The Covid-19 pandemic has changed the parameters of NHS planning for the future. The NHS “Long Term Plan” has had to be rethought, and new NHS England guidance even before the pandemic hit began calling for an end to plans that reduced numbers of acute beds. Any plan for a new hospital that is near the decision stage must have been drawn up in the pre-Covid period: but Boris Johnson wants to push these through faster. ROGER STEER, of Healthcare Audit Consultants, looks at how this could go wrong.
The Sunday Telegraph June 7 headlined “Boris Johnson speeds up hospital building to aid economy,” an article by Edward Malnick, the chief political Editor and thus presumably carrying some authority:
It stated that the Prime Minister’s plans also include:
“Measures to increase the “resilience” of the NHS before the winter, including with fast-tracked recruitment campaigns for doctors and nurses. …”
Also: “A major drive to reduce delays in the delivery of government projects, with a new team already examining the effect of cumbersome planning rules and ‘endless consultations’. The team is studying possible reforms to the system of judicial reviews, resuming work begun in February, when Dominic Cummings, the Prime Minister’s chief aide, warned that there must be “urgent action on the farce that judicial review has become.”
It’s all to happen “in the autumn” rather than overnight, so there is time to react to this. The stripping away of the checks and balances – which Johnson and Cummings regard as simply obstacles – could open the doors to a rash of ill-founded and half baked plans that squander billions and make systems worse than they are now.
The NHS has been spending hundreds of millions of pounds on management consultants, media consultants and “engagement” experts every year for at least twenty years in pursuit of “major reconfigurations” of one sort or another. A huge proportion of senior management time has been bound up in pursuing these schemes.
Unfortunately most of that time and effort by the NHS has been futile.
In the past, new hospital building projects could be claimed to be modernising old hospitals and replacing them with more efficient new ones adopting new models of care, displacing more work back to GPs and community services. The argument was that the ‘efficiencies’ would cover the cost of the expensive PFI schemes and the annual payments they required.
Those projects that did go ahead have acted as test beds for this theory: but what actually happened time and again was that new hospitals turned out to be more expensive than expected to build, and the ongoing interest payments and servicing charges even more unaffordable.
Outsourcing of services to private contractors undermined the quality of catering and cleaning services, while in many new hospitals bed numbers were cut to such an extent that until the Covid crisis broke occupancy often exceeded the 90-95 per cent level.
Access was made worse, land sold off, and profits reaped. But the end result of reconfigurations actually delivered has often been counterproductive. PFI schemes in Bromley, Woolwich, the Royal London, Romford, and in other places, have saddled local health economies with debt, forced the hand of managers to cut staff and services, and left a weakened, overstretched service vulnerable to surges in activity and without sufficient staff and capacity when the NHS most needed it.
Not that this was inevitable. The consequences could have been foreseen and mitigated.
So Johnson’s reported plans for infrastructure investment in the NHS have to be placed in context. The NHS has been starved of capital resources: so when substantial capital is finally made available it can seem like all the buses arrive at the same time. It has been called feast and famine, or boom and bust, although more often it’s just famine and bust.
The consequence of this is that it breeds a certain cynical opportunism amongst NHS managers. It is not the quality of the economic case that weighs in the final analysis, but being in the right place at the right time with a scheme that ticks the right political boxes.
Returning then to Johnson’s attributed plans, what do we see?
Wishful thinking, “u” turns, dressing up of one thing with another to make it more palatable, and now counterproductive measures to ease the path to doing the wrong things more effectively. My biggest concern is the promise to halt delay in NHS investments, scrap planning rules and “endless” consultations, and to stop the “farce of judicial reviews”.
It’s clear that Boris wants to see new hospitals built: but like Blair and Brown, not necessarily the right hospital in the right place for the right price or with the support to ensure success: just enough new projects to fuel voter turnout prior to the next election.
By now the Tories were supposed to have published a revised capital funding regime for the NHS, replacing the discredited Private Finance Initiative policy that dominated NHS capital projects for 20 years.
Until the new regime is established, the old rules apply. This effectively means that the costs of new hospitals become a financial curse on local health economies. Investment, far from being a benefit, costs extra tens of millions of pounds of overhead costs each year that have to be found from revenue budgets.
As a result PFI hospitals have become black holes absorbing more and more resources and leaving the remaining services weakened, vulnerable and without resilience at times of greatest need.
People who scrutinise plans for new hospitals and point out the costs, risks and counterproductive proposals are decried for being obstacles to progress: but it needn’t be this way.
Changes to the capital funding regime could be introduced centrally to fund the additional revenue costs of capital schemes – as existed prior to the 1980s. However Treasury and Conservative chancellors much prefer to “starve the beast” and to punish local communities for pushing for increased public investment.
Since they still guard the financing rules, any extra investment will most likely continue to come with a large bill attached.
Johnson only sees as far as the next election and seems relaxed in promoting investment that will create havoc behind it.
Are we being too harsh? Let’s look at the other measures being promoted: the first is to increase the “resilience” of the NHS before the winter by recruiting more doctors and nurses. Such positive measures are long on good intentions and hypocrisy, but short on practicability and sufficiency.
In reality the NHS continues to plan to cut NHS staffing levels (which is central to the most developed of the plans for new hospitals, in South West London, which would cut back on both staff and on acute beds).
The real intention is not to recruit additional trainees (the Tories cut numbers of medical training places post 2010) or to help local or international recruitment (badly affected by Brexit and additional immigration controls): both of these would be much more expensive to deliver.
Instead the aim is to deliver a smaller NHS, requiring fewer staff to deliver its services – starting with the new hospitals. That’s why they want to reduce scrutiny, strip out consultation, and streamline decision making.
So we should be careful what we wish for, and cautious about the direction of the Johnson government, regardless of the claims made on his behalf by the Telegraph. It’s likely to speed up the “transformation of the NHS” – but into a smaller, less resilient and overstretched service with fewer trained staff available to keep it going in fewer, more remote sites.
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