Updated: The parallel universes of NHS wonder and woe

NHS England chief executive Simon Stevens is worried NHS leaders are too busy dreaming about what life will be like once they are living in the sunny uplands envisaged by the Five Year Forward View. Or perhaps after the government has bailed them out in response to growing pressures and for not facing up to the difficult decision they need to make to deliver the former and avoid the latter. He fears that, like St Augustine, the NHS knows it must improve but does not want the pain that will involve just yet.

‘Few deny the NHS has to take radical action on its cost base, but an argument rages over how quickly and overt that action should be’

Mr Stevens echoed the message of last week’s HSJ leader and the comments of the health secretary in The Daily Telegraph that the NHS has struck a bargain with the government that it must now honour (news, page 4-5). “This [efficiency drive] is not being done simply out of necessity.” he told HSJ. “It is being done out of a sense of obligation that we can see we are leaving money on the table [when] we can see there are many other calls across the public purse for investment.”

Mr Stevens knows that by signalling to NHS leaders that they must directly challenge the financial implications of variation in clinical practice he has effectively blown the NHS management dog whistle. Trust boards will not only get the specific message but understand the seriousness with which it must be treated.

The savings which have to be delivered by acute sector productivity improvements dwarf the contribution of any other factor. For all the forward view’s welcome emphasis on prevention, out of hospital care models and integrated care-led demand management, its success depends on the part of the NHS to which it pays the least attention making a step change in the cost-effectiveness of its day to day activities.

The acute efficiency agenda has at last began to get some serious focus at the NHS Confederation conference in speeches and announcements by both Mr Stevens and Jeremy Hunt.

Stark warnings

Their stark warnings were addressed to a conference with a peculiar nature - as if there were two events happening in the same place and time, but existing in parallel universes.

One conference was busy and buzzy, very well attended by clinical commissioning groups, mental health and community health trusts, and a significant number of delegates from central bodies, third sector organisations and others. They were all excited by the opportunities presented by the forward view and eager to pick up the pace.

The “other” conference was sparsely attended by morose, lonely figures working for acute trusts. Bumping into one of them, you would find yourself grasped by the lapels and warned NHS finances were going to hell in a handbasket and asked “why isn’t anyone doing anything about it?” and “why is everyone blaming us?”

This excitement and angst provided the context to the most important debate taking place among the leaders assembled in Liverpool.

Few deny the NHS has to take radical action on its cost base, but an argument rages over how quick and overt that action should be. On one side there are those who stress the need to use the government’s honeymoon period and to - for example - reveal the list of “unsustainable” acute trusts held by the Trust Development Authority and use their reconfiguration as the national flagship for the NHS’s economy drive. This, it is argued, would hopefully inspire similar urgent radicalism elsewhere.

Others say this would summon up a firestorm and risk destroying the consensus created by the Five Year Forward View. Better to let local health economies deal with their issues at a pace they think appropriate.

Both approaches have merit, but whichever wins the day the clock is ticking.