Hammond’s Trap

Chancellor Philip Hammond had to give the NHS some extra funding to fulfil the government’s pledge of a year on year real terms increase in health funding per head of the population. Predictably, he promised just 40% of what just about every expert authority calculated was necessary for the service to remain upright. He then compounded the pressure by demanding that the extra £1.6 billion for next year must resurrect the long-lapsed targets for waiting for non-urgent operations (18 weeks) and in emergency departments (4 hours). He knows the NHS hasn’t got a hope in hell of doing this, so the strategy must simply be to set up NHS England CEO Simon Stevens as the fall guy for failure.

Stevens incurred the wrath of Hammond and Theresa May by firing a very public pre-budget broadside at a conference in November when he warned that the NHS waiting list was heading for 5 million by 2021, that the government may be forced to “publicly, legally abolish patients’ national waiting times guarantees” and that it would become “increasingly hard to expand mental health services or improve cancer care.” By ordering Stevens to get waiting times back on track with 40% of what he asked for is Hammond’s attempt to put the NHS boss back in his box.

He is unlikely to succeed. Stevens is fiercely political. He had a constructive relationship with David Cameron and George Osborne which allowed him to make the absurd pledge that the NHS could make £22 billion of savings with just £8 billion of extra investment, hoping that this was just a starting position and he could secure extra funding in time. His relationship with May and Hammond is much frostier, and not helped by the government’s persistent misrepresentations about how much new money the NHS has already received (Eyes passim). So Stevens has decided to play hardball, cleverly citing the duty of candour which health secretary Jeremy Hunt introduced in direct response to the Mid Staffordshire disaster, which places a statutory obligation on all NHS staff to be honest, open and transparent if patients have been harmed or are at risk of harm from failures in care and underfunding. If all NHS managers and staff follow suit, it’ll be a very interesting winter.

Stevens also knows he has the experts on his side. The Care Quality Commission, the Health Select Committee, the Audit office, the NHS Confederation, the BMA, NHS Improvement, the Royal Colleges, the Patients’ Association and the Institute for Fiscal Studies have all warned that current funding levels are harming patient care. Independent experts at the Nuffield Trust, the Health Foundation and the King’s Fund together concluded that the NHS will need an extra £4 billion a year just to keep it functioning safely. As Stevens pointed out; ‘There is nothing out of the ordinary about needing such a sum. It would be a return to the average increases of the first 63 years of the NHS’s history, as against the exceptional choking back of funding growth of the past seven years. On the current budget, far from growing the number of nurses and frontline staff, in many parts of the country next year NHS hospitals and other services are more likely to be retrenching and retreating.” By offering 40% of what the best analysis says is necessary, and as a one off, Hammond and May know patients will continue to suffer. Stevens is being lined up for blame, but he will not go quietly.

Meanwhile, health secretary Jeremy Hunt buzzes around like a hyperactive stick insect, picking more unnecessary fights on twitter (scientist Steven Hawking, actor Ralph Little, 55,000 junior doctors, anyone who wants to come and have a go if they think they’re hard enough). His faith that technological innovation and management consultancy will lead the NHS out of the swamp seems undimmed despite evidence to the contrary. Commissioners in London have ditched a planned pilot of Babylon Health’s primary care symptom checker app (Eyes passim) after patients in a test used it to game the system and jump the queue to see a GP, rather than its intended aim of reducing the need to see a GP. The initial excitement about Care B’n’B – a scheme where the NHS rents out the spare room in your house to get patients out of hospital – has died down until the risks of poor care, abuse, and lack of regulation were properly considered. It may resurface in time. MD has recently stayed in a B&B in Australia, without realising it was next to a hospital. One guest was tube feeding with extensive oropharyngeal cancer, another with severe heart failure wore a portable defibrillator and the fridge was full of soup, juice and prescription-only drugs. It worked because patients and carers took full responsibility for their treatment, and what they took from the fridge. The nearby hospital has sensed an opportunity and is now planning a hotel for patients and carers. It’s hoping to make money in room charges and save money by freeing up its beds. But who will be blamed if it goes wrong?