Jul 21, 2024 12 min read

Cowper’s Cut 332: All the things I could do if I had a little money

NHS finance woes: mid-July 2024 edition

Health Service Journal’s Henry Anderson reports that NHS England is forcing nine ICSs to hire management consultants because of their failures to control their spending.

This is being announced in mid-July: the fourth month of this financial year chronologically, but only the first since ICSs’ budgets were (mostly) agreed.

The consultancies will be engaged to help these systems to immediately bring down their financial run rate. As Henry notes, this follows from May’s “overhaul of the financial regime … (which) introduced a new system of nationally set “control total” financial targets, backed by capital incentives and penalties, in a bid to bring down a forecast national gap of close to £3 billion.

“The national body has said no extra funding will be provided and all systems must hit the plans they submitted on 12 June. All but two ICSs are thought to have signed up for the new targets they were given.

“Several sources said the net deficit planned across all ICSs was now around £2.2 billion, a figure NHSE has not disputed. However, with systems and trusts already falling behind their plans and many based on huge efficiency saving targets, the year-end figure is widely expected to be much larger.”

Ooops.

As Ian Kirkpatrick and Andrew Sturdy have shown, the evidence base that external management consultancies help much in NHS management is weak.

Indeed, it is worth revisiting Margaret McCartney’s 2013 critique of a PWC report which claimed that the NHS could save billions of pounds by better use of technology. Sound familiar?

Yet here we go again. Again.

Has NHS England reflected on its own role in encouraging and suborning last financial year’s blatant financial lying, and on the inevitable subsequent bailout?

You will be astonished to hear that NHSE has not.

So it has all just happened again.

‘Well, if it isn’t the consequences of our own very long-standing system-leading actions!’, said absolutely nobody in NHS England.

Depressingly, I wrote about this back in 2019 (on that occasion, it was about provider deficits, but the method is exactly the same): “Imagine a typical scenario for a provider: you’re being incentivised to do this sort of financial malarkey. You screw it up, and attract attention. Then you are put into financial special measures. Ooops.

“This largely involves NHS Engrooveland-Improvement appointing an external management consultant, probably from the ‘Big Four’. Their consultant shows you how to do the trick properly next time …

“The consequences to a culture of financial lying and incentivising the wrong things are not only when these accountancy fiddles reach a wider audience. Which they will, over time.

“The consequences are bad decisions in the here and now. It is starting to feel as if the NHS might need a financial truth and reconciliation commission, as well as a chief anthropologist.”

Waste reduction

Henry also wrote this insightful piece about Leeds FD Simon Worthington, whose approach to achieving financial balance in every year since 2017 he characterises as follows: “we talk about waste reduction. Removing waste from processes cannot harm patients. We had our biggest year of waste reduction ever last year, and our staff survey went up. Patient quality indicators were fine, and going up, and our waiting times coming down.”

“ … As a finance director, you can’t be the enemy of quality… if you see them as separate, then you’ll run into difficulties… [it’s about] empowering clinical colleagues to improve their work, engaging them in the problem.

“The problem is, we’ve got to deliver great services for patients… the government have decided this is how much money we’ve got to do it with – and that is a lot more money than we had a few years ago.”

Towards an end to junior doctor strikes?

After a second constructive meeting, I am pleased to announce that we will enter formal negotiations with the BMA junior doctors’ committee on Tuesday.

This is a crucial step forward, as we work to end this dispute and change the way junior doctors are treated in the NHS.
— Wes Streeting MP (@wesstreeting) July 18, 2024

SOS Wes Streeting this week announced that formal negotiations with the BMA junior doctors committee will begin on Tuesday.

This comes in the same week that the independent pay review body for Agenda For Change staff is reported to recommend a 5.5% pay rise. If this is correct, and is accepted by the Government, then this will pretty immediately break the available workforce budget constraints for the NHS, which was prepared for a figure of about the 2.5% mark.

Corrigan on cash and carrying on

The Times this week picked up on the recent NHS Confederation podcast interview with reincarnated Labour special advisor Paul Corrigan, which also featured the excellent Isabel Hardman.

Professor Corrigan made some valuable points of critique: “the reason the integration doesn’t work very well is that the financial system in the NHS fragments the system.

“We need to have some innovation about how we work the money through the system, so that, for example, the extra money that goes into either primary care or domiciliary care to keep frail older people out of hospital is in some way paid back by the savings that are made in that entirely different stream, in emergency care in the hospital.”

These points build on his previous blog critique of the NHS financial chickens coming home to roost, and on accounts and accountability.

This really calls for a description of what this change might practically look like, and how we might get to there from here. Paul’s previous blog on ‘ring-fencing’ looks at one or two aspects of this, although I am irresistibly reminded of the much-missed PCT Cassandra’s definition of a ring-fence as ‘a financial border made up entirely of loopholes’.

The Times was quoting this because in particular of Corrigan’s points about the fiscal begging bowl: in particular, his claptrap line that “one way to change the impression that we’re always asking for more money is to stop asking for more money”. Tellingly, the piece did not quote his immediately subsequent remark that “that may be a bit simple”.

Discussing “a lot of evidence” of falling productivity in the NHS, Corrigan added, “when people say ‘we’ve had a 20 per cent increase in doctors and nurses, and we need more money’, I just think it’s not feasible … In five years’ time, will there need to be more money? Probably almost certainly yes. But hopefully by that time, there might be some more money to use.”

What the FDP?

Longstanding readers will remember my frequent COI declarations that I used to be a paid member of Palantir’s health advisory board, back when it existed to help them successfully win the NHS Federated Data Platform contract.

Interesting response from Ming Tang this morning:
Asked by @jhoeksma about FDP: “you said this may happen, does that mean you don’t know?”
Ming replied: “I hope it will but you don’t know until you get the ok”#DHSS24
— Simon Eccles (@DrSimonEccles) July 19, 2024

Erstwhile NHS Kiss deputy chief executive and former NHS England chief clinical information officer Dr Simon Eccles reported from this week’s Digital Health Summer School that NHS England digital lead Ming Tang was asked about aspects of the Federated Data Platform by DH boss Jon Hoeksma: “you said this may happen, does that mean you don’t know?”

Ming replied, “I hope it will, but you don’t know until you get the OK.”

Mmmmmmm. Hope is not a plan. It’s not a contractual deliverable, either.

It’s not a well-kept secret that the FDP rollout is underperforming both hopes and expectations. The roll-out is inconsistent in delivery and perceived support; some sites have found it hard to get their data onto the platform; there have been challenges with consent. There has been no standardisation of local data or of information governance. These are the absolute basics of architecture that you need for the foundation of digital reliability: they are notably absent.

There has been over-complication at launch, and trying to do too much at once as opposed to launching a functional product and then extending from a reliable working base with a successful proof of concept.

There is, frankly, a lack of trust.

The silence about the successes of the FDP roll-out is deafening … and this is an NHS England-commissioned thing that we’re talking about here. PR overclaiming of success is meant to come as standard: it’s just what NHSE comms does. Even though formal ‘lessons learned’ take time for the independent evaluation to arrive, there have been no serious efforts by the system to share informal learning. (You might not be surprised to hear that I advocated strongly that this should be a priority.)

Some of this is certainly because putting all the data systems together and ensuring the quality is consistently good is actually hard. Palantir is good at individual support, but the FDP product has, to date, poor experiences of scaling.

One way to understand Palantir is as an agglomeration of individual brilliant code-builders: amazing at building for individuals; but relatively unmarshalled in terms of creating a reliable, scaleable product for use in a universal public sector for which digital has not been a priority.

It is, furthermore, hard to do population health management without primary care data. And NHS England ducked the battle that would have been needed to include primary care’s data.

The FDP ‘marketplace’ was designed for bi-directional data, which has not happened. That makes it hard to be useful.

Some of this is about the broader issue of who owns patient data. Many people would advocate developing NHS digital products based on something like the SDK type of marketplace that Apple use for application developments, including data sharing products. This works using standard digital architecture and a strong commercial basis. It allows the individual to hold their data; Apple to have the core app data; and commercial apps to sit in between.

Under such a model, your app provider would safeguard your data; those apps would take bi-directional data flow.

So Palantir is having to go around health data companies, basically begging them for help. Those data companies, unsurprisingly, want something for something.

Physician associate training courses: everyone’s a winner!

I think we have our current leader when it comes to PA exam results now.

Bristol.

Check out these absolutely phenomenal results and students.

Genuine question: why are these brilliant people not doing medicine (to become a doctor) at Bristol?

94% distinctions https://t.co/a5O41cjbhk pic.twitter.com/Gf1doVU9Lo
— Dr Sandeep Bansal (@iDrSunny) July 16, 2024

The remarkable saga of physician associates took another turn this week, with the results of some FOI work. Dr Sandeep Bansal found that pass rates for universities’ PA courses are remarkably high, with University of Bradford passing 100% of candidates in each year 2020-23.

Even more impressively, the University of the West of England saw 11% merit and 89% distinction for its PA students in 2020-21; 14% merit and 86% distinction in 2021-22; and 6% merit and 94% distinction in 2022-23.

Naturally, no candidates achieved anything so lowly as a mere ‘pass’ - and for course, none failed.

The courses at Swansea, St George’s and Birmingham are all attempting to refuse to answer these FOI questions.

Nursing numbers

More RNs and NAs than ever before, twice as many joiners mostly from international recruitment However, one fifth (20.3 percent) of the nurses, midwives and NAs who left the register over the last 12 months did so within the first ten years of joining their chosen profession. https://t.co/Y14L1UkM1r
— Prof Alison Leary 💙#ProtectNurse (@alisonleary1) July 19, 2024

Sometimes, a number really strikes. Nursing workforce expert Professor Alison Leary picks up on the NMC annual registration data, which shows that although there bare indeed more registered nurses and nursing assistants than ever before, fully one-fifth of the nurses, midwives and NAs who left the register within the last twelve months did so within teen years of joining the profession.

Retention is another crisis.