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Fencing the NHS


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Friday, 18 September 2015

Fencing the NHS

When they assemble a top ten of the best ever interview questions, the list will include “When did you stop beating your wife?” and Mrs Merton’s matchless “What first attracted you, Debbie, to the millionaire Paul Daniels?” put to Mrs Paul Daniels.

Slightly less well known but in the same league, was Sarah Montague’s priceless dig at Andrew Lansley: “So when you told Treasury you were handing over £70 billion of the NHS budget to GPs, what did they say exactly?” Mr Lansley avoided giving a direct answer, suggesting that what Treasury had to say was unrepeatable.

Treasury will have had something equally unrepeatable to say when in the game of manifesto poker in the run-up to the election, Messrs Cameron, Osborne and Hunt allowed themselves to be bluffed all the way to £8 billion of extra NHS funding, rather more than the Labour party and not far short of the wilder bids put in by the other main parties.

That wouldn’t have been a problem if the Tories had lost the election or ended up in another coalition, in which case manifesto commitments could have been revised in post-election horse-trading just as they were in 2010. Rotten luck for Treasury, but after the unexpected Conservative victory, the £8bn pledge remains. The question is: what can be done about it without causing a stink?

The ringfenced – or protected – NHS budget was the coalition’s most inspired piece of public sector budget-cutting spin. Never mind the subtle arguments about whether the “real terms” increase in spending it promised was real in any acceptable definition of reality, the genius was in deflecting criticism from the 25% cut to the social care budget.

What happens or fails to happen in social care has a direct effect on adjacent NHS services, or as Sir David Nicholson put it simply: “We can’t have a successful NHS and failing social care”.

In practice the ringfence has proved as effective as a permeable condom with the NHS wearing it for protection and everyone else trying to poke more holes in it.

Take the Better Care Fund, which allows some of the “protected” NHS budget to flow back to social care under cover of joint commissioning. Then there was the announcement earlier this year of a £200m cut to public health funding. The Ringfence Police didn’t even have to turn on their blue lights because public health budgets went to local government as part of the 2012 act and can therefore be described as “non-NHS” spending.

Now someone has come up with the inspired idea of shrinking the ringfence, according to a story in yesterday’s HSJ. The new ringfence is expected to cover only the NHS England commissioning budget, not the more broadly defined NHS budget which also includes public health and arm’s length bodies responsible for training, regulation and research.

The HSJ found Nuffield Trust chief executive, Nigel Edwards, King’s Fund chief economist John Appleby and Health Fund chief economist Anita Charlesworth reading the same smoke signals from Whitehall. A statement from the Treasury reads like a categorical denial, but stops short of addressing the article’s central claim.

If true, the £8bn promised in funding is less of a substantial pledge than it seems because billions of pounds of soon-to-be non-ringfenced NHS money could be up for cuts in the forthcoming spending review.

As the article points out, playing the “frontline services” card in defence of the changes is spurious. Any reduction in training and public health would undermine the workforce and health improvement principles on which the Five Year Forward view is based, and would also damage the prospects of meeting its ambitious £22bn efficiency target. And if Simon Stevens can’t deliver his side of the Faustian bargain, there’s no saying the £8bn would even stay on the table.

Jeremy Corbyn will need to up his game if he wants to nail this one during prime minister’s questions. If he insists on keeping the local radio phone-in format running, then he should recruit some better-qualified contributors – ask Nigel, John and Anita, perhaps.

If he’s looking for an opening question, Mr Corbyn could start with this: “Can the prime minister assure parliament that the promised £8bn increase in NHS funding won’t be funded by cuts to the NHS?” 

When the leader of the opposition abandons his mirthless pursuit of straight answers and gets down to the real business of point-scoring and popular entertainment, he’ll also need a good follow-up question:  “Anon 3.11 in the HSJ comment section defines ‘ringfenced’ as ‘protected by a barrier made entirely of loopholes’. Does the PM have a better definition he would care to share with us?”

Political editor: NHS Networks


David Perton
David Perton says:
Sep 18, 2015 12:44 PM

Rather more serious than usual Julian, but, as ever, right on the money (what there is of it)

Anonymous says:
Sep 18, 2015 01:14 PM

Delivering an infinite service with finite resources is a decades-old dilemma. Perhaps it can never really be solved.
In the current political climate, we appear to the government as a money-pit. The government doesn't have a plan to sort out health care spend, other than things like the post describes.
Individual providers are looking at their spend, but 5YFW notwithstanding I'm not seeing much coming from the provider sector as a whole proposal-wise that meets the government in the middle on money and delivery and stabilises the NHS.
You know that moment when you put a problem on the risk register, and (just for a little while) you let yourself think it's gone away? That's us, that is.