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The Friday Surgery

Sustainability and Transformation footprints, 5 year forward views and mysterious strangers at the bar

This week the Friday surgery attempts the Herculean task of translating the Five Year Forward View and the Sustainability and Transformation Plan into plain English. To do so we've been forced to place Jeremy Hunt in a pub.

It's the evening of September 5th, 2012 and a despondent Jeremy Hunt sits in the darkened corner of a basement bar on the outskirts of Westminster. Phil Collins’ 'I can feel it coming in the Air Tonight' comes on the jukebox.

"Me too, Phil, me too", Jeremy murmurs gloomily in the vague direction of the speaker.

"Christ pal, you look like you could use a drink", Jeremy looks around to see George Osborne pull up a chair alongside him. "Two Double Babychams over here, love, when you get a chance".

"So why the long face, Jez? You've just got the Health gig. It's one of the biggest in the business".

"Just talked to the PM. If ever there were a wrong time it's now".

"Bollocks, you sweep in, clear up Lansley’s mess, do a few hospital visits, chat to some nurses and in no time you'll be looking at one Foreign office.” Osborne handed the barmaid a £50 note.

"All Lansley had to do was to open up the internal market so that the privates could do some asset stripping”, Hunt said, “but the PM and I were told today that by 2020 we need to break the NHS up completely, starve it of funds so that running costs become doable for the privates to pick up AND the privates don't want trusts being loaded with debt either. And the PM wants enough transition care so that we don't get lynched. Oh, and to top it off, they don't want it to go through parliament this time. No listening pauses, no watering down clauses, they want it gone". Hunt took a big hit on his double Babysham.

"Shit, how can you starve trusts financially and have them debt free?", George considerately moved his phone out of eye contact as he texted 'Hunt's screwed. I give him 12 months', to an unknown recipient.

“It's so much easier to suggest solutions when you don't know too much about the problem”, whispered a voice from along the bar.
Jeremy and George turned to notice the figure at the end of the bar, looking straight ahead. They squinted to try to see who it was but the light meant that they could make out little more than a silhouette.

"I'm sorry, were you talking to us? I'm afraid we were having a private conversation", George said.

"Bartender, could you get my two friends here another round of double Babychams?". The stranger refocused on the two colleagues, "The first thing you're gonna need is a five year plan", he said, while running his finger over his bourbon tumbler.

"Do you mind, we were...", Jeremy interjected indignantly, but the shadowy figured continued.

"…put together a big plan vision for the NHS, five years and hang it on the two things people can't argue with- better integrated care and more local accountability".

Jeremy had sat upright. "So I need to launch a five year vision for change?".

"Nope, you don't launch anything. They will tear you to pieces if you try another big shake up within a few years of the last mess. You get a patsy to do it".

"Patsy? Who is Patsy?", George blurted, confused.

"A patsy. You get a company guy, UnitedHealth or KPMG, but who has a clean history, Labour ideally so he doesn’t look like a Tory stooge. You put him in charge of NHS England and you tell everyone that it is an independent transformation. No parliament, no votes, no bullshit. Just an internal restructuring outside of political control".

"Shit, I like this guy", George said, "Don’t suppose you've got any ideas on how to sort a deficit out, have you?"Jeremy ignored his friend and fixed on the stranger, "Okay but how does that get rid of the debt? How do I starve NHS trusts of funds and keep them debt free?".

The stranger smiled and knocked back his bourbon, "Simple. 80% of trusts are in deficit. You simply make them each responsible for their own 5 year plan. And that includes them being responsible for their own debt and for breaking even. You make your chronic underfunding their problem."

"And if they refuse?", Jeremy was starting to warm to this idea.

The stranger smiled, "You deny access to a £1.8bn Transformation Fund to those who do not produce a satisfactory plan".

"£1.8bn!", George coughed, "steady on old chap".

The stranger continued with a smile "....and if they don't make a satisfactory plan to break even and slash services to manage their debts, you impose alternative leadership".

Jeremy could barely contain his excitement as the vision came together, "…enter private sector discipline! Yes!".

The stranger smiled.

"Yes, that's it, we brand it the "NHS responsibility pathway", Jeremy exclaimed excitedly.

"Yes, you could....", the stranger said, unconvinced.

"What, you don't think so?".

"It needs to be clean, new and fresh, no pathways, plans or pilots. It needs to be a........a sustainability footprint. Nobody can argue with sustainability".

George was thinking aloud, “Hmm maybe I need to do a sustainability budget…”.

Jeremy suddenly looked troubled, "There's just one thing, what about if people die as a result of the massive cuts that are made to balance these budgets. Is that going to hurt my career?".

The stranger smiled and looked at Osborne, "Did it hurt his?".

Jeremy and George looked at each other and smiled, "This calls for a celebration, what are you dri....", but when Jeremy turned to the corner, the stranger had gone.

It was at that moment that Jeremy woke suddenly and sat, bolt upright, in bed. He pieced together what he could remember from his dream and then got his PA on the phone. “Call Simon Stevens in the morning and tell him I have a proposition for him”.

In 2014 ex-UnitedHealth executive Simon Stevens became chief executive of NHS England. In October 2014 he launched his five year plan and next month, 44 new groupings (transformation footprints) of NHS trusts, CCGs and local authorities will submit their detailed 5 year plans and balancing budgets to NHS England.

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