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Refusal to discuss 'unthinkable' cuts

Quinquennial Council Dinner Sir Simon Stevens
STEVENS: Health leaders must get on with making cuts
  • NHS leaders refuse to publish details of millions of pounds more cuts – despite telling local managers to push on with plans
  • Local areas dodge questions about staffing, downgrading of services and waiting times – and say releasing details would ‘prejudice’ ongoing financial negotiations
  • NHS staff criticise ‘ridiculous pace’ of process and feel bullied by national bosses
  • Patients may no longer be able to expect the NHS to keep them safe owing to brutal cuts, frontline clinicians warn
  • 44 NHS Improvement staff working on the controversial cuts programme – with an annual salary bill of more than £4.5m

Health service leaders have refused to publish details of plans for severe cuts which could ‘bring the entire NHS into disrepute’.

As part of the CEP (capped expenditure process), NHS staff and frontline clinicians have been told to ‘think the unthinkable’ – including proposals such as considering extending waiting times, cutting down prescriptions and treatments and merging or closing facilities – in a bid to meet financial control targets totalling around £500m.

The 13 areas involved have submitted plans and NHS England chief executive Simon Stevens has now told commissioners and managers to get on with delivering the proposals – warning that more ‘difficult choices’ are on
the way.

The BMA has written to NHS Improvement and each of the 13 areas involved requesting the proposal documents but health leaders have refused to provide the plans – and few local areas have been willing to discuss any details whatsoever.

Senior NHS leaders involved in drawing up local plans have told BMA News that even the more modest of the proposals ‘would cause uproar’ – and that they are frustrated by the ‘ridiculous’ pace and secrecy of the process. One said he felt local leaders were being bullied.

One trust chair with oversight of the process of drawing up the plans in his area, who wished to remain anonymous, said the process had felt like fighting in a war, but not being sure whether he was being shot by the enemy or a friend.

‘We were descended on and asked to think the unthinkable in no time at all,’ he said. ‘The NHS seems to go into a zone of secrecy as an automatic reaction. That’s the thing that really upsets me – the secrecy of it all and the ridiculous pace [at] which solutions are to be crafted and agreed. It’s the management culture too – it’s all hierarchical power and bullying.’

He said his area had considered extending waiting times and stopping use of external providers – and said staff across the area were trying to find savings but that the ‘devastating’ cuts demanded were ‘just too great’.

‘Even the most modest proposals would cause uproar,’ he added.

‘Simon Stevens said we will not contemplate change unless it’s clinically driven and has popular support of communities but there’s no way on this earth any of the CEP proposals do that. It’s going to make a mess. It’s bringing the whole NHS into disrepute.’


Tough decisions

The CEP involves 13 local health economies, most of which are STP (sustainability and transformation plan) areas. They are all included owing to being unable to meet stretching targets for budget cuts – and NHS England and NHS Improvement have asked each area to draw up proposals for how the money could be found.

The process was launched in April with the areas involved sent a letter from NHS Improvement and NHS England telling them to make the tough decisions needed to return financial balance to the health service.

They were asked to submit plans by early May and negotiations are ongoing between many areas and national leaders, BMA News understands.

One area, North Central London, admitted the proposals could not be delivered without ‘major’ changes to NHS services and an impact on patients and urged national leaders not to force the cuts.

A senior clinician in a hospital trust covered by one of the process’s financially troubled areas said there was ‘serious doubt’ in her trust whether the savings could actually be made.

She said: ‘They are having regular meetings with our finance directors to talk about what we can do but the trouble is the savings are extremely hard to achieve and we’re already fighting hard to avoid catastrophic things happening.’

The consultant said discussions had included the potential sale of estates and closing services where staff numbers were low.

‘It’s dreadful,’ she said. ‘They haven’t involved clinicians at all. I don’t think many people even know this is going on and probably haven’t heard about it. Doctors went into medicine to look after patients. The worry is you can no longer expect the NHS to look after you safely – and certainly the next generation can’t.’


Make savings

NHS Improvement told BMA News it did have the business cases set out by each of the areas but that they were ‘proposals’ not ‘final returns’ – despite the process being driven by NHS England and NHS Improvement, telling local health managers in a letter that ‘final returns’ were expected by two months ago and Mr Stevens urging areas to get on with making the savings.

In a response to a Freedom of Information request, NHS Improvement also said the documents belong to local health authorities and suggested requests were forwarded to those organisations in order for plans to be released.

BMA News wrote to organisations in each of the areas requesting the final return – or the details within if not the whole documents.

At the time of going to press, representatives from just eight of the 13 areas had responded. None provided the full documents or significant details of their plans. FoI requests have also been sent to the areas.

Cambridgeshire and Peterborough STP told BMA News a number of options were being considered including introducing minimum waiting times for non-urgent cases, ‘strengthening self-care policies’ and reviewing clinical pathways to reduce outpatient ‘activity’ where hospitals and GP practices are paid poorly for the work.

A spokesperson for Papworth Hospital said the full document could not be disclosed as it could ‘prejudice’ negotiations.

South East London STP said there were no proposals to close or downgrade services, the number of beds in the area would stay the same and that ‘more focus’ on primary and community care was planned, to help cope with rising demand on services. It said there may be opportunities to reduce back-office and administrative staff, but cutting the clinical workforce was not part of the proposals.

Proposals which would impact prescribing were being considered, however, it said.

Despite a list of detailed questions regarding the CEP being sent to organisations in each area, a number of representatives responded with vague – and largely generic – comments.



A spokesperson for Humber, Coast and Vale said it was drawing up ‘short-term financial recovery plans’ to improve the situation locally – and said ‘engagement and involvement’ events would be held throughout the year about changes to services.

Bristol, North Somerset and South Gloucestershire said it would ‘work collectively’ to make changes but that there would be no adverse impact on services for patients. It said details on a public involvement process would be made available ‘shortly’.

Sussex and East Surrey said it was awaiting feedback on plans and would begin an engagement and consultation process if any ‘significant service changes’ were proposed.

The Devon STP said local health leaders understood the area needed to ‘live within its means locally and make best use of taxpayers’ money.

Staffordshire said the plan local organisations are working to is the STP. The forecasted black hole in health and social care funding in the area is £542m in 2020/21.

And North Lincolnshire said it ‘is working to return to a balancing figure’ and that ‘detailed questions’ could not be answered at this point.

BMA council chair Chaand Nagpaul said: ‘These plans for yet more crippling cuts will have serious consequences for the care and treatment patients receive and can expect in hospitals and GP surgeries around the country. It is one thing to go ahead with the sort of brutal cuts which could threaten the services the NHS has provided for decades but to do it in such secrecy is an even worse kind of treachery. Patients, the public and frontline staff – who have worked so hard to keep the health service afloat through years of callous underfunding and petty politics – must be at the heart of any plans for the future of the health service.’

But he said clinicians and the public were being ‘frozen out’ of discussions.

Dr Nagpaul added: ‘This government must stop and think before pressing ahead with these savage cuts at a time when it is widely accepted that the NHS is already woefully under-resourced and survives on little more than the sheer talent and goodwill of the staff who dedicate their lives to helping patients. This simply cannot go on. The government must provide adequate funding for the health service before it is too late.’

NHS Improvement told BMA News the number of national staff working on the CEP was 44 – with a total annual salary bill of £4.7m.

Responding to the BMA FoI request, a spokesperson for NHS Improvement said: ‘NHSI does not have a “final return” for each of the CEP areas. As indicated in Mr Mackey’s letter to chief executives of providers engaged in the CEP process, current CEP submissions are viewed as proposals. Therefore, this is still work in progress and NHSI do not hold any final area CEP plans. NHSI does hold copies of business cases from in-scope health authorities which NHSI’s consultancy approval panel needed to approve. These, however, are documents belonging to those health authorities. The latter share those business cases with NHSI in confidence, as part of spend controls processes which exist between NHSI and bodies that it regulates.’

The spokesperson said there were no plans to collect ‘revised, final’ area plans – despite saying the  documents were proposals only.

Widespread initial reports regarding the CEP incorrectly suggested Northumbria was one of the areas included and excluded Somerset.

NHS England clarified these details in response to a BMA News request on Monday, 24 July.

Responding to BMA News research an NHS England spokesperson said: 'The NHS has always had to live within the budget that parliament allocates, and the usual requirements for public consultation on any suggested major service reconfigurations of course continue to apply. However, it's 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.'

Somerset has been approached for comment.

Find out more about the CEP

'Scandalous' savings: £61m demand on STP a threat to care

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