NHS management challenge stays much the same, rich or poor

It is hard to imagine there could be any worthwhile comparisons between that hallowed day and last Wednesday’s grim public spending review - but there are.

Eight years ago, HSJ remarked on six implications of Mr Brown’s largesse, concluding that:

• most NHS managers should be celebrating;
• giving the NHS such an enormous sum would mean it was subject to intense scrutiny;
• overdoing organisational reform would endanger the government’s goals;
• despite the focus on political action, the success would be determined by the work of NHS staff, especially managers;
• treating local authorities as a poor relation would harm the NHS;
• unrealistic pay demands by the unions would fundamentally undermine the ability to deliver the reforms.

All of these claims could be made about George Osborne’s parade of pain - and their relationship to the government’s NHS reforms. Even, or perhaps especially, number 1. Work almost anywhere else in the public sector and the NHS, even supposedly doomed primary care trusts, must seem like Nirvana in relation. This means number 2 must be true too - special treatment in a spending review is always a Faustian pact containing a fear that money will be wasted and, therefore, demands that every decision be analysed.

The fourth point rings just as true. For all the focus on GP commissioning - it will only begin to have significant impact on the service after the middle of the decade. The priority for the next four years is to pilot the NHS from one financial flight path to another. As NHS Confederation acting chief executive Nigel Edwards commented, the chancellor’s mention of the £20bn quality, improvement, productivity and prevention programme converted it from “an ambition, to a commitment”. It is NHS managers who will have to deliver on that commitment.

The renewed focus on efficiency will see QIPP move out of the shadows of the white paper reforms to share centre stage. The rationing of care that HSJ revealed in its analysis of the QIPP programmes will soon be painted as part of the government’s “cuts agenda” - unfairly, of course, as they predate this administration.

The 2011 version of the fifth point could come as the unions react to any proposals to freeze incremental pay rises and reconfigure pensions.

Equally, forces that have been building up in the system over a number of years are now likely to assume that status of signature issues in what could yet turn out to be the first real NHS financial crisis for at least 15 years. The most prominent of these will be the tensions between freezing the tariff for emergency admissions and rising demand - echoing the misalignment of finance and service reforms during the early days of payment by results.

• The impact of this tension on individual trusts is revealed for the first time by HSJ’s new Performance Healthcheck - a monthly data analysis tool produced with Dr Foster. You can interrogate the data at www.hsj.co.uk/healthcheck or read the highlights here.Note: you must be a subscriber and be signed on to hsj.co.uk to use the interactive tool.

There are many similarities between the challenges of 2002 and 2010. However, there is also one crucial difference. At the start of the last decade public expectation of NHS performance, schooled by decades of underinvestment, was relatively low. Not any more.

One of the goals of New Labour’s reforms was to raise the public view of what the NHS could deliver - in this, at least, they succeeded. With indications that performance on waiting times is beginning to slide in some parts of the country, those expectations may soon be colliding with the new NHS reality.