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King’s Fund: Key targets must be relaxed if finance to be top priority

The government may have to review its key waiting time targets and the feasibility of a seven-day NHS as it comes to terms with the fact that the health system can no longer meet demand and deliver current standards of care whilst also staying within its allocated budget, the King’s Fund has said.

In a major report on the NHS deficit, the influential think-tank called for realism and honesty with the public around the state of NHS finances and what it can achieve until 2020. According to the report, saving £22bn will not be one of these achievements.

Citing the massive £1.85bn deficit that providers and commissioners racked up in 2015-16, the King’s Fund said that cuts in staffing and reductions in quality are inevitable if the government’s priority continues to be restoring financial balance.

This is especially true in a post-Brexit landscape, with the political and economic uncertainty left by last month’s vote to leave the EU meaning health and social care funding could face further cuts to offset financial shocks.

The report also recognised that new models of care focused on transforming services offer “significant opportunities” to improve care, but stressed these initiatives needed time and investment and would not deliver savings in the short term.

There are also major opportunities to deliver better value by improving clinical practice and reducing waste, as advocated by Lord Carter, but these cannot be achieved at the pace or scale needed to save £22bn by 2020-21.

Helen McKenna, senior policy adviser at the King’s Fund, said: “There are no easy choices, but it would be disastrous to adopt a mindset that fails to acknowledge the serious state of the NHS in England today.

“We are drawing attention to these issues now while there is still time to have an informed and honest debate about the best way of sustaining and transforming care.”

Regardless of the impact of Brexit, the King’s Fund said the government must review its priorities now, specifically including its ‘seven-day NHS’ ambition and key performance targets.

“Existing commitments may also need to be reviewed; for example, the aim of treating 95% of patients in A&E departments within four hours, which has not been achieved across England for the past nine months, and other waiting times targets may need to be relaxed,” the report added.

“To be clear, we are not advocating that standards and targets should be relaxed, but rather highlighting that there may be no other option if restoring financial balance is the overriding priority. The fact that Simon Stevens praised the NHS in a recent speech for treating nine out of 10 patients within four hours suggests that national leaders may already be thinking in this way.”

There must also be an open and honest debate with the public about all this, given it is something already “widely understood within the NHS”.

“Of course, the government has a duty as well as a right to decide how much funding should be allocated to the NHS given the state of the economy and the public finances. However, it also has a responsibility to be honest with the public about the consequences for the NHS ‘offer’, particularly in view of its manifesto commitment to ‘protect and improve’ the NHS,” said the report.

It added that it is “touch and go” whether the Department of Health managed to stay within the budget voted for by Parliament for 2015-16, and, if it has, it would be just down to one-off financial control measures that “mask the size of the underlying deficit”.

Problems are ‘systemic’, not individual

The leaders of major health bodies came out in agreement with the report’s headlines, with NHS Providers’ director of policy, Saffron Cordery, who wrote for the last edition of NHE, emphasising that “we cannot keep pretending this gap [between quality of care and funding available] doesn’t exist and passing it onto NHS trusts”.

“They know they need to strain every sinew but they are being asked to deliver the impossible and then find themselves chastised when they fall short,” she added.

“The King’s Fund report is the third piece of independent evidence in recent months that supports the view that systemic issues, not mismanagement, are causing NHS trusts to fall into deficit. This systemic pressure, coupled with spiralling demand, rising costs and the growing deficits evidenced in this report, mean that trust directors are working flat out just to keep the service afloat.

“It is not a feasible strategy to just keep asking people to work even harder as finances are set to become even tighter in future.”

The chair of NHSCC’s finance forum and CFO at NHS Wakefield CCG, Andrew Pepper, added that commissioners are also “not immune to these system pressures” and said the report “starts to explain why many CCGs will struggle to balance their budgets for the first time”.

“The growing provider deficit means that CCGs will have to dedicate more of their resources to sustaining, rather than transforming the current system,” he continued.

“Add to that the drawdown restrictions which means many CCGs are unable to access any additional money to support local services and implement new delivery approaches to enable transformation, and we begin to see the full picture across both providers and commissioners.”

But despite today’s warnings – which come as a double whammy, joined with a Health Foundation report on workforce gaps – the Department of Health insisted the NHS is “performing well and delivering safer, more compassionate care”.

“We know some providers are under financial pressure caused by big rises in demand and our ageing population, but are investing an extra £10bn a year by 2020 to deliver the NHS's own plan for the future,” added a spokesman. “High quality care and good financial management go hand in hand and we are determined to make the NHS the safest healthcare system in the world, delivering a 7-day NHS.”


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Dr Michael Crawford   11/07/2016 at 14:16

The Battle Bus used by the Leave campaign in the recent referendum suggested that money going to the EU could be used for the NHS. That promise was quickly shown to be empty but the idea was attractive because everyone knows that NHS funding is hopelessly inadequate.

Lainey184   11/07/2016 at 17:25

Going backwards and losing all of the gains made since 2000, small wonder that the clinicians are so dismissive of performance management targets!

Max Moullin   12/07/2016 at 10:25

This is a clear case of what the quality guru Deming calls 'goals without methods'. If you give people targets with no means of achieving them, then they are always counterproductive. My view is that 'all targets are flawed, but some are useful' (Moullin, 2009). However to make them useful we need to focus on outcomes, encourage people to work across organisational boundaries, incorporate risk management, and most importantly develop a performance management culture based on improvement, innovation and learning, rather than a top down blame culture. Some of these aspects have been addressed in NHS targets over the years, but the NHS now needs to listen to staff and in particular avoid 'goals without methods'. Moullin, M. (2009) What's the score? Feature Article, Public Finance, 21 May Chartered Institute of Public Finance and Accountancy, London. To download go to:

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