Cowper’s Cut: Hancockism, plans and money

How exciting: we’ve got a new health but social care secretary to play with! Another Brexit bonus … Indeed, it’s quite probable that Brexit is now going to be the new 2012 Health And Social Care Act: it might happen in legislative terms, but it won’t in reality correspond to what its authors intended.

This is of course also goodbye to the longest serving occupant of the health job to date. Jeremy Hunt’s survival was multifactorial, as I briefly outlined in this piece for the British Medical Journal.

Mr Hunt was by no means perfect, but he got to two important realisations:

1. The NHS does actually need to be funded properly – and also to change and improve services, which is hard, and takes time and consistent effort.

2. Patient safety, appropriate digital technology and transparency are all important, and are all less central in the NHS than they should be.

Many health secretaries have left the NHS far worse legacies. I wish Mr Hunt well as he takes on another “cleaning up the place” gig as foreign secretary in the wake of The Buffoon Of Brexit, Boris Johnson.

This is simultaneously hello to Matt ‘The App’ Hancock as our new political lord and master. HSJ has this and this about Mr Hancock: this Conservative Home profile is also good.

Mr Hancock lost no time in declaring via HSJ that he *hearts* the NHS and will defend undervalued NHS staff: time alone will tell whether the feeling is mutual, and indeed whether he will attack overvalued NHS staff.

The plan bit

After years of Huntism, BBC Radio 4 Today presenters will clearly breathe a sigh of relief … but what will Hancockism mean?

There is certainly continuity on enthusiasm for technology. As a former Bank of England economist, Mr Hancock is likely to be a socially liberal and economically dry CamBorne (Cameron-Osborne) character. Hancock was a junior minister under Osborne’s imperial period at the Treasury – how much of the Treasury Mucnhkin mantra has seeped into his soul?

We will soon find out. As various shrewd people have been noting, the new NHS money won by the Hunt-Stevens one-two on May and Hammond doesn’t hit the road until 2019-20. And that means the coming winter is going – bar some remarkable new cash – to look, feel and be a lot like the past winter. Which is to say consistently lousy across much of the NHS, which is still struggling to recover.

The money bit

And as NHS Providers’ new analysis explores (and I pointed out some time ago), the financial workarounds, incentivised financial lying, capital-to-revenue transfers, uber-depreciation, 6 per cent Department of Health and Social Care loans to troubled trusts all mean that the financial boost could not go very far at all.

Curiously enough, on the day of England’s last game, the Department of Health But Social Care published its annual accounts. The analysis for Incisive Health by Richard Douglas, longstanding DH director-general of finance is obviously essential analysis.

Douglas observes, “the Department has managed within both the overall Revenue Budget (RDEL) which underspent by £692 million (0.6 per cent) and the Capital Budget (CDEL) which underspent by £360 million (6.4 per cent). The RDEL underspend was despite the fact that, in government accounting terms, the commissioner underspend of £1,013m (table 35) did not quite offset the provider overspend of £1,038m (table 37).

“It does, however, appear as though there was a breach on the narrower and historically critical measure of current expenditure (the non ring-fenced RDEL which excludes depreciation). And, remember there were also in-year additions to the RDEL of £335 million for the NHS, and a reserve claim for European Economic Area medical costs of £267 million.

“Second, the NHS. Within the DHSC group, the NHS figures are close to those reported at quarter 4 so there were no significant problems during audit. The provider sector recorded a deficit (post-receipt of Sustainaiblity and Transformation Fund funding) of £986 million (£816 million in 2016-17) and the commissioning sector a surplus of £970 million (£902 million in 2016-17). Overall the NHS as a whole was broadly in balance – for pedants a very small deficit – and the numbers on both sides showed little change from last year.”

As Lawrence Dunhill points out, this means the DHSC breached Treasury control total, but not the Parliamentary vote, so Treasury/OBR data does not have to be recalculated, nor new money voted.

Lawrence notes that a footnote within the accounts says this figure includes the benefit of a £777m underspend against ringfenced “depreciation” budgets, which cannot be used in calculating the key Treasury indicator.

It says: “The total Revenue DEL underspend of £692 million consist(s) of a £777 million underspend against the ringfence control. This is not cash-backed, and cannot be used to fund healthcare services.” This implies an £85m overspend on the non-ringfenced RDEL, which will have required separate approval by HMT.

The report says NHS providers were overspent by £991, which was £31m worse than the figure reported by NHS Improvement. NHS England delivered a £970 underspend, which meant the NHS overall was around £20m in deficit.

The 10 Year Forward View

It has been proven beyond question that forward views are inflationary – we have gone from five to 10. The 20-Year Forward View is bound to give us all great joy in the late 2020s.

One of the key influencers of the Five Year Forward View has often described in private as “a provocation”. What on earth is the 10 Year Forward View going to be: an insult to someone’s mother?

In all seriousness, the best that the 10 year plan can be is obvious, predictable and best of all, credible.

There will be a blizzard of think pieces about what should go in that plan. I’ve been writing about and editing about health policy for nearly two decades now, and almost as prevalent as the ”the plan should include this/that/the other” comment pieces, is the genre of ”the NHS could best learn from XYZABC” article.

I’ve read more of these than I would care to remember. The common features of most of them is that they are tendentious, insightless and dull.

So it was delightful to read one that isn’t. Stephen Black’s superlative piece points out the importance of good planning, timely and accessibly presented data to inform the best deployment of the resources available.

Stephen is quite right: the NHS needs to get far better in all three respects. I commend his article to you unreservedly.