Ministers take high risk bets on debt, pay restraint and reform

The summer days of 2015 have not been quiet ones for the NHS. No silly season for healthcare leaders, the issues they have been wrestling with are as serious as they come.

Front of mind is the NHS’s deteriorating finances and the increasingly frantic efforts to avoid the seemingly inevitable increase in the provider deficit.

However, rising rapidly up the agenda is the growing tension created by continuing pay restraint and proposed contract reform. The government appears unflinching in its determination to drive NHS workforce reform as the route to deliver seven day services.

New contracts and chains

A renegotiation of Agenda for Change now appears a probability, but only after what will be a mixture of hard bargaining and imposition of new medical contracts. As a result, the NHS is likely to see significant industrial unrest, up to and including strikes, within the next 18 months. Maintaining NHS staff commitment in this context is just one of the high risk bets this government is taking.

‘The NHS is likely to see significant industrial unrest within the next 18 months’

Another is the creation of hospital chains to dramatically improve the performance of struggling trusts. The government apparently has a list of around 100 organisations it would like to parcel out to chains.

The three chief executives behind the proposed Enterprise initiative wisely dodged that bullet and have gone in a different direction. It may not deliver the pace of change some at the centre want, but it is slow and steady that will surely win this race.

So where do the various national or regional players and initiatives stand at the end of this frantic summer?

The National Institute for Health and Care Excellence is experiencing its rockiest period for a decade - though that is partly a tribute to how smoothly it has proceeded in the past. It must work hard to stop the safe staffing debacle turning into an unpicking of its hard won reputation.

Academic health science networks appear to have dropped down the pecking order. Clinical senates (with very few exceptions) have gone straight from underachieving youth to a largely redundant dotage.

The health secretary has committed to fight his “inner Stalin”, but the Department of Health is, if anything, strengthening its grip on the service in the short term at least - no doubt at the encouragement of the Treasury.

Push will come to shove

It is devoting significant energy to the creation of NHS Improvement. The new body will be the de facto performance manager of the service. Its new chief executive will have power and problems, almost matching those of their NHS England equivalent.

Simon Stevens will be relaxed about this - partly because he will have influence over the choice of the NHS Improvement chief executive. He arrived at NHS England wanting to focus on commissioning, yet was forced to spend much time wrestling with the many problems of the provider sector.

‘Recent rumblings about the Carter review have been disquieting’

With the arrival of NHS Improvement, Mr Stevens can focus his attention on the twin priorities of driving home the “battering ram of change” represented by the NHS Five Year Forward View’s vanguard sites and improving both specialist and local commissioning.

The latter focus will threaten the future of many underperforming clinical commissioning groups, but also cement the role of those making the greatest progress - albeit often in concert with local authority or provider partners.

The Carter review of NHS efficiency and procurement will deliver its next report in autumn, but recent rumblings have been disquieting.

The centre is clearly frustrated by the size of the prize so far identified and the time taken in beginning to win it. Lord Carter is, equally understandably, irritated by the expectations loaded onto his careful work and keen to maintain credibility with NHS chief executives by not pushing too hard.

Here, as in many places, push will soon come to shove.