Capped Expenditure Process: New national savings drive will 'challenge the values' of NHS leaders

From Health Service Journal (paywall) - 5th June 2017 -  DAVE WESTLAWRENCE DUNHILLBEN CLOVER, ALLISON COGGAN


Closing wards and services, blocking choice of private providers, systematically extending waiting times, and stopping some treatments are all being considered under a national programme targeted at the health economies with the highest overspends.

The controversial measures are currently being discussed privately by national NHS England and NHS Improvement officials, with senior local NHS leaders, as part of the new “capped expenditure process”. The principle of the process, introduced this year, is to “cap” NHS spending in the targeted areas so that they meet ”control total” budgets in 2017-18.

NHS leaders from areas covered by the CEP have been told to examine “difficult decisions” and “think the unthinkable”, including modelling changes which are normally avoided as they are too unpleasant, unpopular or controversial. HSJ has spoken to senior officials in most of the areas.

One chief executive said it was the most extreme and difficult NHS finance process they had experienced, and that the some of the options - if pursued - would “challenge the value base” of NHS leaders.

Ideas under consideration across several areas include:

  • Limiting the number of operations carried out by non-NHS providers so the funding stays within the NHS. Considerations differ between areas but include both limiting patients’ choice of providers, and reducing work which is outsourced by NHS trusts. In some cases it would require the NHS to find the capacity to carry out more operations.
  • Systematically drawing out waiting times for planned care, including explicit consideration of breaching NHS constitution standards. Some plan to target delays at specialties/areas where waits are currently lower than average.
  • Stopping NHS funding for some treatments, including extending limits on IVF, adding to lists of “low value” treatments, and seeking to delay or avoid funding some treatments newly approved by the National Institute of Health and Care Excellence.
  • Closing wards and theatres and reducing staffing, while seeking to maintain enough emergency care capacity to deal with winter pressures.
  • Closing or downgrading services, with some considering changes to flagship departments like emergency and maternity - though these would normally take too long to deliver savings this year.
  • Selling estate and other “property related transactions”.
  • Stopping prescriptions for some items, as suggested by NHS Clinical Commissioners earlier this year.


Leaders in the areas have been told to first consider whether they can make further efficiencies by normal means, such as reducing follow-up appointments or unnecessary referrals. But all of those HSJ spoke to - covering more than half the areas involved - said they were also putting forward new “difficult decisions”.

Meetings to discuss the CEP proposals with regional and national officials, including NHSE and NHSI finance chiefs Paul Baumann and Bob Alexander, took place throughout last month. No proposals have yet been formally approved or rejected, sources said.

Decisions are expected after the general election, and some of the officials involved have been told they will be put to the new ministerial team. There is no expectation of details being made public until after the election. 

About 14 health economies - most of which are sustainability and transformation partnership ["STP"] areas - are subject to the process. They were chosen because they were expecting to fall substantially short of their “control total” financial targets in 2017-18.

They include:

  • Bristol, South Gloucestershire and North Somerset;
  • Cambridgeshire and Peterborough;
  • Cheshire (Eastern, Vale Royal and South)
  • Cornwall;
  • Devon;
  • Morecambe Bay;
  • Northumbria;
  • North Central London;
  • North Lincolnshire;
  • North West London;
  • South East London;
  • Staffordshire;
  • Surrey and Sussex;
  • Vale of York and Scarborough and Ryedale.


The programme comes amid the longest ever sustained squeeze on the NHS budget, and with lower spending growth in 2017-18 than last year. These areas report gaps between plans and targets running into hundreds of millions of pounds, but NHSE and NHSI have not made public the total national gap.

Several sources complained that the national process - which is likely to require some 2017-18 contracts to be reopened - had run more than two months into the financial year, rather than being completed earlier.

Many also said that, while they had put forward “difficult decisions”, there were no sensible options which would save significant sums during 2017-18, without storing up problems for the future.

There is also debate over whether it is fair to target health economies based on their “control totals” - which require some to have surpluses and are based partly on past performance - rather than looking at absolute surplus or deficit.

An NHS England spokeswoman said: “Within their fair share of the NHS budget, local doctors and hospitals are planning how best to deliver services to patients focussing on the priorities of the public, including modern cancer care, expanded mental health and convenient GP services.

“While many options will have been considered locally, the choices of which options to pursue are still to be evaluated and agreed and would require national sign-off in due course.”


Manifesto: Tories open to legislation to curb internal market

From Health Service Journal - 18th May 2017


The Conservative manifesto says the party is open to introducing health legislation if the NHS’s leaders ask for it to help deliver the Five Year Forward View, for example to create new integrated care models.

It also commits to “review the operation of the internal market and, in time for the start of the 2018 financial year, we will make non-legislative changes to remove barriers to the integration of care”.

Health secretary Jeremy Hunt told HSJ that the “internal market is too bureaucratic”, and indicated that changes could include a shift to capitation funding, under which providers receive budgets for the care of their entire population, eliminating some commissioner functions.

The manifesto states: “We will hold NHS England’s leaders to account for delivering their plan to improve patient care.

“If the current legislative landscape is either slowing implementation or preventing clear national or local accountability, we will consult and make the necessary legislative changes.

“This includes the NHS’s own internal market, which can fail to act in the interests of patients and creates costly bureaucracy.”

Over the past year senior NHS figures, including NHS England chief executive Simon Stevens, have indicated that parts of current NHS legislation, including the Health Act 2012, can make it more difficult to develop integrated care and new contracting and organisational models.

Potential options for legal change range from changing competition and/or procurement law; merging NHS England and NHS Improvement, and potentially other quangos; to creating new NHS structures locally or regionally – potentially eliminating or dramatically reforming the commissioner/provider split.

The NHS has begun work on developing accountable care structures, but is at a relatively early stage. Many of those involved see it as very difficult within current legislation and rules.

NHS England is currently working to prepare to announce next steps for the NHS’s first “accountable care systems” shortly after the general election, with up to nine areas of the country

Comment:   Abolishing the market and purchaser/provider split once new Accountable Care Organisations are in place will cement the regional nature of ACOs and will facilitate capitated funding.  The final step in the regionalization and privatization of the NHS will have been completed.

World Economic Forum and McKinsey & Co decide UK health and social care policy

If any further proof were needed that the UK is not in charge of its own health and social care policy, please read the following article dated 25th May by Stewart Player on Socialist Health Association's website:

It is about two reports apparently prepared in 2012 and 2013 by McKinsey & Co for the World Economic Forum (of Davos fame) entitled "The Financial Sustainability of Health Systems: a Case for Change" ( and "Sustainable Health Systems: Visions, Strategies, Critical Uncertainties and Scenarios" (

It is not clear when these reports were uploaded to the WEF website. If it was recently then the delay is suspicious.

These are explosive documents: they give the lie to assertions by NHS managers and the Government that STPs are "local" plans.

Please read carefully the list of participants at the end of the two enquiries and resulting reports. It is a roll-call of the powerful players in the "global healthcare market", as they see it. The "Project Steward" of the "Steering Board" was Simon Stevens, then President of Global Health at UnitedHealth Group, now CEO of the NHS. West Yorkshire STP lead Rob Webster was a workshop participant there. Amanda Doyle, STP lead for Cumbria was another.

Simon Stevens was recruited by the Coalition, directly from UnitedHealth in 2013 to dismantle the English health service. UnitedHealth has been acquiring contracts under the NHS logo using its English subsidiary Optum. Already one area has Optum as both Commissioning Support Unit and 'provider of services'. What conflicts of interest are there? The councils do not have a veto, whether they subscribe to the STP plans or not. This was revealed in the House of Commons in response to a question by Justin Madders MP. The public have not been consulted, nor have they voted for any of this.


While I was giving out "Save Charing Cross Hospital" posters in Hammersmith, wearing "Save Our Hospitals" badge and T-shirt, I talked for a long time with an Australian senior hospital manager in a shop. He recognised instantly the phrase "Sustainability and Transformation Plan" - this is now common currency in the global health management business.

Updated 6th June 2017 to incorporate details about STP leads Rob Webster and Amanda Doyle and the career of Simon Stevens.

CrowdJustice - update to legal challenge to the STPs by 999 Call For NHS

In late May 2017 "999Call for the NHS" closed the present round of the crowd-funding appeal having raised £12,500 from the public.

Leigh Day and the campaigners are proceeding with the opening skirmishes of the legal battle and making a continued appeal for publicity and outrage against STPs:

"The CCG has (belatedly) replied to the initial letter from our lawyers. Neither we or our lawyers are impressed and we're working together now on a reply that lays out clearly why their reply is totally unsatisfactory. We'll keep you posted.

If you have any questions contact us at: This email address is being protected from spambots. You need JavaScript enabled to view it.


While we press the pause button on DONATIONS, we are turning up the volume on a message to all Parliamentary Candidates that new NHS and social care organisations called Accountable Care Systems must not go ahead!  They will end the NHS as a comprehensive service that provides the full range of care to all who need it, free at the point of need.

Please help us with this. Here is a first step.

Find who your Parliamentary Candidates are and tell them all that you will not stand for the destruction of the NHS. And that you refuse to accept American health insurance - style funding arrangements for the NHS and social care.

These are being introduced through new local NHS and Social Care organisations, called Accountable Care Organisations/Systems.

Their fixed budgets are supposed to cover an area's population but they will be insufficient to meet the public need. These finance restrictions will force our NHS to behave like an insurance company.

This will decisively end the NHS as a comprehensive service for everyone who needs health care.

Please tell them ALL to say “NO” to  Accountable Care Systems/Organisations in the NHS

Find your candidates here:"