What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West.

The “capped expenditure process” is now receiving some wider media and political interest. While that will put some unwelcome heat on particular organisations and proposals, this was never realistically going to be kept in the dark.

It doesn’t take a wild imagination to wonder if the CEP was designed precisely to make sure politicians get a nasty taste of the cuts the NHS must make; probably not true but you never know.

Away from the politics, the real limitations of the CEP are more pedestrian.

The problem with “difficult choices” is not only that they’re difficult but that they often don’t help the situation. The idea – reflected in coverage and political commentary – is that the NHS has a stock cupboard of ready to go cuts, which would do no good except save money, and have little downside other than their sheer unpopularity. This is not the case.

The truth is that even if public and political opposition wasn’t a factor, there is a small, shrinking number of quick, no brainer, significant cuts available to the NHS.

A couple of examples from those being considered under the CEP:

Closing beds, wards, theatres and shedding the associated staff could be a route to take – if most hospitals weren’t already working hard to recruit more, not fewer, clinicians. They are under pressure to maintain capacity this winter, not reduce it. Leaving the system to scramble capacity and staff at late notice would likely push costs up, not down.

Cutting use of private providers will have superficial appeal to many. But it only helps if the operations can be carried out in the NHS instead – often they are performed in the independent sector in the first place because oversubscribed NHS hospitals have sent them there.

Alternatively, the would be patients can be left on the waiting list – a “difficult choice” the NHS has already made nationally; but it’s harder to reap the benefits on the ground. Crudely growing the list is not only storing up costs for later but also exacerbating things down the line. Managers in some areas are exploring, with great complexity, whether certain types of electives can be delayed and inflict less damage (eg: those with smaller lists and waits). This approach can throw up a set of messy operational difficulties, and/or a small industry of prioritisation, which make it barely worth the bother.

There’s also a very high but uncashable value to the public trust in the NHS that will be lost if people get the message “we cannot treat you, you’ll have to go private”.

One flavour of cut which is likely to survive national scrutiny is the cancellation of some planned (ie, hoped for) investments. HSJ’s mental health correspondent Joe Gammie has covered how it might hit that sector. The same could be said for general practice and other improvement priorities, which, in theory, would pay back their investment in savings.

For non-CEP reasons I have been looking into the wider Bristol health economy, which is one of the CEP areas. To save money it needs to tackle long and unnecessary stays in hospital, and improve system coordination – could this be achieved if it were to shirk investments and a focus on the longer term?

Untouchable reforms and low hanging fruit

There is a happy converse of the fact that there are few cost free, no strings, “difficult” savings available. This is: where there are genuine savings to be made, it is normally through changes that are also clinically sensible – even if they’re unpopular and “difficult” in the short term.

Unfortunately, there are other limitations: the savings can be pretty small, hard to reach, require upfront investment, and take years to achieve.

Raising funds from surplus sites seems a common sense thing to do, for example, if done in the right way, so it’s a shame Labour and others resorted to knee jerk opposition to this.

Limits on procedures and drugs of low or no value could also qualify here – so too could a more circumspect approach to expensive new medicines that haven’t proven their value. The case is rarely clear cut but NHS Clinical Commissioners has identified medicines being prescribed that are dangerous, while as one HSJ reader put it: “Why do some GPs still prescribe Mrs Crimbles gluten free macaroons?”

On the other hand, many of the CEP areas have already changed relevant prescribing rules, taken as low hanging fruit, and “banning” treatments doesn’t mean they immediately stop – it can be a long game changing clinical behaviour.

Consolidating smaller specialties – particularly where workforce is tight – is often sensible and has been a focus in the CEP as in last year’s financial “reset”. In some areas where this is happening, a common focus of reconfiguration, but for many there is no great saving, and there is transition cost.

Finally, the bigger ticket reconfigurations – turning hot sites to cold, centralising paediatrics or obstetrics – can be necessary for safety and workforce reasons; but as Candace Imison and others have stressed, it often doesn’t save money, and certainly not quickly.

One thought going around the minds of those asked to contemplate difficult choices is: if the NHS is to face public opprobrium, we might as well make sure there is a worthwhile outcome. Are there reforms that have been so untouchable they’ve not even been considered? More radical change to primary care for example, or uncompromising changes to end of life care. Probably not going to fly, is it?

No window breaker

Of course, everyone involved in the CEP from top to bottom has known all this from the outset. It was always likely that feedback from the centre would knock back many of the difficult choices on one of the grounds discussed above. 

With a weaker than weak government, and a continuity health secretary, this is presumably even more true – there is no “window breaker” minister wanting to use CEP to smash some NHS taboos.

That is the tone in a conciliatory letter on CEP from NHS Improvement this week and a suggestion that the pressure for savings in these areas will now be eased. 

It may not ease everyone’s frustrations about the process – have they expended much time and effort, well into the financial year, being marched up the hill, to be hastily marched down again?

There is probably no right answer to the CEP, but health economies in trouble must balance short and long term objectives, and hope to come out of the process getting on better together, not worse.