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Friday 22 September 2017

When the books don’t balance

By Jon Restell

Managers face an unenviable task in balancing financial targets against their duty of care to patients. But just how clear are our statutory responsibilities?

Jon Restellsmall

We need to talk about the statutory duties of healthcare bodies.

This column was conceived on a recent visit to Belfast. NHS leaders in Northern Ireland are currently consulting staff and the public about draft savings plans to meet revised targets sprung on them by the Department of Health. In essence, trusts need to save an extra £35m on top of existing plans to save £35m. Funding simply isn’t covering costs and the books won’t balance.

With a budget of just over £5bn, this may sound like small beer. But with only a few months in which to release cash, the impact will be felt directly in patient services. In Belfast, for example, managers need to find another £13m on top of existing plans to save £13m. They are consulting on temporary proposals including stopping the use of off-contract agencies, deferring routine elective care and closing beds, cutting back on domiciliary care packages and placements to residential and nursing homes, and deferring fertility treatment and access to some high-cost drugs.

Out in the open

What an unenviable job for managers faced with implementing proposals that they know will inevitably affect the health and lives of people for the worse. On this occasion, the public and NHS staff do seem to sense that the cause – and therefore the solution – lies with the politicians, and managers are not getting it in the neck. But that could change, as we’ve often seen elsewhere.

What struck me most was how managers were carefully addressing these difficult issues within a statutory framework – principally the duty to provide quality care and the duty to break even – and doing so in the wide open.

For NHS managers elsewhere in the UK this story will elicit sympathy and recognition – the four health services have not yet diverged that far. But in England, I wonder if statutory duties are quite as clear as they once were, and as they appear to be in Northern Ireland.

It seems to me that more and more change is occurring under the radar, out of sight of parliament, and that more individual decisions are being made which stretch or ignore statutory purposes and duties.

Fixing the system

This is one of the enduring, and depressingly predictable, legacies of the Lansley debacle. A system that was never likely to work, despite some good work in some areas, now needs fixing. As Dean Royles has argued in Healthcare Manager, accountable care systems and the pressing need for a single voice in the system make it urgent. But recent memories of the 2012 Act have scared off politicians from meddling with the structures of the NHS for a generation. Even if they had the appetite – and the Tories made provision in their manifesto for tidying up legislation – the focus on Brexit and the government’s parliamentary weakness makes such meddling impossible.

So well-meaning system leaders and managers have started to fix the system. National bodies are being spliced and diced without any coherent policy. Providers and commissioners are doing their bit to develop accountable care systems, possibly off-piste. As at least one foundation trust chief executive has pointed out, doing what’s right for the local system may not be doing what’s legally expected of your individual organisation.

But everyone has been reluctant, our union included, to embrace another reorganisation of management structures.

Right and proper?

I’m a pragmatist, but I wonder if we’re going beyond what’s right and proper. Does it feel right that statutory bodies are having their rules re-written out of sight of the parliament that set them up (and votes them the money)? What are the risks run by individual managers who, as in Northern Ireland, must make increasingly difficult and controversial decisions? The encouragement and support we see for managers now won’t be seen for dust if things go wrong. With Fit and Proper Person accusations being thrown around like confetti, managers are being placed in a dangerous position.

We must have openness about what’s happening in the NHS, and give managers who are being asked potentially to go outside the statutory framework genuine and bankable assurances that they won’t be blamed for the consequences of political decisions.

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