There is an ebb and flow in reporting on the NHS as Trump, Syria and Brexit dominate front pages. But the pressure-cooker state of the entire service still worsens. This morning’s latest figures are just a snapshot of deterioration – but every target is missed: for A&E, ambulance response times, for treating psychosis within a week, for cancer waiting times, blocked beds and diagnostic tests.

“Demand” is rising, the government says, as if serious illness were a choice, though the pressure comes from well-predicted, rapidly increasing numbers of old, sick people: this February’s A&E figures are, as ever, better than deepest winter January, but worse than February last year, as this crisis ratchets up.

Major A&E centres are treating 81.2% of patients within four hours, against a target of 95%, which used to be hit before 2010. The government likes to blame frivolous users of A&E, but those are easily triaged to on-site GPs. Serious delays are because of very ill people needing to be admitted with no empty beds: bed occupancy is at dangerous levels, as Chris Hopson of NHS providers warns, where doctors often have to decide “one in, one out”, discharging those who still need more care too early.

Take the temperature in virtually every part of the NHS and the wonder is how the heroically overstretched staff keep the wheels on the trolley. Take this week alone: the Royal College of Physicians says 84% of doctors have to cope with staff shortages and gaps in rotas.

GPs? Two years after a government promise of 5,000 more GPs, numbers are still falling. They dropped by 400 just in the last three months of last year: as doctors find the workload unmanageable some escape abroad, take earlier retirement or become locums. Too few new doctors want the burden of running a GP partnership, so 92 practices closed last year, tipping hundreds of thousands more patients on to already overloaded neighbouring GP lists.

Today the Royal College of Nursing, traditionally most reluctant of unions to take action, starts consulting its members on whether to hold a strike ballot. But with public sector pay frozen yet again at 1%, when inflation will shortly hit 3%, nurses are departing – as are doctors – for less stressful, better-paid work. Recruitment from the EU is plummeting, as predicted.

As everyone firefights, hand to mouth, all the preventative services are being cut that might help keep patients from needing a crisis bed. The government has lines to take but no answers, and some of those “lines” are fictions. No, the NHS has not had £10bn, as Theresa May keeps claiming: it’s more like £4.5bn over four years, says the Kings Fund.

No, the £2bn given to social care will not ease the beds crisis, for all the exhortations to councils to use every penny of it in releasing bed-blocking patients with new care packages at home. NHS Providers, representing NHS hospitals, mental and community trusts, says councils are using that money to stem the collapse of existing care services and care homes, as the higher minimum wage and rising costs cause multiple closures. Cuts leave at least half a million old people getting no care, who would have done – and that risks falls, neglect and extra hospital visits. The care crisis is seeing 900 care workers a day leaving underpaid and overworked jobs.

Money, you might think, comes last in hospital managers’ priorities. But they are being severely harried and punished by NHS England to rein in ballooning debt by plundering capital funds and selling bits of land to cover running costs, in one-off moves that many say they can’t repeat this year. An NHS England-commissioned report says £10bn is needed to cover this depleted capital: that’s not for grand new projects, but for basics such as worn-out dialysis machines.

A chair of a leading teaching hospital tells me “heroic assumptions” are being made by most trusts agreeing their “control totals”, their spending limits for this year. Debts will swell again. This year the NHS gets just a 1% increase, next year an unprecedented zero.

One of Labour’s NHS triumphs was to cut waiting times for operations from 18 months to 18 weeks – but now that totemic 18-week limit has been abandoned. However, that only adds to hospitals’ financial woes as they rely on income from elective surgery, while every extra emergency costs them money.

Two in five GPs in south-west of England plan to quit, survey finds
This is the dismal background to the reorganisation that the head of NHS England, Simon Stevens, is attempting, almost undercover. His state-of-play review of his five-year forward plan passed hardly noticed, announcing a first tranche of England’s 44 STPs, (sustainability and transformation plans) to reconnect local services fragmented by the Lansley 2012 act.

Most observers think it the right way to go, putting the NHS and social care under a united structure with one finance hub, ending destructive and expensive competition and tendering of services. But hardly anyone thinks this can be done with no new money: every STP calls for capital for new beds and units. Virtually all involve closures and mergers stirring a local political outcry.

Jeremy Hunt, who always presented himself as the patient’s ally, rooting out poor quality, wallowing in the Labour disaster at Mid-Staffs, has fallen uncharacteristically quiet. He has nothing much to say about patient safety in A&Es or elderly patients turned out of beds too soon. Not even deaths on trolleys in A&E corridors in Worcester roused his usual righteous ire.

Health chiefs believe that low interest rates mean the NHS has a “golden opportunity” to raise money for infrastructure without relying on the chancellor.

The Times has learnt that health officials have reached the outline of an agreement with one or two hedge funds, as well as other investment companies. However, no deal can be signed without Treasury approval.
Jim Mackey, chief executive of the financial regulator NHS Improvement, is to meet Treasury officials today to urge them to sign off a round of private borrowing to create a central NHS infrastructure fund to which local services can apply.

Health unions called the discussions a “cry for help” from managers. Hedge funds are investment companies, some of which are known for aggressive strategies. Simon Stevens, the head of NHS England, has agreed not to ask for more day-to-day funding after a spat with Downing Street this year, and negotiations in Whitehall now centre on cash for infrastructure.

Billions of pounds is needed for buildings, equipment and IT systems to implement Mr Stevens’s vision of tests and specialist care at GP surgeries, rapid-response teams to keep elderly people out of hospital and quicker and better treatment for cancer and mental illness. He warned last month that a lack of cash to get such services up and running was one of the “significant risks” to his plan.

A £5 billion maintenance backlog also needs to be cleared after years of raiding repair budgets to cover hospital overspending. “We have to be realistic because we are not going to get a £10 billion cheque to pay for all the transformation under way and the massive maintenance backlog, so we need to think long and hard about another way,” Mr Mackey said.

“Historically low interest rates are a golden opportunity for the NHS but we are constrained by rigid rules around borrowing that prevent us from taking action. An NHS fund could power the improvement needed to sort out problems at our hospitals and to drive the change required to get the NHS ready for future challenges.”

Ministers have accepted the need for some private cash after an official review concluded that £10 billion was required to boost an “insufficient” NHS infrastructure budget. However, they expect public money and land sales to provide most of it.

Jonathan Ashworth, the shadow health secretary, said: “It’s shocking that NHS leaders are in secret negotiations with hedge fund bosses . . . Theresa May has refused to respond to the needs of crumbling hospitals, ageing equipment or provide the necessary investment in community facilities.”

The NHS could expect to receive similar interest rates to the 1.1 per cent available to the government for ten-year loans. Concerns about how the borrowing would show up on government balance sheets must be overcome, as must Treasury scepticism about NHS financial acumen.

Mark Porter, head of the British Medical Association, said that while the Stevens plan “could have offered a chance to deal with some of the problems that the NHS is facing, this move shows how desperately the health service needs more funding. The government must take heed.”

Analysis: Proposals will scare Treasury

A new front has been opened in the NHS campaign for cash. The service’s leaders have largely accepted that there will be no more money until nearer to a general election but now the focus is on raising infrastructure funds.
There are two good cases for a one-off injection.

First, capital budgets have been raided to the tune of about £2 billion in two years to bail out struggling hospitals. Second, this has come at exactly the time the NHS needs money to set up the better local services that underpin its five-year plan. Cash spent now on therapists, equipment and computer systems to keep people well will pay off many times over in hospital visits avoided in future, the argument runs. Philip Hammond accepted the logic in last month’s budget, allocating £325 million for the most advanced transformation plans, describing it as a down-payment on a package to be negotiated this summer.

Today’s revelation raises the stakes in talks, which were already looking delicate. The Treasury tends to have a very poor opinion of NHS financial management skills and the prospect of the health service negotiating terms with seasoned hedge fund bosses is likely to cause palpitations in Whitehall. Then there is the spectre of the Blair-era private finance initiative. Although this helped dozens of shiny new hospitals to get built, many believed that they would have been cheaper in the public sector. The NHS is still paying £2 billion a year under PFI deals, with some hospitals claiming that they have had to cut other services to meet inflexible repayments.

Ministers do not want to say no to private funding if that will increase pressure to find more public money. Most likely is a compromise where less eye-catching ways to raise private capital are matched by taxpayers’ cash. If not, the winter row over NHS funding will erupt in a new form over the summer.”

Times – paywall