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Last week the King’s Fund had its annual thrash.
The star guest was The Jim Reaper who delivered a brutally frank message that terrified even him.
Ouch... the up-sum … a radical overhaul of how NHS money flows.
I’m tempted to say Sir Jim has taken a leaf out of the Trump-Playbook.
Change global tariffs and you shift geopolitical and economic shapes and also, beware…relationships…
Change NHS tariffs and you can shift the geography of care and the economic shape of primary and community settings and also, beware… relationships…
… but I wouldn’t dare.
What I will say..
… shift from stability; block contracts, deficit support, control totals, towards; accountability, precision, activity-based, unbundling, outcomes-linked payments…
...just beware.
Knowing what’s paid for and to make funding follow prevention and community-based care, rather than just hospital throughput, is no bad thing…
... just beware.
It’s a logical ambition… realign incentives, clean up data and stop paying for inefficiency, but…
… beware, even Sir Jim admits, it’s also; ‘absolutely terrifying.’
The NHS, has never managed to rewire its funding system at this scale, whilst…
… at the same time...
...downsizing its own national staff, whilst under the threat of industrial action, with collapsing social-care services and shaky local financial governance.
The likelihood of success? As much as I want Sir Jim to succeed… by the time of the next election…
… low to moderate.
Stepping back, it’s clear this wave of demolition isn’t something The Reaper has dreamt-up, for sport.
It’s being driven by the Treasury, the state of the public finances and a government in disarray.
New rules will be a product of economic necessity, not managerial ambition.
Inexperienced politicians talk blithely about ‘moving fast and breaking things,’ but in a system as complex and vital as the NHS, breaking things means missed targets, struggling providers and avoidable harm.
Change on this scale needs the patience of an engineer, not the swagger of a disruptor.
The objectives of dismantling the block system, creating fair-payment-flows and stabilising local finances, are conceptually sound but operationally enormous.
The biggest obstacles are:
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Capability and bandwidth.
ICBs struggling with basic financial management.
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Data quality and coding reliability.
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Community and prevention services lacking robust activity data.
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Cultural resistance and a politicised medical workforce.
Hospitals fighting to protect their funding…
… shifting money ‘out of hospital’ has been a political promise for 25yrs and ever been achieved… why?
It requires not just new rules but trust between organisations… something I think is missing. Most ICBs haven't had long enough to build it and now they face more upheaval.
Timing is critical… this demolition coincides with mass redundancies creating uncertainty, demotivation and loss of institutional knowledge and memory.
What to do?
For any reform to survive contact with reality a slow tempo and phased implementation are prerequisites… discrete, learnable stages.
After years of churn, the NHS lacks senior finance leaders with deep costing experience.
We need a Financial Leadership Academy. A rapid programme to up-skill ICB finance teams in the new rules.
We need to be clear about why this change matters, would help. No more cockamamy from Streeting.
We need a moral narrative... explaining how the public and staff will actually benefit is an imperative.
We need to spell out specific health outcomes, fewer admissions, shorter waits, better community follow-up.
But the upshot?
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Concept… is right.
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Timing… is perilous.
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Execution risk… extreme.
Chance of success probably 30–40%…
... unless...
The Reaper’s ability to lead through honesty and deliver through discipline can turn ‘terrifying’ into ‘manageable.’
The risk is that financial orthodoxy… ending deficit support, phasing out blocks, introducing blended tariffs... collides with operational fragility.
Organisations already struggling, turns financial reform from a technical exercise into an emotional one.
Much of the heavy lifting to make these reforms balance come from redundancies. The cost topping +£1bn.
That hollows out expertise and morale. The discretionary effort that keeps the NHS functioning … goodwill, the extra mile.
Streeting and his gang of geriatrics should be careful what they wish for. Not even Big-Jim can simultaneously strip out capacity, overhaul financial architecture and expect performance to improve.
Stability is not the enemy of efficiency; it’s a precondition.
Sir Jim’s candour about being terrified is a signal… not of weakness but of realism.
Unless Streeting heeds the warnings, the NHS could be about to teach yet another secretary of state for health…
… reform fatigue and fiscal pressures make a combustible mix.
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