The patience deficit

by Steve Brown

04 October 2018

The 10-year plan needs to set credible expectations for how quickly change can be achieved.

The confirmation of providers’ underlying deficit was a bit of a surprise last month. Not the size of it, but the fact that it has been publicly acknowledged. There was a time when managers were encouraged to talk of overspends rather than use the D-word – such was the term’s potential negative impact.

But we live in different times and the fact that NHS providers are in deficit – forecasting a £519m deficit this year on top of last year’s £966m – is no longer news. But the larger underlying deficit is.

The £4.3bn figure revealed in the NHS Improvement Q1 report is the size of the underlying deficit carried into 2018/19 – providers’ real recurrent financial position if you strip out one-off and short-term actions. This figure treats the £2.45bn provider sustainability fund as non-recurrent, whereas if you treat it as funding that will in some form or other be spent in the provider sector in future, the underlying deficit falls to £1.85bn.

Whichever figure you look at, it helps to capture better the scale of the challenge facing the service – especially when you consider the access and performance figures that accompany this deficit position. And it also puts the £4.1bn real growth coming the service’s way in 2019/20 into perspective.

There continues to be talk in some circles about what the new money should be spent on. But the reality is that the additional funds are already being spent on existing services. The challenge remains to keep finances on as even a keel as possible while the service goes through the slow, meticulous process of addressing variation service-by-service and transforming the model of care to meet current demand in a more effective and cost-effective way.

There are no short cuts and the service has shown how difficult it can be to take a model that works in one part of the country and apply it to another with a different context and set of conditions. The NHS is getting better at this. But to be successful, change often needs to be driven locally by clinical teams understanding their own position and making change, rather than having change imposed upon them.

There are increasingly tools that will help local health economies. NHS Improvement’s Model Hospital – which was given a make-over in September – is starting to help trusts to identify opportunities for improvement. This is a good tool that could be great in a few years once confidence further improves in the data – on the back of better collection, improved definitions and the use of more detailed patient-level costs.

But it is not as simple as spotting a variation and fixing it. The Model Hospital certainly provides a starting point and should get conversations going about challenges and solutions. But this needs to become embedded in working practices – with clinical teams using the tool themselves to identify opportunities to improve. And this won’t happen overnight.

Other changes – and moves towards value-based healthcare – will involve cultural changes. Clinical pathways will need to be redesigned with healthcare professionals taking on different roles to those they have undertaken in the past. Some transformation programmes will involve wholesale changes such service relocation – with all the consultation and time-consuming political debate that goes with such changes.

The point is that the one thing the NHS needs alongside increased funding is patience. When we finally see the 10-year plan, it needs to be credible in terms of what it wants to be delivered. The publication of the underlying deficit is helpful in that it provides a more realistic benchmark against which the new plan’s proposals can be measured.

This blog first appeared as a comment article in the October issue of Healthcare Finance