Comment / Time for some straight talking

By Keith Wood

Am I the only one that finds it frustrating that halfway through the current Parliament and two years into the period of austerity there are still subjects the NHS cannot and will not discuss openly?  A few weeks ago the King’s Fund reported that a (relatively small) group of NHS finance directors had come to the conclusion that the financial future facing the NHS would have an impact on the quality of services provided to patients. 

The report was greeted with such outrage it was one of the lead items on Radio 4’s Today programme.  A couple of weeks later the Royal College of Surgeons speculated on links between the financial position and a reduction in levels of certain activity in over-75s. Rationing was the implication. Although perhaps there is a lack of evidence to make such a link, the mere possibility helped secure headlines – evidence of the political powder keg that is rationing. 

Amid all this we have shadow health secretary Andy Burnham’s ‘over my dead body’ reaction to the South West health economy initiative on pay. His performance at the Labour Party conference may have been directly aimed at Labour’s key union constituency but is further evidence of an uncompromising reaction to change.

Let us be very clear, saving £20bn from a health service budget needs significant change.  If we intend to be realistic – a good starting point – £20bn and five years looks very much like the start of a far greater target over a much longer period of time.

If the low-hanging fruit has effectively been harvested, then we need to have a proper debate over the real changes that need to happen if we are to deliver. A senior finance manager said recently that  ‘necessity is the mother of invention’. There is some truth in this, but in my humble opinion it will only get us so far. 

I have spent the past decade working in the ambulance sector and have watched the debate over vehicle specification. Van conversions are cheaper to buy or lease, maintain and fuel than their modular-build ambulance counterparts. They are successfully used in two NHS ambulance trusts (and partially in a couple of others) but shunned by the rest.

A shift to van conversion can save 2%-3% of the operating cost of the ambulance trust (or 20% of the fleet cost). Yet the debate is blocked because staff ‘like’ the specific model, ‘like’ the inch or so extra headroom and ‘like’ the tail-lifts perched on the back.  If that is enough of a barrier to prevent a sensible nil-patient-impact decision being reached then ‘necessity’ really does have its work cut out.

The debates that have been treated with such hostility over the past few weeks should be lauded. In an environment where roughly 65% of expenditure is pay, how can you possibly save 20% without at least considering terms and conditions? The plans do not look like a wholesale rewrite to me and may just protect jobs and help guard against the quality and service reductions warned about in the other reports.

Just this month Vauxhall agreed a four-day week for staff in its Ellesmere Port factory. This is no reduction in hours; rather the same hours compressed into four days with savings in utility costs and elsewhere. But it shows a willingness to think about transformational new ways to deliver in the face of significant financial challenges. We need a similar ‘everything on the table’ debate.

In reality, the time for discussion was more than a couple of years ago, and yet we still avoid open debate on issues that might be considered contentious to staff, unions and patients. It might be a little early for Christmas, but please, let’s talk turkey.

Keith Wood is chair of the HFMA Financial Management and Research Committee as well as finance director of Thames Ambulance Group