Editorial Tuesday 23 February 2016: NHS funding - Dagenham finances and The Calais Defence

It is difficult to see what possessed the sensible and savvy Sir David Dalton to have recommended, or hinted at recommending, any endorsement for imposing the new contract for junior doctors.

Sir David took a reputational risk by agreeing to take over negotiations on behalf of NHS Employers - who were, let us remember, invented to take the heat off politicians and NHS leaders in the event of just such bitter contractual wrangles with critical groups of staff.

Less the man in the arena; more the dog in the fight
Having done this, and made significant progress, Sir David would have been wiser to have said 'that is what I can achieve: that's your lot'.

He did not owe Health Secretary Jeremy Hunt (or anyone else) public suggestions of a subsequent course of action. To do that was simply not Dalton's fight.

This is what made his 'support' letter to a group of fellow NHS chief executives so extraordinary. It's possible to see why, in a collegiate spirit, they might have offered a view whether his deal was 'fair and reasonable' (although given that Jeremy Hunt had repeatedly mentioned imposing the new contract, that was also unwise).

It is far less clear why or how the co-signatories NHS Confederation and NHS Providers thought they had a dog in this fight.

The negotiations were already toxically politicised pre-Dalton (if you're interested, I wrote about this for the BMJ).

You also have to feel some sympathy for the cohort of doctots who were screwed at their start of training by MTAS and Modernising Medical Careers, and who have now run into this (thanks in part to their intransigent, politically naive and negotiation-light leaders; you get what you vote for).

In the real world, the view of chief executives (most of whom are probably unknown to most of their junior doctors) were never going to sway acceptance or drive momentum in the doctots community, let alone influence public opinion.

That was a foolish gamble, which deserved to fail.

To the considerable surprise of absolutely nobody, this attempt duly backfired publicly. In two decades of writing about NHS politics and policy, I have never seen anything misfire so badly or so fast.

There is a good explanation how it unravelled here by HSJ's Shaun Lintern.

Where next for the contract?

NHS Improvement chief executive Jim Mackey joined in the confusion over junior doctors' commentatory role demarcation, suggesting that the contract should be implemented "consistently".

What fresh WTF is this?
Far worse, in a bizarre communication, Health Education England hinted its funding for junior doctors' training would be contingent on providers adopting the new, imposed contract.

Which is probably illegal.

System leaders' tactics seem to be The Calais Defence: when the local nuisances don't seem to understand you, simply speak M O R E  S L O W L Y  A N D   L O U D L Y!

Clearly, there are better ways to be in Europe than this.

A reboot up the backside
Maybe we should just switch system leaders off for five minutes, and them switch them back on?

This plan by HEE (if we dignify it with such a name) butts up against the rarely-used but wholly legal freedom for foundation trust providers to vary from national terms and conditions.

FTs' latest freedom restriction may not matter: almost none saw the point of varying from national contracts, or had the capacity and capability to negotiate and monitor local deals.

Moreover, there are huge logistical advantages all-round to having junior doctors rotatable on a national contract.

But if junior doctors refuse the new contract in numbers, this could get seriously Lionel. This isn't helped by the illustrative new contract rotas being a non-compliant mess.

2006: A DEL Odyssey
Nostalgia isn't what it used to be, but there's a heady odour of desperation and panic that reminds me of the NHS system leadership in 2006. NHS finances have gone Full Dagenham: we are currently several stops beyond Barking.

In 2006, strategic health authorities were stuck with the heavy lifting of beating organisations up over finances. Since Our Savour And Liberator Andrew Lansley abolished them (and planning in general), they have been variously reinvented as 'control totals' which will permit or prevent access to the Amy Winehouse Fund for good little stabilisation and transformation plans.

To deliver these, today saw a call for a generation of Colt Seavers to bury what remains of their careers at The Tomb Of The Unknown Stuntperson.

Meanwhile, new guidance on the 16-17 Operating Framework suggests that providers who agree control totals may be spared fines for performance failures. Here we risk the results mirroring those of cutting A&E target tolerance form 98% to 95%.

It can also, as HSJ news editor Dave West pointed out, be seen as an income cut for CCGs.

The scale and pace of the financial mess was thrown into sharp relief by Monitor/TDA's announcement of the current financial picture of the provider sector. The picture is far beyond abstract Impressionism, and well into the Francis Bacon-Hieronymous Bosch territory.

The Kings Fund's excellent Quarterly Monitoring Report provides deeper, richer content, including the really worrying reported observation that "deepening deficits in the hospitals and the severe cuts to adult social care are now worsening the care that the system can provide".

We should remember the root cause of this is funding below demand. Nuffield Trust financial diva Sally Gainsbury's useful phrase 'the trading gap', outlining the difference between cost of care production and what's being paid, deserves to be in wider currency.

Each quarter's figures have seen the finances run further off target, and so even the NHS England doubled underspend and the billion-pound bung spotted by the Health Foundation's Anita Charlsworth may not land 2015-16 on target.

Thus far, we have only had a financial crisis, which is the right call.

Having put medical morale unnecessarily in the toilet, and after the toughest Parliament ever for funding rises, the NHS now aims to radically transform care delivery during another Parliament of funding growth below trend, which looks set to take NHS spending to 6.3% of GDP by 2020.

No wonder that Don Berwick told the launch of NHS Improvement that "you're not just skating on thin ice, I think you're now skating on water.... You have to reaffirm the original vision of the NHS as a service to meet need. I think that’s at risk now ... You can provider universal healthcare on ten, maybe nine percent of GDP. Seven? No ... This could be an existential issue".

The Don is rarely wrong, and he's certainly not here.

There are none so deaf as those who will not hear, of course: hello George Osborne and HM Treasury!

The health sector has fucked up, too: manifestly failing to come together to make a clear, evidenced case that improvements in health funding and delivery (and yes, we need both) have already contributed to the increasing longevity of the population at £x per year per person in cost, and the next bit will cost £y per person per year, so what do you think your life's worth?

In the context of an efficient single-payer system, of course. People are chuntering hopefully about hypothecation, but it's a magic-free different name for a tax rise.

Those who consider themselves Serious Political People Inside The Tent seem to find it difficult to say out loud what is perfectly clear to everyone else: the NHS is underfunded relative to demand.

We can put more money in after there is an explicit crisis, and so waste a fair bit, or act now. It's a difficult choice, but not a tricky one.