Health Policy Insight
Healthcare management online analysis and intelligence
The home of UK health policy

Editorial Thursday 2 March 2017: The War On Reality, the end of the market and smoking dope on a burning platform

Publish Date/Time: 
03/02/2017 - 14:57

The War On Reality is nothing new.

George Orwell previewed it in 1984. In 2004, Karl Rowe told the New York Times that people such as the journalist occupied "what we call the reality-based community … (people who) believe that solutions emerge from your judicious study of discernible reality … That's not the way the world really works anymore. We're an empire now, and when we act, we create our own reality. And while you're studying that reality—judiciously, as you will—we'll act again, creating other new realities, which you can study too".

If the arithmetical progression followed, the next stage would probably be due in 2024. It doesn’t, though. The War On Reality has reached its apotheosis in the USA’s election of President Donald Trump.

It has come to UK politics, in the form of blatant, shameless misinformation feeding in to last year’s Brexit advisory referendum.

Rarely can a political victory have made the victors less happy: Jonn Elledge of the New Statesman accurately diagnoses a ‘Tinkerbell Syndrome’ in British politics.

The rising tide of finance, demand and workforce pressures facing the NHS has been a long time coming, and it’ll be a long time going. There is little ambiguity about how challenging things are for almost all organisations right now.

The existence of pockets of organisations who are in less trouble than others is in no way surprising. A rising tide gets up to the nostrils of even the tallest eventually.

Once Dame Julie Moore’s University Hospitals Birmingham is on Newsnight, and she is describing pressure in these terms – that ”this is a health system problem that’s manifesting itself in A&E”, we are unambiguously at the point where the shit has hit the fan and the fan is getting up close to full-speed.

Telling the truth
You can tell when NHS finances are getting really bad: people start telling the truth. This was true in 2006 (when as a consequence, I successfully predicted and advocated the departure of NHS CE Sir Nigel Crisp).

Lord Carter’s been at it in The Guardian, describing the situation as a war.

Carter told the Royal College of Anaesthetists audience "We need to be incredibly proud that our hospitals are running so hot, and yet they haven’t broken. It’s a staggering achievement. This is like being [in] a war actually and we should be extraordinarily proud of it. But you can’t continue on a war basis forever, as we know”.

Sir Robert ‘Inquiry’ Francis QC’s been at it in HSJ, tellking Shaun Lintern ” the NHS was facing an “existential crisis”, and was “manifestly failing” to keep pace with demand. He also warned of “depressingly familiar” pressures on NHS chief executives “coming down from the top”.

Even Health Secretary Jeremy Hunt’s been at it, telling Hugh Pym of BBC News that NHS pressure-related performance is ”completely unacceptable”.

Yes, you read that right. Not slightly unacceptable. Not a tad unacceptable. Not even fairly unacceptable. “Completely unacceptable”.

Makes you wonder what monkey’s been Secretary Of State For Health for the longest tenure ever … oh.

The fan is approaching top speed
You can choose your data source - there are no shortage of sources.

They all say about the same thing: the pressure is huge.

The Office for Budget Responsibility report on NHS funding makes for no cheerier a read. It concludes that ”public sector net borrowing would rise from 0.7 per cent of GDP in 2021-22 to 16.6 per cent of GDP by 2066-67, lifting public sector net debt from 82 to 234 per cent of GDP. Getting debt back to 40 per of GDP by then would require additional tax increases and/or spending cuts of 1.5 per cent of GDP (£30 billion a year in today’s terms) in the early 2020s and in each successive decade”, in line with the assumptions of the IFS Green Budget.

The Institute for Government / CIPFA report is also worth a read.

NHS Improvement has admitted that the provider sector’s finances are off track. Oh, and there are risks from the rise in business rates.

The Nuffield Trust’s latest offers rather a good summary on STPs and their chances. STPs are, once aggregated, an attempt to form the NHS Provision Board that I called for just over four years ago.

Oh yes, and the public are starting to notice. Concern about the NHS is pushing near the top of the long-running Economist / Ipsos MORI 'Issues Index'.

Interestingly, individual private medical insurance seems to be on the rise, according to market analysts LaingBuisson. This is, they note, ”reversing a declining trend in recent years. Latest figures from healthcare market intelligence provider LaingBuisson have revealed that the number of private medical cover subscriber policies in the UK grew by 2.1% to reach 4 million, following flat demand from 2012 to 2014 and shrinking demand from 2008 to 2011”.

LaingBuisson add ”Total spending on UK private medical cover (insured and self-insured Healthcare Trusts) grew by 2.8% in 2015 to reach £4.7bn. … nevertheless, volumes are yet to bounce back to pre-2008 levels when subscriber demand stood at 4,350,000 – representing market penetration of 12.4% of the UK population. What is more, the medical cover sector faces further headwinds from recent and forthcoming rises in insurance premium tax (IPT) and uncertainty from the UK’s impending exit from the European Union”.

HSJ points out the planned nursing cuts in STPs. Which are significant.

NHS England’s New Care Models evaluation of the Vanguard care homes programme (led by the talented Samantha Jones) is worth a read. It states that ”local savings will vary according to footprint and the starting point of the local health economy; however, initial analysis by the new care models programme’s finance team suggests significant expected reductions in ambulance call outs, A&E attendances and non- elective admissions, along with significant cost savings from reductions in prescriptions.

“The new care models programme’s team will continue to work with the six care homes vanguards to understand whether the initial expected savings will be sustained, and how the model works to moderate demand after initial savings are made.

“Every element of the EHCH care model has already been successfully implemented in part, or in isolation in some areas around the country. However, despite the benefits associated with each element, no area has adopted them all in full, and there is great variation in the quality and extent of provision, as there hasn’t been a policy or funding context which drives widespread adoption of these interventions”.

The integration fairy
Can integration save the day? The National Audit Office is sceptical, observing of health and social care integration ”so far, benefits have fallen far short of plans, despite much effort. It will be important to learn from the over-optimism of such plans when implementing the much larger NHS sustainability and transformation plans.

“The Departments do not yet have the evidence to show that they can deliver their commitment to integrated services by 2020, at the same time as meeting existing pressures on the health and social care systems”.

For want of an Opposition
If politics were not heavily embroiled in The War On Reality, Mrs May’s government would be in deep trouble.

They aren't.

Because Jeremy Corbyn.

It takes a special kind of stupid to tweet, following voting with the governent to trigger Article 50 for Brexit, that the "real fight starts now". Mr Corbyn has just that kind of stupid, alongside most other kinds yet known and several we are surely going to discover during his tenure.

So opulently shit a leader is Mr Corbyn and so hopeless is his iteration of the Parliamentary Labour Party that a majority of those polled trust Theresa May more with the besieged NHS than they do Mr Corbyn.

Labour’s constant campaigning on the NHS with no nuance and no plan of their own probably has something to do with this. Jonathan Ashworth is trying hard, and may in time amount to something as Heidi Alexander did - but as I have previously written, the Dear Leader’s office still will not release an adequate share of Short money to enable Mr Ashworth to hire researchers.

Mr Corbyn has achieved the amazing feat of negative approval ratings in all sectors of the electorate. Truly, he is The Special One.

Monday’s PAC report scolded Number 10 and NHS England Sun King Simon Stevens for “bickering” about NHS finances.

Smoking dope on a burning platform
This week’s PAC evidence session this week produced the entertaining spectacle of Tory MP Anne Marie Duff asking Simon Stevens whether STP plans’ basis in reality mean “we’re smoking dope”.

The smoke/fire theme continued with Professor Sir Mike Richards’ view that the NHS is ”on a burning platform” at the launch of the CQC’s latest ‘State Of Care’ report.

Last, and probably least, Simon Stevens told the PAC that the most evolved STPs will in effect end the purchaser-provider split. They will become “accountable care organisations or systems, which will for the first time since 1990 effectively end the purchaser provider split, bringing about integrated funding and delivery for a given geographical population”.

The likelihood is that the end of the internal market is probably voluntary. My think is that NHS England will be the Dignitas of the internal market: all the players in a non-internal market STP will have to agree that it's in the best interests of patients. The private and third sectors may need bungs to agree.

Sigh.

We are where we are. This is not a perfect storm: it’s a shitstorm. Just ask the people working at the front line.

The War On Reality will end: reality will win. Reality, like entropy, always wins in the end.

But it won't be a short war.

And every war has casualties. Don’t be one.