, how and when it takes formal regulatory action against trusts who refuse to accept their control total.”
As ever, it is workforce that looks to be the real sticking point. Extra money can buy you more staff, but not if they: have left the country or the service; do not work in the right discipline; are unwilling to take on new roles; have not yet finished their training; simply do not exist; or work for more attractive employers.
CCGs and trusts will plan to keep most of the increased elective work in house, but there will be regional hot spots where operations will have to be moved elsewhere in the NHS or to the private sector. This will add significantly to the financial challenge for some.
Finally, as Mr Stevens warned, the NHS will begin a financial year with a plan not to deliver the statutory services levels contained within the NHS constitution. It is far from certain this will inspire any legal challenge or what the outcome of any resulting judgement may be – but it underlines the fact that there are some fundamental problems afflicting the NHS on its 70th anniversary that even the most sensible of compromises cannot fix.