Count your blessings

The recent announcement of L8bn for three years of NHS building and refurbishment capital has been met with understandable praise from many quarters, but also a surprising level of cynicism and nit-picking that even many journalists would be hard pressed to achieve given the scarcity of capital over the last few years.

Even a Liberal Democrat MP, the last person you would have expected to come out in support of John Major, said recently that the overall L21bn NHS spending increase would only bring Labour's annual increases in its first five years to 3.7%, weighing this against 4.1% from the first five years of Major's administration. In addition, NHS inflation is believed to be higher than that elsewhere, due to ever more costly changing medical technology, and other factors, thus making the money look rather less like a benevolent handout and more like bringing spending on the service more in line with its realistic requirements.

Indeed it is no secret that capital budgets have been slashed in the last few years, in theory to be replaced by private finance, which is yet to emerge from its teething period. Before this announcement, gross capital expenditure was due to be reduced by another lOOm this financial year, so the boost that the 8bn will give to the drive for deserving publiclyfunded schemes is a fortunate about-face. Thus we should be welcoming this move with open arms, and not be looking a rare gift horse in the mouth, and after all, it's Frank Dobson's.

It should not be long before we see more schemes like the Gloucester Royal Trust's L25m sorely needed scheme, announced with the recent prioritisation of eleven schemes, but with public capital, having somehow slipped through the PFI net. The three schemes that survived being rejected in the 1997 prioritisation: Leeds Teaching Hospital, Peterborough Hospitals Trust and Kent and Sussex Weald Trust, all now have a chance of public funding in 1999, if they can prove their worth.

Of course the problem of backlog maintenance may have grown so large that the new funds will only scratch its surface, if PFI cannot bundle in some facility for dealing with this seemingly immovable object. And there is a lack of clarity about how large a chunk the promised building or refurbishment of 1000 GP surgeries will take.

NHS Confederation chief executive Stephen Thornton's exclamation that the increase was "beyond [his] wildest dreams," was later tempered to a more sober realisation of continued pressures on the service, for example the need to take on more doctors and nurses in what is a difficult recruitment market. He also believed that a 3% year on year efficiency gain target was "unrealistic," another worry to achieving the desired level the Government requires to justify its increases. He said the necessary cuts were "usually controversial", and he more than anyone knows the difficult decisions facing managers, having been closely involved with the Child B case as a health authority manager. Another fundamental problem with attracting staff is the need to keep pay rises under control (between 2%-3%); another hit the NHS is expected to take to honour its side of the bargain. This will paradoxically be one of the biggest obstacles to achieving efficiency, with nurses' groups unwilling to stand back and let the Government's laissez-faire approach control their situation.

It is also contradictory to expect to achieve efficiency by cutting management, when it is the management that will drive efficiency measures through. If the service is left to muddle along without genuine guiding initiatives such as benchmarking and risk management, there could be a general duplication of effort and a lack of co-ordination that could negate the crucial funding that will be allocated for capital schemes in the next three years.

Copyright Wilmington Publishing Ltd. Aug 1998
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