Thread by @ChrisCEOHopson

1/17 Very technical thread for those interested in detail of NHS finances. We've been discussing how to move to more system focussed finances in 2021/22 with members and @NHSEngland. We've turned that work into the following asks: nhsproviders.org/media/690684/f…. Asks in thread below.

2/17 If funding flows change before ICSs are put on a statutory footing, @NHSEngland must clearly set out the legal underpinning for how funds will flow to and within ICSs. Including how this will align with the formal responsibilities of accounting officers & trust boards.

3/17 @NHSEngland must publish its full methodology for determining the size of each ICS funding envelope. This should account for how each constituent element is calculated, including the logic behind any provider level allocations so this is fully visible to all within the ICS.

4/17 @NHS England should report each year on how (and why) responsibility for capital budgets will be split between national level, ICSs and individual organisations. Decisions on capital investment should be based on the principle of subsidiarity and minimise complexity.

5/17 @NHSEngland should publish clear guidance to help ICSs equitably prioritise business cases for capital funding across acute, mental health, community and ambulance services. It is vital there is an appropriate balance of spend across these different sectors.

6/17 There is a very important £6 billion+ maintenance backlog in the NHS that we need to get through at pace. @NHSEngland must ensure that individual organisations have appropriate delegated authority to proceed with backlog maintenance and other essential works.

7/17 @NHSEngland must support different levels of ICS maturity. They should set out universal accountabilities / default governance arrangements that all systems should follow. They should allow more mature systems to go beyond these, as needed and agreed by the ICS.

8/17 @NHSEngland should ensure the new financial responsibilities of ICSs are accompanied by a robust regulatory framework, which supports the assurance of operational performance, quality and safety. Regulation needs to adapt to and align with any new financial flows.

9/17 @NHSEngland want to make much greater use of blended, as opposed to tariff, payments in 2021/22. It should therefore publish a default methodology to help providers and commissioners agree the fixed element of relevant blended payments, based on provider cost base...

10/17 ...This needs to be accompanied by guidance on dispute resolution and how changes such as subsequent covid waves are accounted for. The guidance should also set out the circumstances under which alternative approaches to the blended payment model would be permitted.

11/17 @NHSEngland should clarify how good financial performance at system & organisational level will be defined/rewarded, and how providers in deficit will be supported to return to surplus. This requires a shared understanding of each provider’s starting position / efficiency.

12/17 @NHSEngland must ensure productivity & efficiency gains expected of providers are realistic given ongoing operational pressures. As @NAOorguk has consistently highlighted, failure to do this in late 2010's simply drove an unsustainable sector deficit/individual deficits.

13/17 @NHSEngland should continue to work with providers to understand how good operational performance, service quality and patient outcomes can be rewarded. This should include consideration of both financial and non-financial incentives at ICS and provider level.

14/17 @NHSEngland must shape the 2021/22 financial framework based on meaningful engagement with acute, community, mental health and ambulance providers. Important to agree a realistic pace of change reflecting current ongoing operational pressures and uncertainties.

15/17 @NHSEngland should work with ICSs and their constituent organisations to formally review how well system funding arrangements are working after six months. The results should be made public to help rapidly troubleshoot emerging issues and inform the 2022/23 framework.

16/17 NHS finances currently, rightly, working on basis of past cost patterns and reimbursing extra covid-19 costs incurred. @NHSEngland should work with ICSs and their constituent organisations to plot a clear path back to a sustainable and fair distribution of spend.

17/17 @NHSEngland must continue to listen to providers of all types to ensure any new approach does not inadvertently disadvantage any particular provider type, or particular services. Changes like these can disadvantage community, mental health and ambulance services.