Modernisers must cut the deficit to keep their side of the deal

“I felt like the mad man in the corner,” a very senior NHS figure remarked of recent top level meetings discussing the financial travails and sliding performance of the provider sector.

While other leaders discussed the need to accelerate plans for new care models and to bring trusts with ballooning deficits to heel, this particular NHS chief felt his warnings about the pressures the sector was operating under were considered irritating at best and dangerous heresy at worst.  

‘Many of the “excuses” for not delivering the forward view have been swept away’

The delineation between these two camps is becoming clearer.

One group – let us call them the “modernisers” – have been further emboldened by the clarity that emerged from the election result.

Many of the “excuses” for not delivering the NHS Five Year Forward View have been swept away, and the modernisers want to make progress as fast as possible, mindful of how badly the long and wasted years at the start of the last Parliament damaged the coalition’s NHS record.

Back in the black

A key part of this mission is the deal struck with the prime minister and the chancellor to “fully fund” the forward view.

It was originally negotiated by NHS England chief executive Simon Stevens, whose links with the Treasury are longstanding and whose political nous is appreciated.

The re-appointed Jeremy Hunt played a key role in cementing the deal, successfully arguing the Conservatives should specifically commit to the £8bn by 2020 figure during the election – an intervention which wrong-footed the opposition and looks increasingly significant.

‘A lot of senior people have committed significant amounts of personal capital in securing scarce public funding’

In other words, a lot of very senior people have committed significant amounts of personal capital in securing a large chunk of scarce public funding, and in return feel it important they are seen to be doing all they can to get NHS finances back into the black.

HSJ’s interview with Monitor chief executive David Bennett represents a significant escalation in this drive; expect further salvos from Mr Stevens and Mr Hunt in the next few days.

Financially challenged trusts face direct and recurring intervention. Those foundation trusts in breach of their licence will find specific spending decisions challenged and, in some cases blocked.

Efficiency plans are apparently still not significantly “stretching”.

Takes time to hit targets

As we also exclusively report, a second front is being opened on agency spending.

The seriousness of intent can be ascertained from the comments of one senior system leader involved in the plans that trusts facing a cap on agency spend might struggle to staff wards and have to close them as a result. “But we just have to get on with it,” they added with a shrug.

Mr Bennett says safety is paramount in any decision taken to restrict spending, but tellingly he does suggest it might be time to take a more flexible approach to access targets.

That at least may be welcomed by trusts.

‘Efforts must bear fruit relatively rapidly to give all confidence the strategy is the right one’

However, much of what the modernisers propose is facing growing opposition from the provider sector which feels unfairly picked on.

The resistance first emerged in the tough, and largely successful stance, taken by the Shelford Group over top-up payments for specialist work.

The NHS Providers representative group continues to make waves to the irritation of policy makers, while inside government the leadership of the NHS Trust Development Authority is openly questioning the amount of blame being heaped at the door of trusts.

The modernisers are in the ascendant at present. But they know their efforts must bear fruit relatively rapidly to give all confidence the strategy is the right one.

As Mr Bennett acknowledges, they face the challenge of convincing the provider sector there are significant efficiencies to be made – a case which the Carter review will show is largely true.

He suggests this is “not just about shouting more loudly at people”. Providers will note the word “just” and prepare accordingly.