The elephant in the exhibition hall: what we did and didn’t hear from national health service leaders at Confed’s 2015 conference

There’s an old saying of ‘if you can’t say anything nice, don’t say anything at all’, which is generally a good rule to live by in everyday life, and probably explains why nobody speaks at all when commuting on the underground. But all rules have exceptions, and sometimes the thing that isn’t pleasant to hear is the very thing that needs to be said.

Recently I had the pleasure of attending the NHS Confederation annual conference in Liverpool. For me this was (rather geekily) a great health policy ‘celeb-spotting’ occasion. But more importantly it was an opportunity to find out more about the current mood amongst the top tier of the NHS as the election dust settles and the reality of delivering the NHS Five Year Forward View amidst financial pressures really bites.

I deliberately refer to mood here, as perhaps what I found most interesting was what wasn’t explicitly said, as much as what was said.

So let’s start with what we definitely did hear.

• First, we heard that the NHS Five Year Forward View is plan A, B, C through to Z. There was a sense of enthusiasm behind the vision of the Forward View which permeated every major speech, most breakout sessions that I experienced, and was the common theme around which every National Arm’s Length Body Chief Executive rallied. So, the NHS has a plan. People seem to know about it. We’re on the case – hopefully.
• Second, we heard explicitly and in relatively firm tones that there won’t be any new money this year. So, balancing the books without this injection of cash is the order of the day. Until this news, there was perhaps still a lingering thought that some emergency money might be found down the back of a sofa somewhere, but we are now clear that that isn’t the case.
• Third, we heard more on some of the issues which sometimes get a little lost amidst the money structural reform debates, namely a strong focus on the workforce who need supporting to do what needs to be done; greater reference to public health and prevention than can often be the case; and acknowledgment of the impact that social care funding cuts are having both on quality and on demand. It was refreshing to hear these subjects explicitly discussed in the main events rather than left for someone in the Q&A sessions to point out.
• Finally, we heard that centralist intervention is well and truly back on the cards. Whether it be NHS England’s ‘success regime’, singling out areas in difficulty for targeted support directly from the top, or the promise of action on standardising which toilet rolls are being purchased up and down the land in order to maximise cost savings, there was a theme of the National Bodies unapologetically seeking to have a tight grip on the system.

However, there were also some messages which we didn’t hear, or if we did, they weren’t in the same breath as those above, despite raising some questions about these messages.

For example:

• We did hear quite a refreshing amount about public health and prevention, as already noted, however what we heard at the same time - announced outside of the Confed conference – was that the Department of Health’s non-NHS spending, so public health budgets, would be subject to cuts of £200m in the coming year. This potentially casts a shadow over the excited debates about taking investment in public health seriously which were heard in the exhibition halls of Liverpool.
• Similarly, we heard that safety was the number one priority for the system. The Secretary of State made clear that this was linked to the efficiency agenda, not separate to it. But whispers (and on Twitter, shouts) were heard from some who were asking how this fits with the announcements not to extend safer staffing levels (concerns which have since been firmly addressed in a letter from the Chief Nurse); to take immediate action to reduce agency staff spend (what does this mean for areas who have trouble recruiting?); or for CQC to start inspecting efficiency alongside other domains of quality?
• Finally, there was an elephant present in the room as we heard that for this year, the NHS needs to live within its means. This elephant is of course how realistic this is, given the scale of this challenge, with an estimated funding gap of around £2bn in 15/16 (even assuming around 2% provider efficiency savings). Will the NHS be able to do this without reverting to slash and burn? And what will be the consequences for quality of care? The Carter review has since offered some hope, but is only part of the answer and will take some time to implement so is likely to be of less help within the coming year. Another question raised by this is that amid all of the focus on balancing the books this year, how will we provide support to providers to make improvements for the medium to longer term?

On the train back from Liverpool I reflected that the tone of the event was for me, one of cautious optimism. Leaving things unsaid can sometimes shield such positivity and optimism, but sometimes the contradiction or challenge just needs be acknowledged so it can be dealt with.

The mood at Confed’s 2015 conference indicates that NHS leaders increasingly are being required to tread the delicate balance between being honest about the challenges even when these aren’t nice to hear, whilst still engaging people in the positivity and optimism of the transformation agenda. What will be interesting to observe as we move forward is how far this balance is achieved as financial reality starts to bite.

Natalie is a Policy Fellow at the Health Foundation, www.twitter.com/NatalieBerryTHF