Comment / 'Twas the night before Christmas…

23 November 2023 Keith Wood

…which of course means that it’s time for planning guidance.  In recent years the tendency of planning guidance and allocations to arrive with the turkey has become the cause of much amusement. 

Yes, we would appreciate guidance a little earlier; Clement Moore’s poem makes much more pleasant holiday reading than NHS England’s rather more prosaic missive. But I think we also have to appreciate the challenge for the Department of Health and Social Care concluding Treasury negotiations in anything less than a month following the autumn statement. The guidance has to align with the ambitions of our political masters and requires a rigorous process of gateway control.  That is not the work of a moment.  

But that doesn’t stop us from offering a little seasonal prayer that, perhaps this year, we could do things a little better and have things earlier and in more complete form.

Wish one is that Christmas arrives in one day. The twelve days of planning, with new versions of templates, continual changes of allocations, and clarification of elements of guidance that were not available on day one, is a cause of much frustration. If all guidance was out on day one, the template and allocations unchanged from that point, completion of a considered, triangulated and governance-compliant submission would be so much easier. Bear in mind there’ll be 30% fewer of us in integrated care boards to do this next year. That will require a smoother process – why wait?

Wish number two is that the requirements are realistic and aligned. Unfortunately, this year’s plans have proven what most knew a long time before the start of the year. Inflation provision was unrealistic.  Industrial action, like Covid in the previous year, really was likely to continue well into the year and the efficiency expectations have proven to be unachievable. This has been acknowledged by the mid-year increase in funding to recoginse the impact of strikes and changes to systems’ activity targets.  

While the NHS must seek to improve productivity to something close to pre-Covid levels, the world, the NHS and its workforce have moved on. Patients who have been on the waiting list longer are sicker, Covid is an addition to the list of comorbidities if not itself the cause of admission, and the workforce is unlikely to be as flexible and as generous with their time against a background of industrial action than they were before (and they probably won’t be for a long time). 

I welcome the decision to engage with a selection of trusts on the issue of productivity.  One organisation I know has been contacted knows that they are less productive, and can provide evidence for many of the reasons why. But they not as unproductive as crude headline figures would suggest, and some of it will not be resolved in the short term. 

This year can the assumptions be more realistic, and improvement be stretching but achievable? One system recently submitted a medium-term financial plan that required improvements in efficiency of 5.5% to 6% each year for the next four years.  If the planning guidance effectively allows them – or even requires them to do that – that’s not a plan unless you believe in Christmas miracles.

Wish number three is for some straight talking.  Now there are two sides to this.  Systems need to be realistic in their submissions. But the centre (or regions) also needs to allocate all the funding up front – rather than holding back funding (non-recurrent or otherwise). Robust challenge is one thing. Submissions need to be realistic, but then accepted as robust analysis rather than expecting heroic or impossible levels of efficiency. 

This isn’t a pantomime, and you’re not a genie, so I’m going to make a fourth wish; keep it local. Integrated care boards were set up to effectively manage and integrate their systems. The more targets there are, the more money that is held back, the less likely we are to submit realistic plans, and the less efficient we will be.  Ringfencing is surely an admission of failure; that you have to protect a resource because it is not being used for a local priority.  Set as few targets as possible, distribute all the resource, and make it recurrent.

Well that’s my little sleigh full for this year. There’s lots of other little things that could be improved, but just leave them in the stocking hung by the fire with care. I think I’m on the good list? 


Mr Wood is a member of the HFMA System Finance Special Interest Group