Cowper's Cut 181: Cleaning up the mess

“We still cling with part of our minds to the infantile belief that the world was made for our gratification and pleasure, and we combine this narcissism with an assumption of our own immortality. We believe that someone else will clear up the mess we make, because that is what someone else has always done. We trash our habitats again and again with the inductive reasoning that we have got away with it so far, and therefore we will get away with it again.”

PM Boris Johnson, speech to UN General Assembly, New York 22 September 2021

In April 2022, the new Health But Social Care Levy will come into force at an interesting time.

Clearly, we don’t yet know how hard this winter is going to be. However, we do know that the NHS is fragile and having big problems already, right now, in this mildest of Septembers.

A lot of the service is struggling now. There is a high probability that this will be a very bad winter indeed, with an ongoing succession of NHS crises.

On top of this, a combination of inflation and winter shortages are already on us. These are not only in the realm of NHS blood tests: they will affect all of society, and rising inflation will mean cost-of-living price and utility rises will hit the poorest hardest.

The UK shortage in supply and indeed storage of natural gas for heating; the shortage of HGV drivers; of petrol station resupply; and the consequent inflationary pressures are not going to go away.

The driver shortages are nothing to do with Brexit only in the minds of those who advocated Brexit: it may not be their sole cause, but it’s a significant factor.

As I remarked in my review for Civil Service World, NHS England’s new Pope Amanda Pritchard very clearly won her battle on the ‘no firm commitments’ in their 'HSC Levy' document. Her Holiness continued this ‘no actual firm commitments’ thread in this Twitter thread. That’s the right move, by the way. We don't yet know how big a problem we’re facing.

Nor do we yet know how serious the revealed preference of the Government will be to fund an adequate approach to recovery.

This is all very far from settled.

Then there’s the workforce. HSJ has been leaked survey data showing that the ‘People Pulse’ monthly survey’s results recorded between May and August saw “a drop of 9.6 percentage points in “perceptions of wellbeing support”, with “positivity” sitting at 57.3 per cent. Almost a quarter of the survey respondents reported a “negative” experience of health and wellbeing support”.

And the new tax kicks in after all that.

Mmmm. If not mmmmmmmmmmm.

So the NHS is a big priority for the Government just now?

Ahem.

The Government has been repeatedly lending its support to a campaign in the right-wing press about face-to-face GP appointments. This has been so hard of thought that I published an article by NHS management thinker Steve Black on HPI this week, which nicely addresses the paucity of data in the debate. (Steve is always worth reading on data issues.)

So reason won the day?

Well … in the wake of that, it was fascinating to see power-posing Health Secretary Sajid ‘The Saj’ Javid endorsing the Mail campaign. He promised, in the Mail’s words, to “slash red tape to give family doctors time to undertake more appointments in person”.

There was, of course, no mention of what ‘red tape’ Mr Javid will be cutting. Specifics came there none. It’s almost as if this were a PR-first, knee-jerk reaction to curry favour with the right-wing press.

What a surprise.

Report time
When the shit is in the process of hitting the fan, the NHS community issues reports as if there’s no tomorrow (which most of these reports conclude is quite probable).

The NHS Confederation have what they badge as a manifesto for recovery, which “warns that waiting lists have grown more rapidly in more deprived areas during the pandemic, with marginalised groups likely to make up many of the missing 7 million patients who would have been expected to have come forward for treatment had it not been for the COVID pandemic”.

The Health Foundation’s new report suggests that “while the waiting list for hospital care continues to grow, so too does the number of ‘missing' patients who have not yet been added to the list. There were 7.5 million fewer people referred for routine hospital care between Jan 2020 and July 2021 than would have been expected based on numbers prior to the pandemic. These ‘missing patients’ are in addition to the record 5.6 million people already on the waiting list”.

IPPR’s new report on cancer services suggests that it could take until 2033 to clear the cancer backlog, even if hospitals increase treatments by 5%.

Nor was the Government to be lefty out, with this week’s release of its overprescribing report and its response to the Health But Social Care Select Committee’s maternity report.

The CQC also come in with a report on maternity care.

Ahead of the Spending Review, NHS Providers’ deputy CE Saffron Cordery has written to outline the case for capital funding.

Safety first
In HBSCSC chair and erstwhile Health Secretary Jeremy Hunt’s newsletter, he reviewed the Government’s response on his committee’s maternity report: “overall I was mildly encouraged by both the tone and content of the responses. Out of 15 recommendations they only completely rejected one (on implementing the Rapid Redress and Resolution Scheme), partly accepted eight, and completely accepted five. They are still considering the big one though – the additional £250m to £300m funding required to provide the maternity staff the NHS needs. Even if you are not as immersed in maternity safety issues as I am, the case for this is surely a no brainer given the NHS incurs a shocking £5.7 bn (yes you read that right) of liability every year relating to clinical negligence.”

“Shaun Lintern has crunched the numbers to show how unsustainable the current system is finding that within all clinical negligence claims maternity alone has cost the NHS £8.2bn in the last 15 years enough to pay for 13 new hospitals - that is cash actually paid not simply liability incurred”.

Hunt also highlighted that “the Select Committee today launches a new inquiry today into NHS litigation reform. This will look at the ridiculous cost of the process, the damage it does to a learning culture and the unfairness to families of having to wait five years or more before a court settles the more complex claims”.

Labour’s shadow health lead Jonathan Ashworth tells The Independent’s Shaun Lintern that patient safety is now their priority (well, it beats campaigning against fictional privatisation): Labour want to amend the HSC Act to outlaw secrecy over Royal College reviews of NHS services; to maintain safe staffing levels and increase transparency.

Signs of life in the Opposition?
Labour’s conference in Brighton this week may not turn out to be the non-event some have been predicting.

At the time of writing, Labour’s leader Keir Starmer got some proposed internal voting reforms through that will consolidate his position and dispossess the Corbyn faction within what remains quite a deeply broken political party. ‘Oh: Jeremy Corbyn’.

So far, Mr Starmer is not getting great reviews or poll numbers. Yet he does keep on winning his battles. In time, people will start to notice that.

People who are paid well enough to know better were hasty to dismiss Starmer’s essay for the Fabians setting out his beliefs. Long as ‘The Road Ahead’ is, both literally and metaphorically, the piece is well worth reading. I’ve selected some key excerpts below.

“From the neighbourhood-level efforts of communities to look after one another, to the way businesses, scientists and the NHS drove the vaccine effort, we have seen how much more we achieve collectively. On the other hand, the moments that were most damaging and detrimental to our national effort – such as when senior Conservatives decided that the rules did not apply to them or enriched their friends with taxpayer money – were characterised by selfishness and arrogance”.

“The next Labour government will be focused on creating jobs people are proud of, reimagining our public services for those who use them, creating a new and better relationship with business and delivering world-class health and education. And we will build this on solid foundations, with security at home, in the workplace, on the streets and from those who would do us harm”.

“The projects of the Conservative government in Westminster can be broken up into three distinct but related periods. First, using the global financial crisis as a smokescreen for rolling back the state. Second, a lazy, complacent veer from patriotism to nationalism, resulting in a botched exit from the European Union, the erosion of our defence and military capabilities and an unfolding foreign policy disaster in Afghanistan. And third, the ongoing attempts to import American-style divisions on social, cultural and sometimes national lines.

“A £6bn gap has opened in adult social care through the salami-slicing of council budgets. Across the country, a decade of Tory slash and burn economics has resulted in everything from fewer bin collections and increased fly-tipping to the closure of children’s centres and lengthening waits for mental health treatment”.

“Just before the Conservatives took power in 2010, Professor Sir Michael Marmot published a report on the state of England’s health. In February 2020 he updated it, laying bare the sheer scale of decline. Among its shocking findings were that that life expectancy had stalled for the first time in a century and that for some of the poorest women in the country it had declined.7 It is an appalling legacy after a decade of government”.

“When Covid-19 reached these shores, it was hard to find a part of Britain that had not had its foundations weakened disastrously by decisions taken over the previous decade”.

“It was the NHS that stepped up most spectacularly during the crisis. But it was forced to do so from a position of weakness. We had 10 per cent fewer hospital beds at the start of 2020 than we did in 2010/2011. During the same period, the rate of occupied beds increased. Waiting times were at a record level before the pandemic, with 4.5 million people waiting for treatment, compared to 2.5 million when the Tories came to power.11 GPs and hospitals were missing almost all routine targets. The NHS had nearly 100,000 staff vacancies, including 50,000 nurses. PPE supplies were disastrously low and supply chains were feeble.

“National plans for adult social care barely existed and the poor pay of Britain’s carers, about a third of whom were on zero-hours contracts, meant staffing turnover was high”.

Is there an original idea in there?
There is one such: it is one that has not been adequately voiced by a previous Labour leader in the past decade. This is the idea of ‘the contribution society’.

Starmer says that during the pandemic, “we could see the glimmers of what our country is at heart and what it can be again. This isn’t about being Pollyannish or sentimental. It is about the idea of a society based on contribution: being part of something bigger, playing your part, valuing others not just because of what they can offer you. I make no apology for believing that these kinds of traditional ideas must be a crucial part of our future. They are what inspire people to become nurses or carers and businesses to prioritise their employees’ happiness and wellbeing.

“In order to put contribution and community at the centre of our efforts, we would build an effective partnership of state and private sector to prioritise the things that we have seen really matter: health, living conditions, working conditions and the environment”.

Neither Ed Miliband nor Jeremy Corbyn would ever have written the following section: “If we are to come back better than before, we need to fundamentally rethink how our country works … It means banishing the culture that unthinkingly accepts public services not keeping up with the sort of advances we have come to expect in the private sector. We will no longer allow corruption, waste, anachronism and falling standards to be met with a shrug, as if there is something inevitable about each of them.

“The first task in remaking the nation will be resetting the relationship between the government and business to create an economy that works. That will require a new, common-sense, practical approach: one in which we don’t treat the economy as a battle for supremacy between public sector and private sector, but a joint effort. We need to drive innovation and change and drive up standards for employers and employees.

“The state must become an investor and a leader. British businesses large and small must know the government has their back. Workers must see their pay, skills and conditions improve.

“Business is a force for good in society, providing jobs, prosperity and wealth. But business has been let down by a Tory government that has failed to plan for the long term and provide the conditions in which long-term decisions can be made”.

After taking a valid sideswipe at the coronamillions/cronyvirus procurements, there follows an intriguing ‘buy British’ section: “the shambolic experience of public procurement, both before and during Covid-19, must end. Why when government departments are funded by taxpayer money are we so lax about ensuring that money is spent appropriately?

“Labour would set high standards, ensuring public bodies give more contracts to British firms both large and small and design contracts to ensure we spend more in this country. We would report on this annually, with public bodies required to explain how much they are buying from British businesses. All major infrastructure projects currently in the pipeline would be reviewed to ensure we maximise the use of British materials and firms”.

There is a courageous pledge on transparency: one certain to bite him should he achieve national power: “where the current Tory government has muddied the waters of transparency on the money it spends or the things it does, I want to make it easier to hold government to account. That means everything from ending the outrageous way government departments refuse freedom of information requests to ensuring the next Labour government gives updates on our progress delivering on our key promises”.

Specifics on health
There is, inevitably, a good chunk on Labour’s plans for health: “across our public services we need to focus on preventing the ills that plague society, not just patching them up. The pandemic has brutally exposed the challenges to our nation and we will act to address them.

“Nowhere is this more keenly felt that in our health. We must now be ambitious. If we are to remake our nation then we should set ourselves the challenge of making this the healthiest country in the world.

“A successful country depends on being a healthy country: the NHS matters to our health and it matters for our productivity. Inspired by the ambition of Wales and New Zealand, and the experiences of the pandemic that kept our minds and bodies healthy, Labour would put wellbeing at the heart of government decision-making.

“The opening-up of discussion about mental health over the last decade or so has been important – but what is needed now is action. The 1997 Labour government set ambitious targets for waiting lists in the NHS and they worked: the next Labour government will set ourselves the same challenge on mental health. The mental health charity Mind suggest that just one in eight adults with a mental health problem are currently getting treatment and waiting lists are soaring. We must be ambitious about tackling this growing crisis.
We know that mental health is at the heart of so many other societal problems and making it as much a priority as our physical health will have so many positive effects for the wellbeing of our nation.

“Likewise, we must drive down waiting lists for treatment that were already soaring before Covid-19, as well as shift our focus from acute care to prevention and improving quality of life. That will require filling staffing shortfalls and providing the NHS with the support it needs to improve standards of care. But it will also mean harnessing the power and potential of technology to transform healthcare provision. If we can make our shopping cheaper and more convenient through the power of modern technology, then it stands to reason we can revolutionise our health and our health services.

“We are not naïve about the scale and importance of this challenge. We have an ageing population, one that will continue to grow over the next decade. Under the Tories, our health is getting worse. and the progress in living longer has begun to stall. Parents want their kids to grow up happy and healthy – but that will require action”.

The whip-smart Isabel Hardman of The Spectator wonders whether Sir Keir has the courage to deliver on all this. She’s right to do so, and only time will tell. But he’s doing better than his legion critics allow.

Clearly, Labour still has quite the mountain to climb: the Telegraph alleges that MPs Dawn Butler and Sarah Owen wanted to accuse the NHS of racism in the joint Parliamentary select committee ‘Covid19: lessons learned’ inquiry.

Covid19 update
Infections rising; deaths and admissions falling. It’s worth reading Bristol professor of statistics Oliver Johnson’s reflections on the latest data.

The creaking system
The Royal College of Emergency Medicine survey given to The Guardian presents a bleak but accurate picture of how it is in too many parts of the service. This winter’s going to be a really, really bad time to get either seriously or trivially ill.

HSJ’s exclusive publication of a letter from consultants to the leadership of University Hospitals Sussex FT (based at the former Brighton and Sussex UH, now taken over in the new nomenclature by the serially high-performing Western Sussex), warning that “we are devastated to report that the care we aspire to is not being provided at UHS… we are forced to contemplate that it is not safe to be open as a trauma tertiary centre and we feel elective activity must be proactively diverted elsewhere.”

The communication claims that a shortage of theatre staff is leading to “clinical safety issues, gross operational inefficiencies and burnout within our remaining depleted staff groups”.

Nicki Credland, chair of the British Association of Critical Care Nurses, told HSJ’s Patient Safety Congress that trust leaders in London have discussed relaxing the ratios from one nurse per patient, to one nurse per 1.75 patients.

It is well worth reading this excellent HSJ article in which Insource’s Dr Rob Findlay interviews John Bennett of Porthmeor and Karen Hyde about the ‘hidden’ NHS waiting lists not included in the national RTT targets, and how and why they have arisen.

Statistics on NHS staff from overseas, updated by the Commons Library this week, may have to be revised upwards as soon as we can pinch people from other nations.

Cronyvirus and Coronamillions update
Those Good Law project folks won yet another victory, as aspiring Comeback Kid Matt ‘Alan’ Hancock is to be required to open his emails and WhatsApp messages to investigation, following a Hugh Court ruling this week.

The Guardian reports that this court case has also seen the disclosure of further confirmatory evidence that the “VIP route” was very much A Known And Acknowledged Thing.

Getting the Bill (Health and Social Care)
Nothing to report this week.

Other important things
Would appear here.

Recommended and required reading
Directors of Public Health were absolute starts of the pandemic. This new Kings Fund report on DPHs is a good read, as is this tribute from Sheffield DPH Greg Fell to the work of Public Health England.

The UK’s biggest care home private operator HC-One emphasises to the FT that they are “the only major provider seeking to make local authority care the core of our operating model”

Excellent and disturbing FT long read on ‘biohackers’ starting to use gene editing technology

The ONS data for August shows that the ASMR death rate remains significantly above the five-year trend average: this very good Public Health England blog looks at what this may mean, and why

David Hare of the Independent Healthcare Providers’ Network writes on whether private providers should be barred from sitting on ICS boards.

Interesting perspectives in this analysis of Worldwide Healthcare Trust

GlaxoSmithKline’s ongoing issues over its chief executive thanks to a prominent activist investor are ongoing

The fragrant Julian Patterson’s LEGO NHS riff is wonderful

The Alan comeback is still very much ‘ON!’ If your stomach is feeling particularly strong, watch this.