Will the cultural chasm between NHS and local government threaten plans?

Serious tensions are emerging between the health service and local government.

There are three sources of conflict – centrally-imposed secrecy over the sustainability and transformation plan (STP) process, whether the aim of STPs is to fix the NHS or develop an integrated health and care system, and disputes over whether the financial plans being sent to NHS England are fact or fantasy.

At least five councils have now published the STP, despite NHS England asking local areas to keep them hidden until the central bodies have given their verdict.

This pointless subterfuge has put local politicians in an invidious position; if they do as they are told they run the risk of being accused of conniving in a cover-up of plans to shut services. Faced with incurring the wrath of either NHS England chief executive Simon Stevens or local voters, it is not a difficult choice. The surprise is that more councils have not taken the same step.

The first local authority to reveal one of the plans was Birmingham city council. Its chief executive, Mark Rogers, articulated publicly the frustrations many in local government express privately. He complained in the Health Service Journal that Stevens and NHS Improvement chief executive Jim Mackey were pressurising NHS organisations to sort out the health service debt crisis rather than make the entire health and care system sustainable.

At the Ncas social care conference on Friday, NHS England operations director, Matthew Swindells, was forced to apologise after he said that councillors needed to be “managed” in the STP process.

“When I said ‘managed’ I meant brought into the whole of the conversation,” he responded to angry lead members for adult social care, who protested that they had been shut out of local STP discussions. “That was not our intention. If that has happened, that is not satisfactory and I apologise for that.”

Swindells admitted that NHSE’s handling of the STP process had been “not our finest hour”, explaining that while “most” of the 44 plans were good work, “a lot” needed rewriting before they were understandable by a wider audience. They would all be published before Christmas.

The Five Year Forward View held out the prospect of moving the centre of gravity of the health and care system at least a few inches towards primary and community services. But the STP process is now in danger of reinforcing the domination of the hospital sector rather than reforming it. The implications of that are far more serious than simply maintaining a system that is failing to cope; it will require even more money to be pumped into hospitals to expand the number of beds.

Arguably the biggest weakness of the STP process is that the pressure on hospitals to get their finances under control is so intense that some are offering up plans for savings that have virtually no chance of being achieved. One council chief executive said a local deeply-indebted hospital was claiming that it would save millions but did not have a credible plan for making it happen.

On Tuesday, Rogers took to the Today programme’s airwaves to ram the point home, pointing out that the funding gap will not be closed by “simply using the transformation word endlessly”.

Another local government chief I spoke to was visibly angry at the failure of his local hospital to take even the most basic steps to improve their estatesmanagement, back-office systems and procurement, while his authority was being eviscerated by another round of cuts – with public health taking a big hit.

There is a cultural chasm between the NHS and local government when it comes to handling public money. It is illegal for local authorities to run a deficit on their services spending, so they are compelled to make tough decisions to live within their means. Chief financial officers have extensive powers to intervene if they believe unlawful expenditure is going to be incurred.

In contrast, in some trusts there appears little connection between the financial decisions of the board and what actually happens. It is that disconnect which lies behind scandals such as the financial collapse of St George’s in Tooting in 2015.

Local government is no nirvana, of course. Several authorities – including Birmingham and Manchester – are still struggling to deliver effective child protection services, and although councils face severe increases in demand, these are not on the scale confronting the NHS. But local government’s financial management is far more effective.

Despite the inevitable tensions, the good news is that local government and the NHS are learning to work together, marrying up clinical services with a stronger sense of place and beginning to develop a clearer vision for integrating health and care.

The challenge now is to drive hospital efficiencies such as those proposed by Lord Carter before hospital debt derails the chance of building one system.

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Will the cultural chasm between NHS and local government threaten plans?

The gap between funds and delivery is a chasm in the NHS: something has to give | Chris Hopson

It is now time for our national health chiefs and political leaders to acknowledge publicly that the NHS can no longer deliver what is being asked of it for the funding available.

Despite the best efforts of hard-working staff, hospital accident and emergency performance is now the worst it has ever been. In the first three months of this year only four of the 138 large A&E departments saw the required 95% of patients within four hours. One in 10 patients had to wait more than four hours, the highest level at this time of year since 2003-04.

Waiting lists for operations, with 3.9 million patients, are now at their highest point since December 2007. The three million mark used to be considered a line not to cross, but experts have suggested that the waiting list target is irrecoverable. There are similar problems of dropping performance against cancer and ambulance standards, with mental health and community services under similar pressure.

At the same time, we ended the last financial year with trusts reporting the largest deficit in NHS history – £2.45bn but, in reality, above £3.5bn once you strip out one-off transfers and accounting adjustments.

These challenges are being matched by unprecedented staff shortages, including nurses, key specialists, GPs and emergency doctors. These have led to closures of A&E departments and other services, unsustainable pressure on GPs and, in 2015-16, an unaffordable extra £3.6bn agency staff bill.

Demand for NHS services also continues to rise much faster than predicted: between April and June, A&E attendances and emergency hospital admissions were up by more than 6% compared with last year – three times the predicted increase. If funding fails to keep up with this demand, the challenge for the NHS grows year on year.

These problems are now affecting the whole NHS. In the first three months, 94% of A&E departments missed the four-hour A&E standard. At the end of 2015-16, nearly two-thirds of trusts, and more than eight in 10 acute hospitals, were in deficit.

It’s no surprise that cutting social care year after year has created major problems. Given the lack of capacity in community and mental health services, the number of patients waiting for a hospital discharge is now the highest it’s ever been. As a result, hospitals are being asked to routinely run at capacity levels that risk patient safety and would be unthinkable in France, Italy or Germany.

Taken together this means the NHS is increasingly failing to do the job it wants to do, and the public needs it to do, through no fault of its own.

This concrete evidence is supported by the testimony of frontline NHS leaders. Thanks to the dedication of staff, NHS performance rarely goes off the edge of a cliff. As the 1990s showed, instead we get a long, slow decline that is only fully visible in retrospect. It’s therefore difficult to isolate a single point in that downward trajectory to sound a warning bell.

But NHS trust bosses are now ringing that bell – we face a stark choice of investing the resources required to keep up with demand or watching the NHS slowly deteriorate. Trusts will, of course, do all they can to deliver efficiency savings and productivity improvements. But they are now saying it is impossible to provide the right quality of service and meet performance targets on the funding available.

Something has to give. This is particularly so since NHS funding increases are about to drop from 3.8% this year to 1.4% next year and 0.3% in 2018-19. As total NHS demand and cost rises inexorably, by at least 4% a year, this will mean even larger gaps after seven years of the deepest and longest financial squeeze in NHS history.

There are unprecedented shortages of emergency doctors and other staff. Photograph: Alicia Canter for the Observer

So what does give? A range of options are now open to political and NHS leaders. Additional funding is the most obvious, with the new government’s first autumn statement on 23 November providing an immediate opportunity.

If, however, there are is to be no extra funding, the NHS must make some quick, clear choices on what gives, however unpalatable these choices may be. The logical areas to examine would be more draconian rationing of access to care; formally relaxing performance targets; shutting services; extending and increasing charges; cutting the number of priorities the NHS is trying to deliver; or more explicitly controlling the size of the NHS workforce. These are all approaches adopted by other public services such as prisons, local government and the police when faced with similar funding challenges over the past decade – though they would clearly provoke public unease and ministerial anxiety if applied to the NHS.

In reality, individual areas are already having to make decisions like these on a piecemeal basis. For example, in the last three months, clinical commissioning groups like St Helens and Vale of York have developed proposals to suspend all non-urgent care for four months or suspend non-urgent treatment for obese patients and smokers for a year. A number of trusts have had to close services on safety grounds and others have announced plans to reduce the size of their workforce. Unsurprisingly these decisions triggered local opposition and adverse national media coverage.

NHS trust leaders rightly argue that this piecemeal approach is unsustainable. It is not tenable to ask local leaders to deliver the impossible, make unpopular local decisions as quietly as possible and then carry the can when the decisions become public. As the junior doctors’ dispute shows, it is also untenable to ask NHS staff to close the gap by simply working harder and harder.

In the absence of extra funding, we need an open, honest, realistic, national debate on what gives, translating into immediate clear choices, with national leaders explaining why such choices are necessary. Any such debate must extend beyond the NHS and involve the public. The earlier that debate starts and the more open and honest it is, the better.

The gap between funds and delivery is a chasm in the NHS: something has to give | Chris Hopson