Essential insight into England’s biggest health economy, by Ben Clover

Pushing down the bump

Quite often in cartoons one of the characters will get hit on the head and a bump will appear. When they push it back down with a finger, it just appears somewhere else on their head.

The same thing might be happening in the London NHS, particularly at the specialist end of the scale.

NHS England, the biggest individual “customer” for most of the capital’s specialists, is thought to be looking at a worse than planned year-end position for its specialised commissioning budget in London.

Early in 2018-19, it was understood to have set optimistic targets for how much work would get done (and should be paid for).

It is now thought that this budget might be now yawning out into a sizeable deficit.

How might this have happened?

The aforementioned optimism on how much work the specialist trusts would do might be a factor.

London Eye understands Guy’s and St Thomas’ Foundation Trust did more than planned. And why wouldn’t it? There is the clinical need. The London specialists are, broadly, so oversubscribed for work they sometimes try and go outside the rules and restrict out-of-area referrals.

And, if GSTT is overactivity-ing, then what might its more unruly neighbour King’s be doing in this space?

Well, the £190m-deficit-predicting Shelford Group trust does roughly £400m-worth of NHS England funded work a year.

How close was the working between the customer and vendor for this huge budget over one year?

KCH’s board papers this month said “the trust did not agree a final year position with NHSE”. Ah, ok.

These budgets might get more difficult to set over the next five years, rather than easier. NHSE/Improvement is, of course, raiding London’s budgets.

The changes to the market forces factor rules will see hundreds of millions leave the budgets of London trusts and be spent elsewhere in the NHS.

Roughly £300m will be lost in London but everyone has been assured its ok, because it’s being tapered over a few years.

But, however successful the tapering is, it is likely to make provider finances in London less stable.

Why does this matter?

Because when provider finances are unstable, things like partnerships with the private sector – important for research – can go wrong.

And they might be tempted to “overperform” on specialist work they can charge NHSE for – the bump reappears elsewhere.

London’s cathedral city

Croydon has long thought of itself as somehow distinct from the rest of London, despite being a London borough officially.

Over the years both the hospital/community trust and the commissioner have been dogged by some spectacular governance problems.

Croydon Health Services Trust’s last substantive chief executive John Goulston deserves substantial credit for taking the organisation out of the bottom tier of trusts (although accident and emergency is still a problem, despite a £21m investment).

Mr Goulston also got the ball rolling on more collaborative working with the clinical commissioning group (a CCG that has had to make some unpopular, postcode-lottery-creating decisions). That ball has continued to roll.

The trust and the CCG will be putting out a job ad for a shared chief executive in the next few weeks.

When appointed, this role will be the first of its kind.

We have yet to learn what legal advice (if any) has been taken on how this might work in the event of a dispute between the commissioner and the provider.

How it works with the South West London Sustainability and Transformation Partnership is also, as yet, unknown.

So far only a memorandum of understanding between the CCG and the trust has been signed but when someone is appointed it will be one of the most ambitious ignorings of the purchaser/provider split yet seen.