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Editorial Thursday 8 October 2015: Toilets, party conferences, the memory of candour and not being TITs about busting the DEL

Publish Date/Time: 
10/08/2015 - 21:00

This latest dispatch from the health policy trenches begins with news of Jeremy Hunt in the toilet.


It is a Virgin toilet, as we would expect for a Very Important Secretary Of State. However, this is a Virgin toilet in a Virgin Train to the Conservative Party Conference in Manchester.

The unlucky among you will know the kind of toilet: it has a curved automatic door, and an amusing notice above the toilet, reading ‘please do not flush nappies, sanitary towels, old mobile phones, unpaid bills, your ex's jumper, hopes, dreams or goldfish down the toilet’.

The notice is tragically silent on the effluent solubility of the new junior doctors’ contract, but you can't have everything. (8/30ths of everything, maybe.)

The Evening Standard diary column reports that Mr Hunt got the wrong kind of flush. Specifically, he pulled the train’s emergency stop cord instead of the flush, halting the train in its tracks and leaving the Health Secretary emerging flushing (as in red-faced).

The temptation to see this as a timely metaphor is huge.

It calls to mind a quote attributed to former health secretary Frank Dobson: that, on reaching office, “we pulled all the levers of government, but found they weren’t attached to anything”.

Fight for your right to party conference
Party conferences are curious rituals. Norman Lamb made a good contribution at the Lib Dems’ Bournemouth affair. Though not yet policy, he (re-)floated the idea of a NHS-and-care-specific tax to increase funding, and also suggested that English councils should be able to raise local taxes to fund the NHS. He also called for a £5 billion cash injection for social care, to prevent the system from crashing.

Labour’s Brighton shindig, its first under its grief-stages-one-to-three leader Jeremy Corbyn saw a competent, well-briefed speech from new shadow health secretary Heidi Alexander.

Labour have a mountain to climb in most areas of policy, but it was a refreshing shock to see no mention of evil, non-existent plans to privatise the NHS (when the real effects of legislative travel are denationalisation and disestablishment).

What is actually happening to the NHS is more interesting, and less planned: it is the political equivalent of a barn door as a target: one which Mascara Kid Andy Burnham never came close to hitting with a banjo. We await proof of Heidi Alexander’s musical marksmanship.

Imperial Conservatives
The victorious Conservative Party is in its imperial phase, and was in buoyant form in Manchester. Jeremy Hunt’s party conference speech unveiled his quite good new joke (“I’m sorry I’m not the most interesting Jeremy in British politics”), but went on to underwhelm in a few regards.

Ahistorically, Mr Hunt told delegates that Nye Bevan “set up the NHS in 1948 - four years after a Conservative Health Minister suggested it”.


Yes, Jeremy, and a mere 37 years after the Fabians first proposed the idea in 1911.

HPI readers know that the only Conservative politician who can mention Nye Bevan (who famously believed that Tories are “lower than vermin”) is of course the legendary Sir Simon Burns, whose timeless bellows of "NYE BEVAN!” kept the 2010-12 health bill committee and debates fitfully awake.

Hunt claimed that among the ”achievements in the last 5 years (were) record numbers of doctors and nurses”, when all of those doctors and most nurses were trained before 2010.

Mr Intelligent Transparency, homeopathic NHS funding and the memory of candour
Mr Hunt also argued that ”peer-review, transparency and openness about performance is a better way to drive up standards than endless new targets”. A hard point to criticise, you might think. And you’d be right.

So Mr Hunt, the self-styled champion of “intelligent transparency”, would be livid at the Observer story revealing the NHS’s worst-kept secret: that Monitor and the TDA had been leant on to delay the publication of data showing that the NHS’ whopping overspend is on course to be, well, a whopping overspend.

Wouldn’t he? Livid, undoubtedly.

And the TDA’s compounding, ongoing failure to reveal the list of Trusts With No Future would surely gall the second-most interesting Jeremy in British politics into a call for candour?

Mr Hunt would surely be enraged, and strike out at such stupid opacity in his speech?

Erm, no.

At no point in his speech did Mr Hunt excoriate the figures in ‘Whitehall’ (for which read the Department of Health) responsible for such blatantly politically-timed failures of openness about financial and system performance.

Mr Hunt is understood to favour complementary and alternative medicine, and to the Government's homeopathic funding increases (diluting NHS cash growth proportionate to population and demand, in order to make it more powerful), we can now add the memory of candour.

Similar oddness was on show from Mr Hunt elsewhere at the party conference. At a Reform fringe event, he told attendees that "the NHS could literally bust our national finances", revealing a worrying lack of knowledge of the difference between the NHS (which can't, on the basis of any realistic overspend scenario) and the banking and financial sector (which did).

He told another event that the funding freeze for general practice was "penance for the 2004 GP contract".


Fantastic! Mr Hunt is a Charterhouse boy (an Old Carthusian, no less), and his renascent Catholic tastes could lead us to all sorts of wonderful scams, such as the sale of indulgences.

Elsewhere, the Mirror had a cracking FOI scoop on NHS productivity minister Lord Prior's correspondence with a McKinsey staff member (during his CQC chairmanship) about how many beds could be cut from the NHS. Half of them, apparently.


At the Tory conference, Home Secretary Teresa May made an anti-immigration speech, prompting condemnation from such typically left-wing organisations as the Telegraph, Economist and Confederation of British Industry for its inaccuracy and lack of evidence.

This was timely, as NHS England's Sun King Simon Stevens told the Institute Of Directors' annual conference at the Royal Albert Hall that "understandably, we're having a national discussion about how to get immigration right. My responsibility is to point out that at time when the need for nurses is growing, when publicly funded UK nurse training places will take several years to expand, and when agency staff costs are driving hospital overspends right now, we need to better 'join up the dots' on immigration policy and the NHS.

"However most nurses I speak to struggle to understand why our immigration rules define ballet dancers as a shortage occupation - but not nursing. And most hospitals tell me that the idea that we would seriously consider deporting some of our most experienced and committed nurses solely because they’re not earning £35,000 clearly needs a rethink".

(The press release of this gave intriguing hints on new ideas about funding social care). The evidence is of course that immigration cuts NHS waiting times.

The money is fucked
Everybody knows the money is fucked. The Kings Fund, Nuffield Trust, Health Foundation, every significant representative organisation: this much is not news, at all.

While ministers at the Conservative conference prefaced their sessions with comments saying ‘we get the money thing, Jeremy gets the money thing’, a clearer picture was offered by Nick Seddon, the Prime Minister’s special adviser on health, tartly saying “there is no more money”.

This is the dominant Treasury view. For a better understanding of the DH-Treasury processes and relationship, you could do no better than to read this excellent Civil Service World article by data diva Sally Gainsbury, who has now moved on from her post-HSJ berth at the FT to the Nuffield Trust, where she will be an invaluable interpreter of the financial shenanigans ahead.

AKA 'get a grip, Simon'
Thus far, we have only got a financial crisis, as the former Comrade-In-Chief Sir David Nicholson said in his NHS Providers lecture (the possible key messages of which are translated here).

One of the Comrade-In-Chief’s main points was that top-level financial planning is widely known to be unserious to the point of being gimcrack. Few health policy illuminati have not learned of the last-minute conversations between outgoing Monitor boss Dr David Bennett and Simon Stevens ahead of their meeting to finalise the financial ask for the Five-Year Forward View.

In fact, most of us have copies of the spreadsheets, in which Bennett suggested asking for £12 billion in cash.

That would have been a very handy £4 billion.

[The Comrade-In-Chief's lecture prompted this excellent piece from Nick Timmins wondering what the future for the purchaser-provider split would be in an NHS moving to accountable care organisation-type health economies. Not much, Nick correctly concludes.]

Even less serious is the economic analysis behind the Carter Review’s suggested £5 billion in potential procurement savings: one insider, hearing that Lord Carter Of Coles was being told to suggest that up to £10 billion could be saved, told him “no, Pat, don’t say £10bn; nobody will believe you. Say five. Some people might go for that”.

Performance anxiety
The money is fucked. HSJ colleagues have run some numbers from board papers, and the £2 billion still looks a lot like £2 billion.

NHS England is asking for the Pothole Care Fund to be frozen.

Others say that even if all central levers are pulled to stop central spending, at best only £1 billion could be stopped. And there are other noises about the financial position in CCGland deteriorating at scale and pace.

Neither are the waiting times much less fucked, as the indispensable Rob Findlay of GooRoo shows in his latest HSJ column.

Meanwhile, the NHS is being asked to trudge towards seven-day working when social care stands no chance of being able to cope with the current need for discharge packages for frail older people.

The latest social care market survey from Laing and Buisson points to deep distress across much of the care sector, observing that "UK long term care for older people is a highly polarised marketplace where at one end those operators with a focus on private pay residents are doing relatively well, while at the opposite end those which cater mainly for government supported residents face becoming the latest financial failures in a sector which is already suffering from a greater annual capacity loss rate than growth rate ... real terms fee reductions by local authorities, a result of the government’s on-going austerity drive, is now clearly the main driver for falling profits in a service provision market worth an estimated £16 billion per year.".

And that's with Part Two of the Care Act deferred.

And before 2020 introduces the Living Wage.

Not to mention the financial position of private equity-owned Four Seasons: a far bigger player in the care market than Southern Cross. Too big to fail?

Oh, and Laing and Buisson noted in August that private medical insurance take-up is down. Which rather strengthens the NHS's bargaining position ...

In a heretical sense, the certain breaching of the DH’s departmental expenditure limit (DEL) doesn’t matter. ‘Oh my Jeremy’, I can hear them saying, ‘now Health Policy Insight’s joined the deficit-denying tendency. Are we doomed?’

No, ladies and gentlemen (and politicians and journalists), we are not doomed. We need to take an inverse lesson from the acronym of the business run by Britain’s most famous Del: Trotter’s Independent Traders.

Thus far, NHS managers have not been TITs. We have a financial crisis, but not a quality crisis. And that is a good result for those people for whom the service exists: patients.

The money can and will have to be sorted. It would just be better if we were planning how to do that now, rather than reactively. But Treasury heads remain firmly stuck in the monetarist sand.

Cargo cult (That's cult; not Hunt)
System leaders haven't let this widespread outbreak of common sense and honour among managers stop them carrying on like a Melanesian cargo cult, going through outdated and scarcely-understood rituals (sack the CE and board; send in management consultants) of regulatory intervention in the hope of getting the goods.

Rituals must happen, it seems. So when the NHS breaches last year's overspend, which it will, there will be a demand for heads to roll. The Treasury will want DH permanent secretary Una O'Brien, who is nearing the end of her second spell in post anyway.

Could Simon The Sun King's scalp come into the hazard? Unlikely. David Cameron and George Osborne still crave a bit of the old Blair magic dust, and Simon is a sharp operator and influencer.

Mr Osborne wants Mr Cameron's job (at the right time), and will be happy to influence the PM to leave Mr Hunt at DH, to take the initial political collateral damage of an NHS overspend. But maybe not for long. 2016 may be reshuffle time.

So we end where we came in, aptly enough. With Jeremy Hunt in the toilet.

Metaphorically speaking, of course.