Comment / Stretched to the limit?

04 June 2023 Lee Bond

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Quart out of a pint pot! It is one of my father’s favourite sayings – and it is strangely appropriate in these uncertain and unsettling times. (The saying is actually ‘quart into a pint pot’, but that’s by the by!)

So where do we start. The accounts have been submitted and probably audited by now and the 2023/24 planning round is over (we think). 


For many of us, we are left to reflect on the most difficult and challenging planning round we have seen for well over a decade. Plans have been stretched and re-stretched, to such an extent that they are barely recognisable to those submitted in late February. 

But they now promise delivery in the bottom right-hand corner that is acceptable to our boards, integrated care boards (ICBs)s and the rest of the regulatory framework. 
These plans are full of assumptions around non-recurrent solutions and ambitious aspirations for transformation. 

For many of us, this will be the highest level of financial risk that we have seen and our boards, ICBs and NHS England will be aware of this. Sound familiar? 
These are undeniably difficult times for the NHS and finance teams. Interestingly, however, while attending the HFMA’s financial sustainability event Strength in numbers across the four nations,  I was struck by the sense of commonality, resilience and hope that there is across the finance function and the Strength in numbers theme chimed loudly throughout. 

We had an excellent session, where we heard first-hand about the experiences in the four nations. We are all in this together and all four nations have massive financial hurdles to overcome. So it was refreshing to learn about the innovative ways in which finance teams up and down the land are approaching the current challenges.
Using information (not just numbers) as the centrepiece of their armoury, each nation spoke passionately about the way in which they hope to unlock resources by redesigning entire pathways – a strategy that will undoubtedly yield long-term dividends. 

The prize for the day went to Clare Green from Wales, who spoke passionately about the diabetic pathway that they are trying to redesign in Wales. You could easily have mistaken her for a clinician straight out of med school!

The approach being adopted in Wales to redesigning whole pathways is being replicated, in part, by colleagues in Northern Ireland. 

And north of the border, Scottish colleagues have recognised the limitations in their own information and are busily trying to create the datasets from which patient-centred redesign, working alongside clinical colleagues, can emerge.

It was also interesting to hear how finance departments are actively recruiting to analyst posts. It is these data experts who will help the service to get under the bonnet of this information. 

It was also a revelation to learn just how much relevant information there is out there – something that NHS England was keen to promote in its narrative about the English experience.

While this is all very heartening, we ought not lose sight of the single biggest common view shared across all four nations. 

Reducing unit costs by redesigning pathways and improving productivity is one thing, but actually releasing costs in a heavily regulated service, dominated by labour costs and a semi-fixed cost structure, is quite another. 

This is the nub of the challenge we face in the short term. The longer term will undoubtedly belong to the end-to-end pathway piece that the devolved nations are so busily exploring (along with most developed health systems across the globe). 

But the challenge of getting real costs out, at scale and pace, is akin to getting a quart out of a pint pot – something we are all endeavouring to do, but which at the very least is stretching us to the limit. 

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