The Primer: The price of money
The Primer provides a rapid guide to the most interesting comment and analysis on the English health and care sector that has not (usually) appeared in HSJ.
Whenever the government issues a new spending settlement to the health service it’s wise to consider what is being demanded in return — what is the price the NHS must pay? Simply providing care is rarely enough.
All the more so when a Conservative government is taking major political heat in order to come up with the money, by putting up national insurance and holding down pensions.
The latest NHS planning guidance issued on Thursday confirms that, although NHS England has very wisely not agreed to hit any firm targets for the cash, it has agreed to keep elective waiting lists firmly at the top of the agenda, consuming the lion’s share of this year’s new money, and with incentives tweaked to prioritise “clock stops” over all else.
But in addition to actual delivery of service targets — or perhaps instead of them — another cost of the NHS’ latest dollop of cash became startlingly clear over the weekend, in the shape of a major new government review of leadership of health and social care, with a particular emphasis on efficiency.
Leadership lessons for public services, in the Conservative playbook at least, must always come from either the military or business. So this review is led by a former vice-chief of the defence staff, General Sir Gordon Messenger. His number two is Dame Linda Pollard, the formidable chair of Leeds Teaching Hospitals Trust, formerly a successful marketer and business leader. Although it was trailed initially by the Tories on the eve of their autumn conference, you can read the official announcement here.
On Saturday’s Today programme Sajid Javid — a former Chancellor who will not have forgotten everything from the Treasury — all but confirmed the review was really about defending the spending growth, arguing he wanted to ensure “every penny” of new money was well spent. Perhaps he was displeased to hear people had been arguing (entirely accurately) that the money for health and care may not be enough to show much by way of firm results.
In the familiar truism, Mr Javid said some NHS leadership is excellent but there is variation. He wants to spread the good elsewhere, to bring improvements in outcomes and efficiency to all. Funnily enough, HSJ editor Alastair McLellan wrote just a week ago about how the leadership recruitment for integrated care systems risks compounding the “inverse leadership law” where patches with the worst problems don’t get the best bosses. One job of ICS is improvement of exactly those outcomes and care - with more than an eye on balancing the books, too, I expect.
Yet sadly, with most ICS chairs now hired and chief executive recruitment well under way, the review’s findings might come too late to take this big opportunity. If he wants to make an impact quickly, Mr Javid might want to step forward and help persuade the best people to get in and run difficult ICSs.
By announcing their leadership review as “the biggest in forty years”, the Conservatives are inviting comparison with the pivotal Griffiths report which, in the 1980s, did indeed augur a major overhaul of how the NHS was run.
The majority of informed observers will suspect that Sir Gordon’s effort, aside from offering a little political cover, will have no more impact than the countless leadership reviews which have taken place since then (ie: little). Some might even agree with what one NHS boss told the Guardian, that the review is about as welcome as “a vat of cold sick”.
One thing the announcement of the leadership review got right - though it’s been said plenty of times before - is that variation in care standards and outcomes between different areas are indeed alive and well out there.
The latest evidence on that neatly highlighted by the Institute of Public Policy Research last week, whose report, with analysis from the consultancy Carnall Farrar, includes an “integration index” for each ICS. Covered in the Independent, the report’s observations include that the rate of maternal deaths is 16 times higher in the Sussex and East Surrey ICS than it is in Suffolk and North East Essex, and that people with severe or complicated mental health problems in Bath and North East Somerset, Swindon and Wiltshire ICS are three times more likely to have a care coordinator than those in Leicester, Leicestershire and Rutland.