Bewilderment over new elective targets
James Illman - Recovering services from the covid crisis is the big task for NHS leaders for the foreseeable future.
NHSE's recently published guidance on how elective recovery funding will be allocated in 2023-24 has caused considerable disquiet among trust finance teams.
HSJ?has heard from several frustrated finance sources, with the strongest critics branding the guidance confusing to the point of incoherence.
It is worth noting that post-guidance discontent is nothing new in the NHS and there are national figures who privately dispute some of, although tellingly not all, the issues raised. But?the strength of feeling on this occasion seems to go far beyond the standard chuntering,?
The guidance sets out how ERF will be allocated, with a national target set to deliver a 107% of pre-covid (2019-20) levels of “value weighted” elective activity, which equates to around 115% in raw volume, in 2023-24.
The target has been upped from the 104% demanded for 2022-23, which trusts are already struggling against. The system hit 98% for the first half of 2022-23 and that was before winter pressures and strikes started to bite.
But the criticisms?are largely logistical ones about the scheme itself rather than the demands. Instead of setting a flat system-wide target as NHSE did in 2022-23, integrated care boards have all been set their own tailored target, ranging from between 103-114%, for 2023-24.
Systems which delivered the least activity in the current financial year, relative to their 2019-20 baseline, will be expected to deliver the most year-on-year improvement, the guidance says.
The main concerns are?around the sheer complexity, with providers being given individual targets for each ICB relationship. Most trusts have significant levels of activity commissioned by multiple ICBs.
Trust finance bosses say the scheme represents a completely different contracting challenge, which at worst won’t work, and at best presents a major additional administrative burden.
Meanwhile, some ICB sources say they no longer have the in-house contracting expertise and that confusion around how the new set-up works will further fuel tensions about who is entitled to what.
There are also potentially worrying implications for clinical prioritisation, according to critics. One unintended consequence could be, for example, that a provider has two patients, but the one the trust deems a higher clinical priority gets leapfrogged by another patient, because they are further up the clinical prioritisation list in a different ICB.
Worse still, the worse-off patient could get trumped by a patient from another ICB, simply because the provider is “behind” on its activity target for that ICB.
Nuffield Trust senior policy analyst Sally Gainsbury told?RW?that trusts will have to juggle cost-weighted activity targets for each ICB they serve, as well as any central contract with NHSE, clinical prioritisation based on patient need (which should be the overriding priority), as well as the long waiters elimination target.
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She added: “There is a risk that clashing priorities will mean capacity is not necessarily focused on the patients that need it most. NHSE will need to watch this carefully to make sure there are no unintended consequences which mean elective recovery exacerbates healthcare inequalities.”
Siva Anandaciva, chief analyst at the King’s Fund, said the new mechanism was part of wider problem facing trust leaders, which was that “financial flows are not always clearly matching up with patient flows and the overall strategic policy direction for the NHS”.
He added: “Introducing new pricing structures for NHS care does come with a cost. Managers and clinicians need to interpret and then implement new guidance – at a time when they are already working flat out.”
Mr Anandaciva also raised concerns FDs could feel “pulled in multiple directions – with some financial incentives encouraging them to do ‘the right thing’ for the system even if it hurts their organisation’s bottom line, with other financial incentives encouraging the opposite behaviour”.
Of course, the block arrangements were never likely to go on indefinitely and driving up the activity levels as is required by the elective recovery plan was never going to be easy. But a more unified approach will be essential if national and local leaders are going to pull together and significantly shift the dial on the huge elective challenge.
2025 elective target ‘highly unlikely’
Meanwhile, a leading think-tank has concluded NHSE is “highly unlikely” to hit its ambition to increase overall elective activity levels to 30% more than before the pandemic by 2024-25.
The Institute for Fiscal Studies’ report published today ?marks a year since NHSE and ministers published their joint elective recovery plan in February 2022.
The report highlights that delivering the 2025 ambition would require double-digit (10.3%) annual growth in treatment volumes over the next two years, which compares with average annual growth of 2.9% in the five years pre-pandemic.
The report’s authors conclude that for the NHS to hit the target it “would need to achieve a truly remarkable increase [in activity]”, or the number of people joining the waiting list “would have to remain unexpectedly low”.
The report’s “central scenario” (a medium-growth scenario) suggests waiting lists will “more or less flatline during 2023, before starting to fall more steadily from mid 2024”, having peaked at somewhere below 8 million.
The prime minister’s pledge to have waiting lists reducing this year ?would be “narrowly missed” under this scenario, the report says.
However, this would meet the trajectory outlined in the NHS-government recovery plan, which says under a realistic scenario “we would expect the waiting list will be reducing by around March 2024”.
NHSE responded to the IFS report by announcing “hundreds of thousands more patients will benefit from NHS treatment by next year, thanks to dozens of new surgical spaces”.
In an announcement also to mark the first anniversary of the elective recovery plan, it said an estimated “780,000 additional surgeries and outpatient appointments will be provided at 37 new surgical hubs, 10 expanded existing hubs and 81 new theatres dedicated to elective care”.