Comment / Finding the balance in planning for 2023/24

The 2022/23 planning round for the English NHS was a difficult affair. This was nobody‘s fault in particular, but there were a number of difficult variables in play. How quickly would Covid costs start to fall and would it be possible to claw those costs out? How quickly could we turn our attention to elective recovery and what would the cost of delivery be?

There was more to think through. Could we afford national priorities funded from system development funding and other sources? How would unprecedented levels of inflation impact on budgets? And critically, what workforce availability could we expect ‘post’ pandemic and Brexit?

There were a number of lessons that perhaps weren’t learnt quickly enough. The stopping of the hospital discharge programme, which had been central to maximising capacity in general and acute beds is an example. Its return is welcome, but it remains to be seen how effectively we will now be able to spend the £500m allocated to the English NHS to have an impact in the short term.

As we plan for the new year, there is a lot to unpick. We need to improve our understanding of the workforce growth we have experienced in the English NHS since 2019/20, which is significant for both hospital and community health services doctors and nurses. How are these bigger numbers affecting service delivery and how have Covid-19 and infection control measures impacted on productivity? In what areas are we now using more staff to deliver the same activity? And how does patient acuity factor into all of this?

Beyond this we need to understand the potential impact of increased social care funding. A long-term solution remains essential, but how will the funding allocated in the autumn statement help to stabilise a volatile residential and domiciliary care market? Getting a grip on how much of our general and acute bed stock this might release for elective recovery and unscheduled care flow will be essential for planning.  

We probably also need to critically appraise some of the national initiatives and their impact. The intended aim of the additional role reimbursement scheme (ARRS) was to help to stabilise unscheduled care demand. As systems, we need to understand how well this is working?

And on another tack, what impact are virtual wards having? We need to fully understand their comparative costs, staffing requirements and how much in-hospital capacity they are really freeing up. Unravelling the interplay between social care funding, primary care investment and the virtual ward programme may give us confidence about a firm platform for elective recovery.

There will be things beyond our control in the 2023/24 planning round. We won’t have a perfect view on the ongoing costs of higher inflation. Nor will we have a crystal ball to work out the result of the pay award disputes and their ongoing cost impact or the pay settlement for 2023/24. We can try and isolate these two issues, however, and understand the potential reverberations on affordability of the broader NHS service offer, once they are understood, if they differ from planning assumptions.

Perhaps the biggest challenge in a very demanding year will not just be balancing budgets, but finding the balance between national and local priorities. If we bake in the current costs of provision as the starting point for 2023/24 planning, we will inevitably find there is little money left for upstream intervention and trying to tackle the many issues related to socially determined disease.

There is a fundamental need to understand the interplay between local priorities and accountability, and those nationally determined. We should understand whether any of the national priorities and their associated funding flows are having a differential or unplanned impact. If so, in the new context of system and partnership working with local government, perhaps we need a more fundamental conversation about local versus national accountability.