NHS Chaos theory


What’s going to happen to our NHS?

I’m going to try to pull together, from a patient’s point of view, the issues facing the health service at the moment and in coming years.

There’s a lot being said…but here’s my take. I’ve been reading loads of things, from board papers to HSJ to the Guardian, to Twitter, to the Kings Fund and the Health Foundation, and NHS Gooroo. Even Roy Lilley’s great newsletters, which are a source of information and “excellent stuff”.


There’s not enough money in the system. Many trusts are now in deficit. It’ll get worse next year.

NHSE bungs funds around struggling trusts to get them through, but it seems that these will become repayable loans.

Hospitals were built for a smaller population, so they can’t manage current demand. It’ll get worse.

Cost improvement plans (CIPs) have not been realistic and have not been achieved. It’ll get worse.

The future funding model requires CIPs of 3% pa. This has not and will not be achieved

The current models of care (including social) are unsustainable and in any case do not provide person centred support for people to live well with their conditions, or indeed to remain healthy for longer.

There is a proposal to increase the Better Care Fund (BCF), using existing NHS funding, in order to further integrate health and social care.

Mr Hunt also says this will help prop up social care budgets. So funding within the NHS will reduce as health budgets cover cuts in social care budgets, made for reasons of balancing the nation’s books.

What’s wrong with a deficit, or debt? We’ve always had them. It’s how countries ( and many of us people) work. (Will Hutton)

CCGs are struggling with their own shrinking budgets, and some are trying to claw back money from provider trusts, through fines and unachieved QUIPP targets. Trusts are resisting.

CCGs are now taking on primary care commissioning. At a time when they are still developing capacity and expertise after the reorganisation two years ago. With shrinking budgets.

CCGs are run predominantly by GPs. They are taking on responsibility for designing and buying services from their own GPs. CCGs are “membership organisations”, meaning they ARE their GPs.

Decisions about all matters primary and GP will have to be made by a few non-exec directors. Lay members. People who who are untrained in health matters and often do not understand NHS complexities. They will act on recommendations from…guess who?

Provider trusts are set up as independent organisations that have to break even, or turn a surplus for investment. They have not evolved from small businesses, and they are not run by businessmen. Indeed, they are not businesses. They cannot significantly alter their income or their expenditure. They are by and large stuck with what they have been gifted.

Provider trusts have little intrinsic reason to cooperate with other trusts if in doing so they will lose income or increase costs. They are bound by rules that require them to break even.

NHSEngland (NHSE) is reducing its workforce in order to save money. As a result it is also withdrawing from hands-on work to lead innovation and remodelling of health care. NHSE is becoming a distant group of watchers and commentators.
There are Vanguard sites for innovation, following models proposed in the Five Year Forward View. These could prove that new models will work better for patients but I t will take at least five years to see results and evidence.

Local health economies that know they need to change have not got the capacity, funds or headroom, or (probably) the willingness to take risks, to make change happen. They are fighting daily fires.

Providers trusts and commissioners and local government blame each other for not doing enough to solve their crises. Few look at their own systems critically and with solutions in mind.

Health and Wellbeing Boards are intended to bring together all commissioners and providers of health and social care, so that they work in partnership to co-produce solutions and better ways of working…for the benefit of people in their purview. You and me.

There is little evidence of this happening. But politicians seem to want to hand health and social care budgets to locally elected councillors, in order to integrate budgets and care.

Who are these councillors? What track record do they have in managing billions of pounds of spending?





You really couldn’t create a better picture of chaos if you tried.

What will happen?

I believe that humankind only takes real action when faced with extinction. Until then we try to deny what is staring us in the face.

So I believe the NHS will be saved, but not until it pretty much collapses.

Our politicians are no different from us. They want to hang on to their jobs as long as possible, and they don’t know how to fix the NHS.

Now and then one thinks he does (aka Lansley) but just gives another iteration of a doomed, unworkable system.

Breakdown then rebirth.

I just hope I’m not waiting at A&E when it happens.





2 thoughts on “NHS Chaos theory

    • Thanks Penny. Yes I saw it, as I read him regularly. Interesting that Nicholson has now said there is a funding bombshell to deal with after the election. Trusts in deficit everywhere.


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