Essential insight into NHS matters in the North West of England, with a particular focus on the devolution project in Greater Manchester. By Lawrence Dunhill

Different hymn sheets

The road to transformation of health and social care services looks ever bumpier in Lancashire, where the NHS appears to be singing from very different hymn sheet to the local authority.

Relationships on the western side of the Pennines have always been slightly strained. So when a report commissioned by the county council suddenly made a raft of sweeping proposals over the shape of services in the future – without any input from the NHS organisations – it was never going to go down well.

Some NHS leaders were furious about the PwC report, which introduced the idea of “wellbeing corporations” delivering all services under an accountable care model (and a timeline setting out dates for staff to TUPE into the organisations).

I’m not sure why “NHS trusts” weren’t thought to be good description, albeit in a new form such as the ACO being created in Morecambe Bay.

PwC also seem to envision a future where eight clinical commissioning groups have been swept away and replaced by one “integrated commissioning authority” led by Lancashire County Council.

Many of the ideas and proposals in the report are good ones; there should be far fewer commissioning organisations in the county, and far more integration of health and care provision.

But they might just have been articulated better, and gained some support, had health leaders been more involved from the off. Instead, the first they saw of the report was on LCC’s website.

Many commentators are quick to criticise the commissioning of premium rate consultancy reports, but I think LCC might have a difficult job in justifying this one, as it’s unlikely to influence the direction of travel.

Perhaps some lessons could be learned from council leaders in Greater Manchester, who are gradually becoming deeply involved in the planning of NHS services. This has only been possible due to genuine partnership building and some rock-solid relationships, with a little help from George Osborne of course.

Bun fights

The really difficult discussions within Lancashire’s “sustainability and transformation plan” will be over acute hospital services – and the perceived winners and losers.

The obvious option would be to centralise more acute services at the Preston-based Lancashire Teaching Hospitals Foundation Trust, which is already seen as the county’s main specialist centre.

But there are lots of uncertainties over the estate at Preston – a new site is probably needed – while the Blackburn-based East Lancashire Hospitals Trust has been gaining in confidence and ambition since coming through its Keogh and Care Quality Commission problems.

With Blackpool Teaching Hospitals FT also in the mix, expect some bun fights as the STP talks get down to the nitty gritty.

Trouble in Wirral

Wirral CCG is the latest to be placed in “legal directions” by NHS England, due to its fast deteriorating financial position.

It is now forecasting a year end overspend of £12m, but has been told to draw up a “credible financial recovery plan” by March 10, to ensure an overspend of less than £9m.

With the main acute trust also falling badly off plan this year (see below), it looks like some tough times ahead on the Wirral.

Difficult decisions

CCGs in Cheshire look to be in similarly difficult spot, with Eastern Cheshire, South Cheshire, Vale Royal and West Cheshire all forecasting significant in-year deficits in 2016-17.

Simon Whitehouse, chief executive of South Cheshire and Vale Royal CCGs, warned last year that the dire financial position would lead to “difficult decisions”, and we are now seeing some of the results with new restrictions to hip and knee replacements for obese patients.

The new restrictions appear to contradict the National Institute for Health and Care Excellence guidance and drawn criticism from the Royal College of Surgeons, but NHS England is steering well clear of this debate.

I can see why national leaders want to leave it to individual CCGs to make these decisions necessary to balance the books, but without some direction from the centre, we’re heading for huge variation across the country, with different criteria depending on where you live.

For the two Cheshire CCGs it also sounds like there are more difficult decisions to come, as recent board papers note the need for “decommissioning services in order that CCGs meet their statutory obligations”.

Pressing pause

I’m slightly dubious of NHS Improvement’s “pause” of Bridgewater Community Healthcare FT’s takeover of community services in Liverpool, despite documents suggesting it could scrap the deal.

The regulator said it wants to review the takeover plans following Bridgewater’s CQC report, which delivered an expected “requires improvement” rating.

As Bridgewater chief executive Colin Scales has pointed out, NHSI will have known about the main finding in the report for months, so I’m not sure why it’s taken so long for this work to start.

Interestingly though, only NHS trusts were invited to enter the selection process last time around, whereas the review document notes how “new and/or novel ideas” could now be considered.

Ears may well have pricked up at Virgin Care, which has recently won major contracts in West Lancashire.

No let up for top CEOs

Congratulations to all at Tameside and Glossop Integrated Care Hospital FT and University Hospitals of Morecambe Bay FT, two former basket cases which have now been rated “good” by the CQC.

Jackie Daniel and Karen James are two of the most impressive chief executives in the north west, but arguably now face an even tougher challenge in tackling two of the largest deficits (as a proportion of income) in the country.

Financial performance

Trusts in the north of England are having far less difficulty in meeting their financial control totals for 2016-17 – only contributing £34m to a £435m national deterioration in the first nine months of the year.

The notable exceptions in the north west are Southport and Ormskirk Hospital Trust and Wirral University Teaching Hospitals FT, which are both forecasting to miss their year end target by £8m.

SOHT will not have received a penny of “sustainability and transformation funding” this year, but WUTH has already received £7m from the national pot due to the phasing of the payments.

WUTH seemingly managed to stay on plan for most of the year by using non-recurrent benefits and technical accounting reviews, before formally revising its forecast.

Pennine Acute Hospitals Trust and East Cheshire Trust, perhaps surprisingly, are among those trusts set to better their financial plan this year, and therefore be in line for a significant revenue “bonus” from the unallocated STF.

North by North West takes an in-depth fortnightly look at one of the NHS’s most challenged and innovative regions. There will be a particular focus on the devolution experiment in Greater Manchester, but my scope will also include Merseyside, Lancashire, Cheshire and Cumbria.

Please get in touch to let me know how I can improve it, and to tip me off about stories you think I should cover: lawrence.dunhill@emap.com. If someone forwarded this to you, sign up to get your own copy here