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No helping hand

Failing Trusts won't be able to get handouts from others in a position to offer aid

The healthcare system in England looks set for a stormy summer. Pat Hewitt chopped Sir Nigel Crisp, bringing his pension forward and offering him a seat in the Lords. A quick and civilized departure for Crisp, based on an end-of-year NHS overspend of around £500m.

Crisp held the combined post of permanent secretary, heading civil servants in the Department of Health, and head of the NHS. On his departure, his old job went to two people, with the NHS bit of his job going temporarily to Sir Ian Carruthers, a long-term career NHS manager.

Rumour has it that Blair wants a permanent NHS boss from outside the public sector and possibly outside the UK.

The immediate job for Carruthers was to reassure the public and the NHS that there was a recovery plan to bring health service spending back into line by the end of the current financial year.

The medicine to achieve this, however, is proving unpalatable in many quarters. Before this year, the NHS could bank any monies not spent freely across England.

In essence, this meant that hospitals that were overspent in London or Surrey could be bailed out by borrowing from under-spent hospitals in Newcastle or Liverpool.

This end-of-year money laundering was criticised as it was felt that it rewarded overspenders at the expense of those who managed more carefully.

The system also sent a signal to over-spenders that there was always a rescue mechanism that allowed underlying financial problems to be hidden or ducked.

A new finance regime has been installed which limits the end-of-year banking arrangements. From now on, each Strategic Health Authority is limited to banking arrangements within its own boundaries, so flows of largesse across the country have come to an end.

In short, by the end of this financial year each local health economy must consume its own underlying financial problems.

For many health economies this will mean tough choices, including redundancies, rationalisation of acute services with ward and bed closures, and in some cases service cuts. This will confuse the public, which is told constantly that the NHS is receiving record amounts of taxpayers cash and that the NHS budget will continue to rise through to 2008.

It is also confusing to front line NHS staff, which, like the public, does not get the niceties of macro NHS finances.

Have your say
As the union conference season got under way, Patricia Hewitt decided to go and talk to the brothers and sisters at the Unison annual bash in May. Unison played her visit very low key. There was no booing or heckling, no banners or placards. Unison members received Hewitt in polite silence, with the occasional derisory laugh at her speech. At the end there were polite questions and light applause.

Unison registered its disagreement with Hewitt effectively but kept dialogue open. A few weeks later at the Royal College of Nursing (RCN) annual congress, Hewitt received a very different welcome. The audience had donned anti-government T-shirts, printed stickers, displayed several banners of protest and heckled her throughout her speech, forcing her to end it prematurely.

Questions were loud and aggressive and it was obvious that the whole show had been stage-managed by the RCN leadership.

~

A Step too far
The problem for the RCN was that some of the stage-managed questions from angry nurses were either stupid or exaggerated.

A student nurse expected the Secretary of State to give every student guaranteed employment in the NHS at the end of their course of study. I am not sure what planet the student lives on, but I know of no sector that offers cast iron employment on completion of studies.

Why should nurses get special treatment? A male nurse made dramatic claims about staffing on a unit for sick babies in an emotive fashion, grabbing the headlines. The problem was, however, that when journalists went to check his story, it did not quite stack up and he ran a mile from any further media contact.

While Hewitt may have looked deeply uncomfortable, the RCN played it badly. By not checking the validity of the questions put to Hewitt and by so blatantly stage-managing the event, the RCN looked both stupid and very poorly led.

A non-nurse looking at newspaper coverage of a howling nurse at the RCN bash said to me: I would not want to be cared for by people like that.

In short, the RCN ploy backfired and subsequently gave Hewitt the upper hand.

Changing tack
In June, Hewitt came to address the NHS Confederation conference, an audience of senior NHS managers and non-executive board members.

This lot want their OBEs and were hardly likely to give her a rough time, but her style at this event was very different to that employed at the earlier conferences. She did not stand behind a lectern but came to the front of the stage. She did not give a pre-written speech but engaged her audience in a conversation, using only a few notes.

Her style was open and consultative. She stayed to field many questions, all tough, none stage-managed, and all of which she answered adeptly and ably.

Perhaps she has learnt something over her first year in office, and that is probably good for her and the NHS. If the public are going to make sense of the spending in the NHS, they will have to accept that some adjustments in services are needed.

Question time
Rates of day case elective surgical work in the UK are inexplicably uneven. Differences in lengths of stay also bear close scrutiny.

Uneven performance that has a logical reason is understandable, but much of the uneven performance across the NHS has no logical explanation and Hewitt is right to question this.

Equally, rapidly changing technologies will drive big changes in acute hospitals in the decade ahead. What the public often does not realise is that the local district hospital that they love so dearly just may not be clinically safe.

In order to run accident and emergency and trauma centres there needs to be a critical mass of clinical teams behind the hospital facade.

Since changes to doctors' working hours and changes in educating nurses have come in, it has not always been possible to maintain a safe critical mass for all specialties across all NHS hospitals.

In short, rationalisation of acute services and their configuration is long overdue. A history of financial regimes which allowed underlying problems to be ducked, coupled with a lack of political will to reconfigure emergency services, conspired to allow inefficiencies to drift on unchallenged.

The silver lining in the current dark NHS clouds lies in the fact that the financial deficit might actually ensure that Carruthers and Hewitt have the courage to implement the new financial regime and stand behind some of the difficult decisions to shape services better for
the 21st Century.

Rough seas ahead
There will be a lot more bloodletting to come for Hewitt. As primary care reshapes and Primary Care Trusts rid themselves of provider functions, the unions will scream blue murder.

If Hewitt and Carruthers have any sense they will talk to the staff in primary care and offer them some fairness in pay, rations and pensions, as services shift into a more diverse and pluralistic provider base.

The signs from the conference season are that they are ready to listen, though that must not deter them from getting the NHS back into balance and delivering effectively by the end of this financial year.

Failure to achieve this will ultimately lead to a loss of public confidence in the NHS and possibly the end of the health service as we know it.

Hewitt famously said the NHS had its best ever time last year. Time might prove that this crunch year we are in will prove best in the longer term.

The author
Ray Rowden is a health policy analyst and former special adviser to the House of Commons Health Select Committee

2nd September 2008

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