Why the £13bn NHS debt-write-off will be good for public dialogue
The announcement was slipped into Matt Hancock’s Press Conference last Thursday, and made to look as if it was yet another item of Government support of the NHS at its time of need. In reality, the proposal had been on the table for almost two years, was widely expected by NHS Managers and in line with changing priorities as the Long-term Plan moved towards its implementation phase.
It is still most welcome. Note that the write-off is for NHS Hospital Trusts, not Clinical Commissioning Groups. It has been estimated that 100 Trusts carried an average of £100m of debt; the two most indebted Trusts owed £1bn alone. Few could ever hope to repay such monies without drastically affecting patients and communities. The entire funding system was unsustainable, and everyone knew it. Think-tanks like the King’s Fund and the Nuffield Trust predicted the move throughout 2019 and described it as being “in the pipeline since last summer”.
The most authoritative analysis of the NHS’ finances came, unnoticed in February when the National Audit Office published its Report on NHS Financial management and sustainability. It does not mince its words. It concludes that “The NHS is treating more patients but has not yet achieved the fundamental transformation in services and finance regime needed to meet rising demand”
It confirmed that the situation had only been managed through a mixture of emergency loans and ‘Short-term fixes’ that had left much of our hospitals estate with ‘unsustainable debts which they have no ability to ever repay.’ It has created a climate of crisis – a cloud of austerity that colours every management decision taken in our hospitals, mental health trusts and community services. Moreover so much of it was caused by the unsustainable financial model imposed on the service in the wake of the 2012 reorganisation. Even this debt-write off leaves many problems in the funding of CCGs – though the numbers are not as great.
So will this help? It’s portrayed as lifting a burden off the shoulders of the system to enable it to focus on the coronavirus pandemic without distractions. But for public engagement professionals, there may be a significant benefit in improving the quality of the public debate.
For as long as service changes and reconfigurations have been initiated against a background of large financial deficits and ever-more-aggressive demands from the centre to fix them, consultations with the public have been dominated by the spectre of cost-savings. Either Managers have been forced to make proposals primarily to save money. Or, even when denying that this is the motivation, campaigners have doubted this and assumed that, whatever they say, the real reason for change is to make cost savings.
On many occasions – such as in the recent High Court cases involving the transfer of functions from the South Tyneside hospital, the case for change was essentially about clinical outcomes. But this does not stop enthusiastic defenders of the ‘status quo’ frequently asserting that unpopular changes are really a disguised attempt to reduce the burdensome deficits that have affected so many Hospital Trusts. It has poisoned the well of public dialogue and distracted from the debates that need to take place about future models of care and the best use of new technology.
The current emergency will, of course have a drastic effect upon popular perceptions. If the NHS can fulfil its challenging role, hospitals and their staffs will emerge as the popular heroes and heroines of the hour, and one suspects that the long-term policy of de-emphasising hospital treatments and switching resources to primary care and community services (not that it actually happened) will be less visible … for a time. Many of the inexorable drivers that made aspects of this very sensible will still remain, but the climate of opinion will have changed, and in this context, the debt write-off is a sensible step – albeit a few years late.
For public consultation and engagement, if we can lift the shroud of inherited indebtedness from the shoulders of Managers, and convince public and patient representatives that cost savings is no longer the prime focus, then maybe attention can rightly be centred around the issues that matter – the way to improve outcomes, remove health inequalities and provide better, not just cheaper services.
At a time with few things to cheer, a better quality dialogue about the future shape of the NHS might just be one such silver lining.