Cowper’s Cut 173: Waits and measures

There goes another totally normal week in health policy and politics, ending with the Prime Minister deciding on Friday that self-isolation if you’ve been in close contact with someone infected with Coivd19 is in fact optional if your name happens to be Alexander Boris De Pfeffel Johnson.

I missed that bit in the Government guidance, I must admit. Doesn't show up anywhere on the Public Health England website, either.

Still, if you want your Government’s internal fissures to really start showing, then you probably threaten to demote your Chancellor to Health Secretary, as the Sunday Times’ Tim Shipman reports the PM did.

Shipman claims that last Monday, “Johnson openly suggested that he might sack his chancellor, Rishi Sunak. The focus of Johnson’s rage was the report in this newspaper last week that Sunak had written to the PM calling for a significant easing of the coronavirus travel restrictions, warning that they were damaging the economy and leaving the UK at a disadvantage to its European Union rivals.

“The problem was that the first Johnson knew of the letter was when details of it appeared in the media. Officials had failed to flag it for his attention, or to put it in his ministerial red box”.

An incompetent administrative set-up around Boris Johnson? Clearly a stretch to believe that one. Shipman goes on to write that a senior source alleged that Johnson said, “I’ve been thinking about it. Maybe it’s time we looked at Rishi as the next secretary of state for health. He could potentially do a very good job there”.

Why does this matter? We'll, you have to remember the Cabinet job that current Health Secretary Sajid ‘The Saj’ Javid did before Dominic Cummings engineered his ousting. Yes, it was Chancellor: well remembered!

This triangulates accurately with the FT piece confirming the traditional tensions between No 10 and No 11 Downing Street about spending. As I noted last week, the failure to do the deal over social care reform was not because Javid, Sunak and Johnson couldn't continue in-person, face-to-face negotiations: it’s because there isn't the willingness to raise taxes to fund it.

The perils of perception
One of the big political themes to emerge over the coming twelve to eighteen months will be the rise in general public perception of the NHS backlog.

To those of us in the know, this seems ridiculous: it had grown huge pre-pandemic, in deliberate political choices regarding underfunding the NHS relative to demand. This is on top of the longstanding workforce shortages, and of course the logistical and safety problems caused by the capital and maintenance backlog.

The bill for austerity has been enormous across the public sector.

The NHS had protection relative to other public services, but the collapse in funding other areas, including local authorities, which commission or deliver public health and social care, drove up already-rising demand on the NHS from an ageing and fattening population. Local authorities’ central government grants were cut 38% in real-terms between 2009/10 and 2018/19, from £34.6 billion to £24.8 billion in cash terms.

The NHS has essentially no choice but to let backlogs grow in this circumstance. It was made clear at the launch of the NHS Long Term Plan in January 2019 that there was no target to eliminate the then-huge backlog (pre-Covid19) and return to the set national performance standards such as 18 weeks for elective care.

Then came the pandemic.

A new Redfield and Wilton Strategies poll for Politico finds that “forty-six percent of respondents … said the NHS had been hurt by coronavirus, compared with 26 percent who thought it had been strengthened. However, 64 percent of people said their trust in the NHS had increased over the last 18 months, while just eight percent said they trusted the NHS less”.

‘The Perils Of Perception’ is an excellent annual survey by Ipsos MORI into how wrong public attitudes can be: the data there is fascinating.

A coalition of organisations led by NHS Confederation and NHS Providers wrote to the Treasury and DHSC this week asking for another £600 million to fund ‘discharge to assess’ for the rest of the current financial year. Obviously if this extra funding isn't provided, matters will worsen fast.

We’re at an interesting moment, where the NHS backlog shifts from something the public apparently scarcely saw as it grew inexorably over the past decade; to something that will shape political discourse over the coming years. It’s notable that this major poll Ipsos MORI did for the Health Foundation earlier this year found that 50% of respondents said that improving (i.e. reducing, we must hope) waiting times should be the top NHS post-pandemic priority. Expect to see that number grow.

The Nuffield Trust has done some economic modelling, briefed to The Guardian, which suggests that the NHS will need an extra £5 billion for next financial year over what was agreed in the pre-Covid19 NHS Long Term Plan settlement. The NT analysis also suggests that the NHS will overspend by about £5 billion this year: very similar to the sum they analysed in 2018 as the NHS underlying deficit, adjusted for inflation. NHS Providers boss Chris Hopson wrote this piece for The Observer, warning of the change of ‘mood music in the Treasury on NHS funding, which again correlated with where we started this column.

It’s worth reading this modelling of waiting lists from the Institute for Fiscal Studies, which gives sobering data. On their most optimistic scenario, “the number of people waiting for treatment would rise to over 9 million next year, and would only return to pre-pandemic levels in 2025. That would require the NHS to increase capacity by 5% in 2021 and 2022 compared with 2019 and then by 10% in 2023 onward (the equivalent of treating around 1.6 million additional patients per year, relative to 2019 volumes, at a potential annual cost of at least £2 billion, before any allowance for additional infrastructure)”.

Commonwealth Fund ratings drop
NHS ‘campaigners’ often point to the gold medal position that it occupied in the Commonwealth Fund’s ratings of a ‘top 10’ of developed world health systems.

That was then. The 2021 iteration of their regular ‘Mirror, Mirror’ survey sees the NHS miss the podium, in fourth place - coming behind Norway, the Netherlands and Austria; and it’s largely because of this very issue of lengthening waiting times.

The survey also finds that in terms of outcomes amenable to healthcare, the NHS’s performance remains relatively poor, coming ninth-placed of the ten countries’ systems.

Some context: the Commonwealth Fund is effectively an advocate for universal healthcare to be introduced to the USA. As Nuffield Trust chief economist John Appleby points out, this affects their survey methodology and weighting. John’s 2011 Data Briefing piece for the BMJ bears re-reading.

The People’s Dominic
Former chief advisor to the PM Dominic Cummings continues his noble quest to be cured of his publicity aversion with an interview in the latest Spectator. It’s generally a dull affair, but he does speculate that Matt ‘Alan’ Hancock was dobbed in to the media by someone in his private office. (Incorrect; it was someone quite junior working for the company that runs facilities for DHSC.)

Perhaps the only notable thing about it is his repeated characterisation of Carrie Johnson (née Symonds) as a “crazy girlfriend”.  It emphasises just how much the Cummings-Johnson bust-up thing was, as I observed in Cut 171, a case of “when bromance goes bad”.

Jealousy, eh?

The new message from the new boss
At the end of her first working weekday as NHS England chief executive, Amanda Pritchard took to Twitter to issue a short series of messages.

She told her followers, “as the new NHS Chief Executive, I’d like to thank staff for everything you have done throughout the COVID-19 pandemic. I’ve always been incredibly proud to work for the NHS since I joined as a graduate trainee and I have never been prouder of what we’ve achieved.

“The dedication, skill and compassion of NHS staff have been matched by innovation, agility and a ‘can do’ spirit that kept vital services running while our hospitals cared for more than 400,000 COVID patients.

“All this alongside the NHS vaccination programme which has been an unparalleled success, delivering more than 71 million doses and giving full protection to more than 32 million people

“The NHS response to the pandemic has now entered a new, but no less challenging, phase. This means we will need the same determination, team-work and innovation that have served us so well over the last 18 months

“Amid these pressures, I know colleagues share my determination to deliver the long term improvements in treatment and care which, coupled with a renewed focus on prevention, will enable many more people to live longer and more fulfilling lives.

“The NHS must continue to innovate and work in new ways to deliver the care that patients need. We must harness this power to ensure everyone can access the care they need, prevent illness and provide better treatment, and deliver on our long term ambitions to tackle major killers like cancer and stroke, saving many more lives.

“The pandemic has required many of you to make considerable personal sacrifice – working beyond your normal hours for long stretches, taking on new and difficult roles at real speed and having to cope with deeply distressing circumstances, including losing valued colleagues.

“Supporting the health and wellbeing of all our NHS staff will continue to be central to our future strategy and recovery. I do not underestimate the scale of the task we face and while I am realistic, I am also optimistic.

“Our NHS people continue to go above and beyond to respond to the needs of our patients and it is hugely appreciated - thank you for all you are doing”.

The messaging is straightforward, and it is smart. The themes continue from what you would have heard from her predecessor, but he would never have Tweeted it.

There is absolutely no new policy on show. This is, frankly, a good thing. There will be a time to Think Thoughts, and some of it is very much now – but not to be public with them.

Ms Pritchard needs to weigh her thoughts, balance them, discuss them with a select team whom she can trust – and then cost them. The ‘insulation’ strategy I have suggested here and elsewhere will require strong and shrewd negotiating positions: ones best worked out in private.

The data day
We are REALLY crawling with the first vaccine doses now. Just 38,858 on 31 July: even for a Sunday, that’s bad.

On the same day, hospital admissions and mechanical ventilation were both still both rising; cutting the NHS’s capacity to start the years-long, slow and hard work of clearing the backlog.

Again on 31 July, testing rates continued their fall since early July, which is what I'd expect if people were trying not to get TAT-ed pre-holiday. (It would be fun to get some corrolative data from private testing companies, no?) Certainly, the collapse in use of the NHS app for venue check-ins and of ‘pings’ for contact tracing suggests that this is what’s happened.

Updating at the time of setting this up to publish, the latest data to Friday 6 shows a further collapse in first doses, to 35,655. I guess the September nightclub threat/bribe may not be cutting the mustard. The rate of patients in mechanical ventilator beds seems to be levelling off, but it’s not quite a trend yet.

Getting the Bill
The Health And Care Bill has moved on into its committee session, but still, the website says that no MPs have been appointed to the committee.

However, I can EXCLUSIVELY REVEAL (no, I don't know why it’s bold capitalised either)  that the committee’s Labour MPs will be Justin Madders, Alex Norris, Mary Foy, Sarah Owen and Karin Smyth. The Conservative and SNP whips need to extract their digits to finalise their representation.

It seems that the first two sittings will be on 7 and 9 September.

Test And Trace
Paul Waugh of Huffington Post (as of next month, to be of the i) has this cracking story about the confused picture over lateral flow tests. Testing providers will be required to meet higher new standards – but this will not apply to existing lateral flow test providers, such as Innova (the non-recommendation for using whose LFTs by the US FDA I covered last month).

Waugh notes that from September 1, “the higher performance standards, quietly introduced this week, include a loophole that explicitly excludes lateral flow tests previously bought by the government such as those bought from Innova Medical Group at a cost of more than £3 billion.

“British manufacturers privately welcome the new regime as they believe their home-grown tests are cheaper and more reliable than the Innova tests. But many in the UK bio industry question why ministers are exempting the Chinese-made devices from the same high standards”. As so often, Paul has the nail having a meeting-without-coffee with the head.

The HuffPo article observes that “the new secondary legislation – The Medical Devices (Coronavirus Test Device Approvals) (Amendment) Regulations 2021 – gives Sajid Javid unprecedented power over which Covid tests can be sold on the open market in England. Firms will have to pay the government £14,000 for any application and any tests not deemed up to the grade will be removed from sale by law. Retailers, distributors and manufacturers of tests that attempt to sell unvalidated tests would face sanction”.

Another big spot goes to Poppy Wood in the i, who notes the Government’s signing a £124 million contract with blood testing start-up Thriva for home antibody testing kits. This looks like a backstop position if they really can’t persuade the under 30s to get the vaccine – or as is also plausible, they are short of supply of mRNA doses.

No wonder the latest ONS survey finds that 94% of UK adults have Covid19 antibodies. Mercifully, thus far, the healthcare admissions data is showing a downturn 7-day trend. Fingers crossed.

Cronyvirus and Coronamillions update
The Good Law Project have been hard at work again. Having won a pertinent victory over the SOS/DHBSC regarding the Abingdon Health document redactions, they have brought into the public domain the issue of Lord Bethell’s use of WhatsApp and text messages on his personal mobile phone.

Lord Bethell’s ministerial remit of course includes data and technology.

Regular readers won't find this new news: I wrote a piece on Bethell’s conduct, ‘The ministry of unsound’, in the pre-penultimate ‘Cut’ to appear in HSJ.

It seems that in December 2020, Lord Bethell “was told his mobile phone would be searched for documents relating to this case. Just weeks later, it seems, he ‘replaced’ his phone because, Government lawyers say, it was ‘broken’. They are now not sure it will be possible to retrieve the WhatsApp and text messages”.

The good Lord apparently claims that he lost all his WhatsApp and text messages when he changed to a new mobile phone.

Regular WhatsApp users and persons of any sense whatsoever will instantly know that this is, to use a mobile telecoms industry technical term, ‘utter bollocks’.

For text messages, this is how you do it for Android mobile phones and for iPhone. For WhatsApp, this is how you do it for an Android mobile phone, and this is how you do it for an iPhone. This has a comprehensive-looking list of other approaches.

You’re welcome, Lord Bethell. Happy to help.

Another Lord (this time, Prior of Brampton) is in the media this week: Gabriel Pogrund of the Sunday Times has FOI-d communications between Greensill Capital and NHS England’s chair. Pogrund writes that “on March 21 last year, less than 48 hours before the nation went into lockdown, Prior was focused on matters other than Covid-19 cases and hospital capacity. He was busy speaking to Greensill, who was lobbying (successfully) to introduce a controversial payday scheme in hospitals.

“At 7.48pm, Greensill wrote an email thanking Prior profusely for “agreeing to take a call” from one official anxious about “our bona fides and ... what we are doing for the NHS”. At 10pm the NHS chairman responded obligingly. In an email with the subject line “Greensill reference”, he wrote: “Happy to take a call.” Asked when he might be available, Prior said, in essence, whenever: “Now or next 30 mins ... otherwise give me a time and I’ll fit it in.”

Pogrund adds that in the same month, Greensill “was given notice of details of a speech Prior was due to give. One of his employees wrote to Prior: ‘I understand from a discussion you had ... that you will be speaking at a conference and might touch on Greensill Pay’.”

Mmmmmm. If not mmmmmmmmmmmmm. That does not look good.

So, would we say that Test And Trace has paid dividends? Well, it has if you hold shares in Serco: the outsourcer is paying its first dividend since 2014, in no small part due to its TAT contracts.

Serco said around 17% of its revenues for the half-year were from work supporting government in its response to the pandemic.

Alan’s Big Comeback
It’s A Thing; well, at least in the mind of a Telegraph journalist (yeah, I know …). After last week’s ‘Recommended/required reading’ report of a Hancomeback (sorry), someone actually wrote another feature on The People’s Partridge’s prospects of a comeback. A-ha!

My views about Alan are fairly clear. If we still feel that we need any further amusement from that quarter, there’s always his 2016 Tory leadership campaign launch footage to re-watch. “Out there today, there’s a metaphor. There are dark clouds over Westminster”. One must have a heart of stone not to laugh.

The Saj gag
Meanwhile, Alan’s successor, Sajid ‘Power Poser’ Javid revealed a novel trait in Health Secretaries of recent vintage while in post: a functioning sense of humour.

Commenting on Shaun Lintern’s Independent story about minority NHS staff being told to use ‘Western’-sounding names by line managers, Javid commented “Ridiculous. Sajid.”

OK, it’s not Max Miller, but it shows signs of mental life. That’s a striking contrast to the Alan experience.

Other important things
Would appear here.

Recommended and required reading
The latest ONS survey has shown falling numbers of Covid19 infections, true. However, actuary John Roberts’ interpretation of the latest 7-day data suggests that we may have come to an end of the fall in Covid19 cases. More to the point, epidemiologist Deepti Gurdasani offers this warning, and emergency care consultant Rupert Clarke gives this honest sitrep/update. We're not yet out of the woods, but at least they’re no longer aflame with napalm.

Health Education England is consulting on long-term health and care workforce strategy. So if anyone’s got any highly compromising photographs of Rishi Sunak …

A Centre For European Reform document on medical devices and the limits of UK regulatory autonomy. Brexit is very, very far from done …

The Royal College of Physicians’ study into the quality of care for hospital patients with Covid19 is a strong read. It finds that overall care delivered was judged to have been adequate, good or excellent for 96.5% of patients (and good or excellent for 77.4%).

The Competition and Markets Authority review has provisionally ruled that Pfizer and Flynn’s 2,500% mark-up on epilepsy drugs was illegal. The pharma companies were fined £90 million for this in 2016.

The NHS Confederation has released a report on the first two years of Primary Care Networks. They’ve been with us as long as Boris Johnson’s been Prime Minister. Which will outlast which, and have the more impact?

Thoughtful Nuffield Trust piece on smaller hospitals.

Interesting Sunday Times piece about robot-assisted surgery and Telegraph one

Good blog from Paul McGovern about the importance of data mapping for health.

Marcus Rashford’s open letter to health professionals about food poverty and vouchers in the BMJ