Cowper’s Cut 179: Understanding it in our bones

It’s been a dramatic one, hence the ‘bonus’ issue of Cowper’s Cut mid-week.

We finally got to see the PM’s promised plan for social care. Only to find out that
a) it wasn’t a plan at all, but a mini-budget (a budgette? a budgetini?); and
b) it was largely not for social care.

Apart from those two minor details, what a splendid plan for social care it was.

We heard a lot from the PM and other ministers this week, trying to sell us the idea that the British people “understand in their bones” that Covid19 wasn’t in the Conservative manifesto, so it was OK to break their manifesto promises on not raising taxes.

I think that’s what they were saying, anyway. I always thought you understood things in your brain: but hey-ho. That’s why they’re making the big Euros, I guess.

There is no plan
The one main issue is that neither the NHS nor social care currently have a plan to clear the backlog. Let alone to improve care quality and safety. At the Select Committee this week, its chair Jeremy Hunt raised the salient question on workforce: are we going how to find 4,000 more doctors and 16,000 more nurses?

Even if we had those staff (and we don’t), there is the capital/estates/maintenance backlog issue, meaning we have nowhere extra to do more work. Not even the fictional 40/48 new hospitals.

Then there is the issue of discharging frail older people out to social care packages that aren't there.

In the absence of all that, our only option is to persuade our existing staff teams to do more work in existing facilities at evenings and weekends. This they may well not want to do because a) they’re knackered from Covid19 demand and b) the pensions taper tax issue still isn't sorted, disincentivising the senior staff needed from earning more. Funny how it all comes down to high house prices, eh?

Not everyone is on a bad place, of course. The private provider sector is in bullish mood about self-pay growth prospects, as Laing and Buisson’s Healthcare Markets reports.

Ministerial wombling
No: what we got instead was Health But Social Care Secretary Sajid ‘The Saj’ Javid wombling on about being “watchful for waste and wokery”. Being watchful is lovely, but what will he actually do about them if he spots them?

The FT suggests that Chancellor Rishi ‘The Brand’ Sunak thinks the insurance industry will now develop policies to cover even the £86,000 now at jeopardy for the wealthy and their heirs, who will be the main beneficiaries of this policy (as they were of Gideon George  Osborne’s ‘£1 million housing for 2 child families’ exemption from inheritance tax (IHT), which drove the compensatory introduction of the pensions taper tax).

Bless him! What an optimist The Brand is. For a rather more reality-based take on financial consequentials, read Charles Tallack of the Health Foundation.

The unravelling begins
People have already started to notice that the shift  of NHS But Social Care Levy funds from the NHS to social care will be manged by our dear chums the Treasury Munchkins.

Mmmmm. If not mmmmmmmmm.

The social care sector as a whole has scarcely been enthusiastic about the proposed reforms. These reflections from Richard Humphries, former Kings Fund social care lead, are well worth reading. Likewise, Sally Warren’s grappling with the issues about the proposed ‘cap and floor’.

Labour start this week on the front foot on the proposed reforms, with analysis extrapolating data from NHS Digital to model the possibility that 70,000 will die in need of social care  before the £86,000 cap on costs is introduced in October 2023.

Camille Oung’s chart for the Nuffield Trust is a striking visualisation of the failure of the ‘plan for social care’ to be anything of the kind.

Budgette? Fudge it
Nor, surprisingly, is the new NHS funding all it’s cracked up to be at first sight.

I know: colour me surprised.

The Nuffield Trust’s data diva Sally Gainsbury gave her reflections on the announcements of more money: “of the £36bn extra cash raised by the tax increases over the next 3 years, table 2 of the document suggests £15.8bn will be allocated to #NHS England over 3 years. A thread on this NHS specific spending and associated curiosities:

“That £15.6bn number cheekily includes a £5.6bn increase against a made up and artificially low baseline budget for 2024-25. If we assumed the baseline for that yr rose in similar terms to the yrs before it (i.e 5.5% instead of 2%) the total extra over 3 yrs wld be more like £11bn

“This extra spending for “front line” NHS spending in England comprises of £6.6bn above the original plan next year, and £3.6bn in 2023-24. To put in context, our analysis published last month showed NHS England was on track to overspend its budget next year by just under £5bn – before taking into account any further costs of dealing with covid or the waiting list backlog

“So these early numbers do not look promising. Even if covid has disappeared as an extra cost consideration by 2023-24, it is hard to see how the “extra” £3.6bn that year will do anything more than just cover the existing overspend, let alone extra activity to reduce waiting lists

“But if ~£16bn is going to the “front line NHS” in England, approx. £4.6bn to adult social care in England and further £5.7bn to Wales, Scotland and NI, where is the remaining ~£10bn going?

“I assume this is to the Department of Health and Social Care. For what? For the expansion of clinical training places? That’s great, but that expansion was promised in the election manifesto, so some transparency about changes in funding plans would be appreciated here

“And the rest? Test and Trace? A central DHSC pot out of which private providers will be contracted to supposedly assist with the waiting list back log (good luck when it turns out most of their staff are *also* NHS staff)? Answers gratefully received”.

I’d guess Sally will be waiting a while for her answers: certainly for good ones. Anita Charlesworth of the Health Foundation REAL Centre also offers pertinent reflections.

Reality re-asserts
Reality has a way of re-asserting itself, and this week’s latest NHS waiting time figures remained, unsurprisingly, very bad.

The number of RTT patients waiting to start treatment at the end of July 2021 was  5.6 million patients; the 92nd percentile waiting time was 43.8 weeks.

As ever, Dr Rob Findlay of Insource’s analysis for HSJ is an essential read on this; the latest QualityWatch tracker update from the Nuffield Trust likewise. Rob reflected, “things have settled into a pattern over the summer. Since May, patients have been referred onto the waiting list at close to pre-covid rates. There is no sign yet of the super-surge as ‘missing referrals’ come flooding back. Many patients must still be staying away.

“The rate patients are discharged from outpatients, or removed for administrative reasons, has also settled at close to pre-covid rates. Much of this activity now happens online.

“However admissions for inpatient and daycase treatment have remained below pre-covid rates. There is no alternative to physically coming into hospital for such care, so it is vulnerable to covid prevention measures.

“The net result is that the waiting list is growing rapidly. Which means the underlying pressures on waiting times are getting worse (whatever fluctuations they might actually go through from month to month)”.

There has been some progress: we should not forget that despite rising Covid19 rates, the system is still doing what it can to meet need. As NHS England quite reasonably pointed out, “there were 3.9 million diagnostic tests and 2.6 million patients started consultant-led treatment over June and July, compared with 2.7 million tests and 1.6 million treatments over the same time last year.

“The increase, which included hip and knee replacements and cataract procedures, came as the number of COVID patients in hospital grew from under 800 at the start of June to more than 5,000 at the end of July. There are now more than 6,300 COVID patients in hospital, compared with fewer than 600 this time last year”.

The Health Foundation have a good new report on Covid19’s inevitable impact on the NHS Long-Term Plan. It notes that “the overall picture is of one of major delay, disruption and increased demands on services. Previous national targets – such as for expanding access to mental health services – will need to be revised to account for greater need”.

Anecdotally, I’m told in confidence by a good source that the new funding numbers released this week have surreptitiously swiped between 13 and 19% of mental health trusts’ planned growth funding for 2021-22. This will undoubtedly become clearer over the next few weeks. Assuming this is widespread, rather than an error, it’s concerning: cutting mental health budgets is Not A Good Sign.

This was thrown into sharp focus by data briefed to The Guardian showing that a third of children’s acute beds in England are occupied by medically well but vulnerable children who have nowhere else to go.

Target reform
So when you're doing badly on targets, what do you do? Ta-dah! Time for a review of targets!

Asked if the 18-week referral to treatment target would be replaced on yesterday’s BBC Meh Show, the Secretary Of State For Health But Social Care blustered, “I’ve had a couple of months to review NHS targets, and I’ve got to say – looking at the targets that have been set under successive governments long before covid – some of them are wrong, they’re just nonsense.

“They don’t all go, but we need a proper review of targets because it’s the act of a lazy politician just to set some target that gives them a short-term headline that actually leads to the NHS going backwards and not looking after patients”.

And it’s the act of a deceitful politician to mess up the data systems that allow us to assess how the NHS is performing. Did Meh ask The Saj which targets he wanted to change, and why their measurements were backwards-driving nonsense? Of course not.

The Tory right is out for the NHS
This tax increase to start funding the NHS’ (and maybe in our children’s children’s time, social care’s) needs provoked the Conservative right into paroxysms of rage. These won't be going away any time soon.

Boris Johnson fanzine The Telegraph (the PM’s self-styled “boss”, remember) has been leading the charge with a spate of even less insightful and reality-based articles than its usual subterranean standards.

This one on how disgraceful it is that NHS managers get paid salaries actually drew support for the value of NHS managers from 10 Downing Street ‘s official spokesman: something I’ve never seen in 22 years writing about this sector. The quote was, "the public will rightly expect every penny raised by the levy to be spent on cutting Covid waiting times and finally fixing the care crisis ... NHS England is already working to be more efficient and cut waste.

"Senior managers will play a vital role in the integration of health and care ... Anyone paid that salary should rightly be held to account for what they deliver, in this case it will be cutting waiting times, bringing the NHS and care system closer together to cut waste and improve patient care. These individuals will be responsible for a population of around a million people with billion pound budgets, and so we want highly-qualified people who can deliver for the public”.

Remarkable to see. I’d call that ‘the Samantha Jones influence’.

The Telegraph also recorded comically inept care minister Helen Whateley showing her deep understanding that the Tories are the party of the free market by making statements about what salaries NHS managers should earn.

This one, about how claims of bullying stop the NHS from being more efficient (no, me neither) actually just seems to be straightforwardly made up out of nothing.

And in this one, the Telegraph discovers that the NHS has staff who aren’t doctors and nurses. It quotes halfwit Conservative MP Marcus Fysh saying “it’s time now to have an honest conversation about the service. It should not be a sacred cow”. So clearly “an honest conversation” is the autumn 2021 marker of arseholery.

Steven Black’s rejoinder to this sort of nonsense is nice. And Labour’s smart Karin Smyth MP observes, “reducing waiting lists also a massive management task unless we want consultants, nurses & GPs phoning & scheduling millions of patients”. A BoJo-Fanzine-run NHS would at least be funny.

There was this largely ill-informed article in the Mail from Professor Steve Smith of Imperial, who certainly should know better, but appears not to.

So we know that henceforth, the fiscally driest Conservative right-wingers and their hard-of-thought media and thinktank stooges will be going on and on and on about NHS waste, “honest conversations” and NHS managers being paid salaries. Anyone expecting reason to enter their arguments is delightfully optimistic. NHS leaders need to be prepared with factual and sharp rebuttals.

Covid19 update
It’s getting worse, particularly in Scotland, as Zoe architect Tim Spector pointed out to The Times.

Data analyst and modeller James Ward has some useful new analysis here. And this thread by Professor Oliver Johnson is an essential read.

The creaking system
So much to choose from lately, but ITV ‘s Paul Brand reported this week that Oxfordshire hospitals went critical, with ambulances unable to offload patients and discharges to the community impossible due to a shortage of care staff. The Radcliffe had, at the time of his report, been without spaces for 24 hours.

Likewise, on Friday, the Royal Cornwall suspended routine and urgent operations due to a surge of demand from patients with Covid19.

London Ambulance Service sent this open letter to Londoners about current demand pressures, but it could have been any one of them.

Is our urgent and emergency care system broadly safe just now? Pretty clearly not, no.

Cronyvirus and Coronamillions update
There were yet more weak ‘something must be done’ noises from the Competition and Markets Authority this weekabout the blatant scandal of private sector Covid19 testing.

Sajid ‘The Saj’ Javid stopped power-posing for long enough to threaten firms with a £10,000 fine from 21 September if they keep ripping off the public. This means that these Tory-donation-prone firms would potentially have to sell a hundred more of their rip-off (but legally mandatory for overseas travellers) £100 testing packages.

What a deterrent that’ll be.

Lord Prior on the CQC
HSJ reported a recent Royal Society of Medicine lecture by NHS England chair Lord Prior, in which he observed that the CQC (which he used to chair) was not very effective at driving improvement.

He told the event, “I am highly sceptical as to whether or not CQC or any regulator can really drive improvement and drive the top hospitals to make them better. And certainly I think there’ll be very few physicians who will say that their clinical work has improved as a result of reading a CQC report.

“I think the sadness I have about CQC is that we have not been able, or it has not been able, to develop a series of predictive metrics that could replace these very heavy handed, very laborious and very expensive visits that we used to do”.

HSJ wryly observes that Lord Prior, CQC chair 2013-15, served at the Department of Health as minister for NHS productivity from 2015 to 2016.

Getting the Bill (Health and Social Care)
The Bill committee sits again this week.

Other important things
Would appear here.

Recommended and required reading
Some good news: NHS England announces a wide testing rollout of the Galleri tests to detect more than 50 cancers at a pre-symptomatic stage.

Stuart McDonald on the new ONS deaths data, showing increasing mortality rates over the long-term average. It’s very unusual to see such increases in the summer months.

Dr David Watkins, whose persistent critique of Babylon’s absurd chatbot ‘AI’ product is a major public service, highlighted this spectacular claim in their publicity: the product "will auto-transcribe clinical interactions in real-time & generate meaningful notes & summaries", thus "allowing clinicians to spend more time with their patients". The (tiny) small print reads “the feature is under active development, has not been commercialised and we cannot guarantee if/when the product will be delivered to members”.

Michael Bang Petersen, a behavioural advisor to the Danish government, shared interesting lessons about what approaches had worked there to retain public support for anti-Covid19 measures.

The NAO report on the adult social care market in England bears re-reading. So too does the Tony Blair Institute For Global Change’s paper.