No Stone Unturned

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Our local area has been fortunate enough to be included in the national intervention programme called the Capped Expenditure Process (CEP). My last blog (Coalition?) was about the positive effect that the CEP has had on our local relationships in that we are working much more collaboratively. This blog tries to explain why we are needing to do this.

Essentially it is about balancing our budget.

My understanding is that the CEP is in place for those areas where they have particularly struggled to manage within their financial allowance and/or to agree contract value between commissioners and acute providers. The line that NHS England and NHS Improvement have taken on why these 14 areas need to work on this is because “The NHS has to live within the budget that parliament allocates and it is grossly unfair if a small number of areas in effect take more than their fair share at the expense of other people’s hospital services, GP care and mental health clinics elsewhere in the country”. So that’s told us then. We are spending more than the money we have been provided with, and as the NHS has a fixed overall budget, we must be spending money that was originally allocated to someone else. I bit like me taking some of your pay check because I’m going overdrawn, while you are saving.


The NHS has a fixed budget, and we are allocated a fixed share of that determined by a nationally developed formula. If you want you can have a look at the CCG allocations here: I recommend that you do. It’s interesting reading. They start with the 16-17 allocations, then as you scroll down the figures move to 17-18 and beyond. What you need to understand is that the while each CCG has it’s allocation, most receive either more or less than that for historical reasons. Everyone has their ‘distance from target’ and each year should move closer to what has been decided is their appropriate allocation. My CCG (NHS Vale Royal) works very closely with our neighbouring CCG (NHS South Cheshire) and we are both receiving less than our target allocation. In other words, we currently get less money than the allocation suggests we should. You can see this in the spreadsheets via the link above. For our local system we are approx £13m below target allocation. There are clearly other CCGs that are over allocation and receiving more money than their target. I will refer you to the NHSE statement in my third paragraph above and let you ponder that for a moment.

I want to be clear though. Even if we were to be in receipt of our full target allocation, we would still be spending more than we have available. Getting our target allocation does not provide us with a solution. We have asked about allocations, and the response is clear – once we can demonstrate that our system is as efficient as any other, and we are not outliers for activity or spend on any benchmarking data, then we can have a conversation about allocations. Until then, we should work on those things. I understand that and it is clear we cannot influence this.

The message is clear and simple. We have a fixed financial resource, and we need to live within that. This is not a message that people find easy to hear. When I have talked with people about how we choose to spend the monies we have, often there is a reluctance to engage in this conversation. People prefer to talk about how we need more money, not about how to most appropriately spend what we have. At a recent meeting people wanted to talk about how much the government spent on Trident rather than face the realities of accepting we have less money for local healthcare than we think we need. It is not that I disagree with the sentiments, and I would like there to be more money, but this is beyond my control. I have to work with what I have. (There is a blog here is worth reading that makes an interesting comment about the concerns that healthcare professionals have raised about our Health Secretary and why they may be misplaced. He argues that criticising Mr Hunt for there not being enough money in the NHS is missing the point – it is how that money is being spent that he could be criticised for.  

The result of all of this is that we have to make difficult decisions. We cannot afford to continue spending in the same way we have in the past. Things have to change.

The bottom line is that we need to focus on providing the best possible healthcare and outcomes using the resources made available to us.

Some things are not contentious. We can be more efficient, and do things that are unlikely to effect clinical services, but there will be harder decisions to be made where reduction in service, or changes in how and where they are delivered will need to be made. The ask of us from NHS England and NHS Improvement has been to ‘leave no stone unturned’. We have done this. We just need to be careful that there are not important things resting on the stones before we disturb them…We have developed high level plans which we now need to work up into reality. We need to share these initial plans with patients and staff and carefully consider the impact they may have. There are opportunities here to do things better, but there are clear risks that we need to fully understand. 

I want clinicians involved in this, although recognise that many find this uncomfortable. Without clinical input and guidance, however, we risk inappropriate plans that could put people at risk of harm. 

This must not happen. 

I also want the people of the area to know about this, and understand what is happening. These blogs are a small part of highlighting that the Central Cheshire area is having to make difficult decisions. 

Comments are welcomed.

Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.

Follow Jonathan on Twitter @DrJonGriffiths

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  1. Jonathan

    We often believe that what we do is the best way to do things, so to improve we feel we need more of the same, which mean more time, more people, and more investment money. However, other places (in the UK and abroad) do as well or better with completely different approaches, so there is something really fundamental to think about. Muir Gray, the public health physician talks about waste in healthcare, which is where we do the wrong thing or the right thing inefficiently, or the right thing well to the wrong part of the population we serve. An editorial in this week’s Lancet makes it clear that both overuse and underuse of health care are global problems, but it’s brought into sharp focus in Cheshire and Staffordshire, where we are told with the ‘capped expenditure process’ that we have to change now.

    You have found talking about doing things differently without more money causes worry, which shows as an unwillingness to talk about the realities of the situation. This is a sudden, serious reality check and it’s very hard to change what you have done done for years. At Leighton, we have found the same when explaining the CEP: incredulity, denial and sometimes anger. However it’s clear from other sources such as Right Care and ‘Getting it Right First Time’, that we are doing too much of the wrong or unnecessary things and not enough of the right ones to some or all of our local population. Muir Gray was right.

    However, there is an up side. We now recognise we are all in it together, and there is increasing urgency to change. Clinicians (doctors, nurses, therapists) and managers have started to think about opportunities to do different things to improve what we do for our patients and public. There are sensible changes we can make that will improve, not worsen, patient care, and strengthen the way we work with other organisations in health and care. Many of them do not cost anything except a willingness to see things differently and change our behaviours as clinicians.

    These ideas are not the last word, nor will they be easy. Certainly we need to get away from the rhetoric of ‘cuts’ versus ‘more money’ as a panacea. We need to discuss our thoughts further internally at Leighton, and externally to get further understanding and more ideas from primary care, social care and from the public, and work together to improve.

    I’m looking forward to the conversations between clinicians, managers and the public because paradoxically, I believe the outcome of the CEP will be better care for more people.

    Liked by 2 people

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