I strongly welcome yesterday’s announcement of an extra £500 million for accident and emergency services. It shows the government has listened to the concerns of NHS trusts.

‘The fact that there are strong arguments for a number of different approaches shows the difficulty of the task ahead’

I particularly welcome the higher level of investment compared to previous, smaller, allocations of “winter pressures money” and the decision to announce the money much earlier than usual. These were both requests made by the Foundation Trust Network in our recent work on A&E.

The devil is, of course, in the detail and in particular what is actually meant when the government says “the new funding will go to A&E Departments identified as being under the most pressure”. I have been struck by the strong reaction from many of the FTN’s members over the last 24 hours as the details of the announcement emerged. These are replicated in the comments on HSJ’s story.

Failure and fury

It’s worth quoting one representative reaction at length: “I am furious. We spent a fortune opening beds and recruiting staff to meet our target. Some trusts have seen a decrease in their attendances and admissions and are still not meeting their targets, yet it looks like they will receive funding as they are ‘under pressure’ and we will get nothing. This is rewarding failure yet again. What incentive is there to perform well? I’d suggest this money should be spent where the additional patients have been treated, not where the target has been breached and the A&E Department is ‘under pressure.’”

‘Congratulations to the DH on finding the money and announcing it early. Now the difficult work of how to allocate it begins’

The FTN understands that the detailed decision on how this money will be allocated is still to be made. But the fact that there are strong arguments for a number of different approaches shows the difficulty of the task ahead.

Understandably, all trusts will be looking for extra funding in an increasingly difficult environment, particularly since acute hospitals are only paid 30 per cent of the cost of emergency admissions above 2008-09 levels.

Where the money goes

As a first contribution to the debate about how this money should be allocated, I suggest six possible principles to guide the decision making process:

Transparency. Too often in the past the NHS operated a system of backdoor bungs. We all agreed this must stop. We need a clear and transparent set of criteria that will be used to allocate this money so that everyone can see who gets what and why, particularly if some organisations get money and others don’t.

Provider input into the criteria. Too often the centre has decided how to allocate funding like this without talking to those who actually have to spend it. It is also vital that whatever decisions are made carry authority and legitimacy with trusts. Ensuring there is quick input from NHS foundation trusts and trusts into the decision making criteria is therefore vital. The FTN has offered to help facilitate this process and we’re pleased this offer has been accepted.

Led by urgent care board plans. We should be funding local urgent care board plans as these are the means by which local health economies have been planning for next winter. Each local health economy has its own dynamics and, in some places, the local NHS has already decided, with their acute trust’s agreement, it is better to invest in community step-up or step-down beds or enhanced GP out of hours services rather than A&E. Clearly we will need to work out what to do in those areas where the urgent care board planning process is either non existent or hasn’t been working well. And no money should be released to an urgent care board unless it can show that all local providers explicitly support its plan.

Timing. Everyone needs to move at pace here. Allocations need to be made by early September or we’ll lose the benefit of the Department of Health having done its bit by announcing this money now rather than in December as it usually does.

Listen with an open mind. The most difficult element will be balancing the arguments for targeting this money where it can best be used and spreading it more thinly and supporting everyone. This includes considering the very damaging incentives that come from consistently rewarding failure (recognising that failure isn’t always the fault of the trust involved). Ministers and NHS colleagues need to approach this debate with an open mind and listen carefully to what providers say.

It is important that decisions are as evidence based as possible, while appreciating that the evidence base is very underdeveloped at this point.

So congratulations to the DH on finding the money and announcing it early. Now the difficult work of how to allocate it begins.

Oh, and don’t forget you also need to sort out the marginal tariff and the long term urgent and emergency care pathway design to stop us getting in this situation again.

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