Following the Money is HSJ’s expert briefing on NHS finances, savings and efforts to get the health service back in the black. Contact me in confidence here.

The financial meltdown at Barking Havering and Redbridge University Hospitals Trusts has aroused huge interest and no little concern from HSJ readers, both in the capital and from senior figures across the country.

This briefing’s investigation of the issue in May, for example, was the most read HSJ article in the last 12 months and received over 100 comments.

The concerns have broadly had two themes: a desire to fully understand what led the trust to its current perilous state and a wider worry about the way in which NHS Improvement has handled the issue.

HSJ has asked a number of basic questions around these issues, including around the role played by a senior employee of NHSI, and does not feel they have been adequately addressed.

In asking these questions, we are not suggesting that the failures at Barking should be laid at one person’s feet. The investigations have been clear about that. They arise because of the obvious concern over the regulator’s ability to fairly assess the role played by its senior employee.

Recap

To recap, the first investigation into Barking’s financial woes was commissioned by the trust in October 2017 and carried out by Grant Thornton. On publication in April it described a multitude of failings from 2015 onwards, culminating in the trust unexpectedly running out of cash in October 2017.

A second investigation, commissioned by NHSI in January and carried out by Deloitte, was published earlier this month. It focussed on what happened in the financial year from April 2017 and included heavy criticism of BHRUT chief executive Matthew Hopkins and suggested medical director Nadeem Moghal’s position was untenable.

Despite describing Mr Hopkins as a visible and respected leader - and recognising that he had been absent from March to September 2017 to undergo a kidney transplant – it said he had failed to grasp the severity of the cash flow problems on his return, and that he lacked the ability to lead the trust out of financial trouble. The findings resulted in Mr Hopkins resignation.

A third investigation was conducted by NHSI’s deputy chair Richard Douglas to look at the role played by Jeff Buggle - the trust’s finance director from December 2014 to March 2017 and then acting chief executive to July 2017 – who has since been promoted to be NHSI’s regional finance director for London.

The regulator has refused to publish the findings of the Douglas review, but said it found no evidence that Mr Buggle “crossed a professional line” or had withheld or hid information in his time as the trust’s finance director.

The transparency test

In May, HSJ asked NHSI several important questions based upon the findings of the Grant Thornton review. We were told – not unreasonably – to wait for the publication of the Deloitte report.

Unfortunately, in our opinion, the accountants’ report has failed to answer the questions. We re-submitted them along with some additional queries arising from the Deloitte report last week.

Among the most significant unanswered questions are:

  • To what extent does Mr Buggle accept responsibility for the failures identified by Grant Thornton and Deloitte? 
  • Why did the trust not plan to draw down cash support from the Department of Health in 2017-18 to ensure adequate cash flow and that invoices could be paid on time?
  • The Deloitte investigation was asked to explain why the failings happened and resulted in clear finger pointing. Yet, the firm was tasked with looking only at the financial year from April 2017, despite problems emerging in the previous year, and the doomed financial plan for 2017-18 being set well before this. Asked about this timeframe, NHSI said the review “needed to start somewhere”.

Readers can see HSJ’s list of questions and NHSI’s full response here.

As far as the actions of Mr Buggle are concerned, NHSI simply invite us to take Mr Douglas’ word that nothing untoward took place.

There is no reason to doubt the integrity of Mr Douglas - a widely respected former chief finance officer at the Department of Health – and NHSI have been at pains to stress its duty of care to its employee.

However, we will let the reader decide whether the refusal to publish any part of the report meets the level of transparency required of public bodies in the 21st century.

NHSI may also want to reflect on the decision not to commission an independent reviewer or have Mr Douglas rely on the two reports and conversations with NHSI colleagues, but not speak directly to anyone at the trust.

Robust and defensible

The imminent shake-up of regulatory functions at NHSI, alongside the integration with NHS England, make this a critical period for system leadership and regulation.

The national bodies are in the process of creating seven new regional directorates, which will exercise considerable influence. The re-organisation offers both NHSI and NHSE the opportunity to reset the relationship with the service. Indeed, NHSI chief executive Ian Dalton was explicit in his recent HSJ interview that he wants that reset to happen.

An important part of the creation of new directorates will be choosing the right individuals to occupy the senior roles within the new directorates. The process of appointing them must be robust and defensible and has to deliver a team and a way of operating which commands the respect and trust of the region’s leaders.