Cowper's Cut 208: Karma Chameleon The Saj has a dream
Where to start on Health But Social Care Secretary Sajid 'The Saj' Javid's major speech on NHS reform?
It was heroic, in a way: the most logistically and politically confused speech by a Health Secretary that I've heard in 23 years of writing about this, by a long margin.
Significant political thinkers (and The Saj)
The Saj sought to put himself in a class of significant political thinkers, contending that "it takes the Burkean reverence of the institution AND the reforming zeal of Blair and Thatcher to sustain the Bevanite dream of world class healthcare free at the point of use for all our people".
Bollocks. It takes adequate and reliable resourcing, and proper planning and systems.
If The Saj aspires to be a weather-making politician, then he needs to brush up on his political history. It was not a Conservative health secretary who first proposed a national health service, as he asserted: it was Beatrice Webb and the Fabians.
Political transvestism
At one point, self-styled "small state Conservative" The Saj was trying to sell the line that “freedom and health are fundamentally intertwined”. In this philosophical wrestling match, The Saj's inner Ayn Rand wrestled with his inner Nye Bevan. Both lost.
He also tried "there's no small state without strong families". A VERY Ayn Rand bit there, in a speech that bets the farm that people agree with his wanting a smaller state. It's highly unclear in our current turbulent economic and political climate that this is so.
He went on, “I’m a small state Conservative. There is no small state that isn’t a 'pre-emptive state’. The NHS is significantly bigger than it would be if we had done a better job at preventing avoidable disease".
Ahem. Mr Javid clearly hasn't looked at the numbers of people with non-preventable long-term conditions. It's something to celebrate that so many people are alive with LTCs that, decades ago, would have shortened their lives.
But it does mean that we need a fairly large NHS to support them.
We learned that ICSs will be performance-managed on prevention: "we will put prevention at the heart of how we hold our ICSs to account in the future. We will expect NHSE and individual ICSs to commit to joint delivery plans to reduce the biggest preventable diseases – starting with cardiovascular disease, but in time, expanding to include diabetes, cancer, and poor mental health".
Which is nice, although the Lansley 2012 Act mandated that CCGs reduced health inequalities year-on-year, and promoted prevention. Was that a big success?
Levelling up?
After thus setting out his right-wing credentials, The Saj claimed concern for the 20-year disaprity in healthy life expectancy between the best-off and worst-off.
It's unclear what he proposes to do about it: auction off licences to hunt the super-rich? That would be a levelling-up of sorts, I suppose, to address “the disease of disparity. We can’t hope to level up unless we level up in health”. Bloke’s a raging Communist, innit.
ABC speechmaking
It was an ABC sort of speech: assertions, bullshit and confusion. The arguments, such as they were, were incoherent and unproven. The analysis was trite, where there was any.
There was no understanding of the real challenges. The absence of any mention of the NHS's workforce crisis, capital drought and management incapacity was the only memorable thing about the speech
At one point when he was eulogising digital, The Saj essayed a joke: "the NHS app is for life: not just for Covid".
Nobody - not even his SpAds - laughed.
Tumbleweed blew across the august floor of the Royal College of Physicians' Dorchester Library. Aeons passed in silence. More aeons followed them. The Saj tried a little joke about the failure of the joke. Someone (presumably on the DHBSC payroll) managed to force out an embarrassed giggle.
I cringed so hard, I think I may have broken a rib.
Promising to eschew soundbites, The Saj talked about "how we build, not just a national hospital service but a true National Health Service" and "hard-wiring prevention into the NHS". He said nothing of substance about how.
(Oh, there was a commitment to "exploring the extension of legal rights to enable significantly more people to benefit" from personal budgets. In other words, this is meaninglessly embryonic. The rhetoric is small: the reality far away.)
Solutions in search of problems
In all the trails of reheated stuff in and the hilarious trailer for The Saj’s speech, there's no sign of understanding of the NHS’s problems now, today, in 2022.
The Times announced that Sajid Javid will say that the government cannot pump “more and more money” into the NHS’. He did indeed assert this, but he didn't offer any evidence that it was true.
Ahem. Perhaps the fact that 2010-19 was the NHS's lowest decade of funding growth in its history gives us a clue about why big catch-up spending is now belatedly happening?
According to The Times, a Whitehall source said: “business as usual won’t cut it. If we don’t embrace reform we won’t be able to provide the level of service patients deserve”.’
This is just standard Politician’s Syllogism bollocks. Something must be done; this is something; therefore this must be done.
The real problems facing the NHS right now in 2022 are largely about workforce and management infrastructure, and somewhat about physical capacity. Workforce: there are too few of them, many of whom are exhausted and at least somewhat burnt out by their working through the pandemic.
The competition for healthcare staff is now international, and has been for years.
Management infrastructure: the NHS is seriously under-managed. It tends to understand patient flow sub-optimally. Its use of data is wildly patchy, and it seems to have given up on outcome data such as PROMs.
It is ridiculous that in 2022, hospital beds meetings are being held around spider phones, referring to numbers written on whiteboards or paper.
These longstanding workforce and management capacity shortages have a common effect: they make any system or organisation effectively unmanageable and almost certainly inefficient.
Back to the future
And the answer?
The Saj announced NHS modernisation that is in effect The Patient's Charter (1991: PM - John Major), Choose And Book (2005; PM - Tony Blair) and Personal Health Budgets (2008: PM - Gordon Brown).
He's a Karma Chameleon, is The Saj.
The Saj promised a new Right To Choose for long waiters. This is meaningless, unless it is matched by a Right To Spare Capacity. And it is not being so matched.
This segued into a claim that "choice is an intrinsic good ... I want choice for all, not just the privileged few". He followed this up by dissing middle-class people in leafy suburbs who push for better treatment: an interesting approach for a small-state Conservative.
O, reason not the need
Why are these reforms urgently needed now? Surely he could answer that one?
Without them, “taxes and waiting lists would rise”, The Saj intoned. Taxes and waiting lists are rising right now.
There was other demonstrable nonsense: “with additional money comes a need to get it right, including putting social care on a sustainable footing with our White Paper last December”. Putting social care on a sustainable footing has not been done at all, as pretty much the entire sector concurred.
His warning of “unsustainable finances” was wholly unproven, and the line “without the pandemic, the choice might have been a few years down the road” is simply balls. The Saj announced gravely that “our health spending is bigger than the entire GDP of Greece”. Look, kids: a meaningless analogy!
At one particularly low point, The Saj essayed that the situation facing the NHS now was simultaneously like and unlike the situation in which the NHS was created. Making this Schrodinger’s NHS Reform, presumably.
At another point, The Saj turned soothsayer, with the vision that "we will have a proper long-term workforce plan". That'll be nice. Nothing on when, though. Nor on whether fully-funded.
And we got a liberation passage towards the end: “In many ways, reform has been going on for some time. It’s about hundreds of thousands of innovators being freed to make tens of millions of improvements … Free at the point of use, and freedom at the point of delivery, you might say”.
The NHS's last liberator was Andrew Lansley, and that did not end well.
In the Q&A afterwards, The Saj made it clear that the forthcoming Framework-15 workforce plan will come with no extra money. Which means they really may as well not bother. Have a read of this BMJ roundtable about workforce retention to really cheer yourself up about where we are on workforce.
Reactions
Imperial College Health Partners boss Axel Heitmueller's elegant critique makes good points about the speech's key weaknesses. Chris Ham's analysis for the BMJ is here. And for a Conservative take on the speech, Robert Ede and Sean Phillips wrote this for Conservative Home.
The best commentary was from Richard Sloggett, boss of Future Health and former special advisor to Matt 'Alan' Hancock. Sloggett says that The Saj's NHS reform speech wasn't really about NHS reform, nor indeed really for an NHS audience. It was, instead, about Mr Javid's take on the internal battle over small-state Conservatism versus Johnsonian brexit-bus largesse.
In other words, it was a sally in the war between the relative fiscal hawks and doves within the Parliamentary Conservative Party's leadership.
Meanwhile, back in the real world ...
The latest referral to treatment data shows no significant overall increase in the waiting list, at about 6.1 million. NHS teams carried out 280,000 more diagnostics test in January 2022 compared to locked-down January 2021, and checked 2.6 million people for cancer over the past year (over half a million more compared to 2021).
That is the good news.
However, the data also shows 311,528 patients waiting over 52 weeks (up from 310,813 in December 2021), and the number of patients waiting over two years has risen 19% (from 20,065 to 23,778). Given the target to eliminate all two-year waiters by July, this major jump in number is, as HSJ's James Illman noted, a big concern.
93% of people who GPs suspect may have cancer should be seen by a specialist within two weeks of their urgent referral: in January 2022, just 75% were - the lowest proportion since records began. While 152,093 of the 202,816 people GPs referred to hospital for cancer were seen within two weeks, 50,723 were not.
Another target is that 96% of people with confirmed cancer should start treatment within 31 days of doctors deciding to treat them: just 89.6% did so. The wait from referral to diagnosis and decision rose from 38.6 weeks to 39.5 weeks. As always, Rob Findlay of Insource has excellent analysis.
A&E performance at English hospitals hit new lows. 60.8 per cent of patients were seen within four hours in Type 1 A&E departments in February 2022 (down from 62.3% in January). The Royal College of Emergency Medicine has recorded more than 6,000 12-hour waits per week in February, from just 40 sites, when measuring time from arrival to departure in emergency departments.
The changes to A&E and ambulance handover waiting times recording have come under review, with the new Standard Contract likely to see rocketing reporting of 12-hour waiting breaches. As HSJ reports, this comes on top of calls for publication of data and outcomes for the sites that have trialled NHS England's new performance measures. It is worth remembering that peer-reviewed evidence shows that delayed admission in A&E is associated with increased mortality.
Inflation
Nobody will have failed to notice the current inflation in the UK economy. It will have significant impacts everywhere on the NHS's cost base, and indeed on the Government's 40/48 'new' hospitals programme.
Health Service Journal's Emily Townsend observes issues around the reconfiguration of emergency care services at Princess Royal and Royal Shrewsbury hospitals: "in January, HSJ reported that the controversial proposals had been sent back to the trust by NHS England for revisions after it emerged inflation had pushed the scheme’s cost to around £500 million. That sum would be significantly more than the £312 million originally allocated to the proposal in March 2018".
HSJ's Henry Anderson noted on Twitter that University Hospitals Plymouth Trust have been asked to achieve a cumulative 5% in annual efficiency 'savings', which the Trust notes has "never been delivered by the NHS in a single year". We've reached the 'fantasy financial planning 2022-23' stage early, I see. Anyone else thinking of Mid-Staffs chasing financial targets, and the consequences for patient safety?
And the Spring Statement due on 23rd is going to reveal that the Chacellor would need an extra £10 billion (£1,750 per worker) to protect public sector pay from inflation, the IFS revealed.
Meanwhile, announcing its annual results, Spire Healthcare suggested that there has been a "seismic shift" in use of sustainable self-pay private elective healthcare. Heightened demand for self-pay treatment helped boost the Group’s revenue by 12.8% in the 2021 financial year. The company presumes that this is likely to continue, due to the length of NHS waiting lists. Spire reported record revenue of £1.1 billion for the year, but it made a financial loss of £9 milllion after tax, and is £225 million in debt.
Covid's not gone away
The numbers are rising quite sharply now. Community prevalence of antibodies remains high, according to the ONS survey, so this seems likely to be about the Government's ending of all meaningful restrictions. The REACT study shows a strong rise in infections in the over-55s, with an R of more than 1.
And Tim Spector's ZOE study has not had its UKHSA funding renewed.
The Covid19 public inquiry website was published this week. It is here, and the inquiry's terms of reference (being consulted on for the next four weeks) are here. There is already correspondence with the Cabinet Office about not deleting or editing records from the period: bodies must ensuree that "a full and clear record of their part in events exists, is accessible, and that they apply a precautionary principle by retaining all material that could be relevant - including emails, text or WhatsApp messages and other communications".
The Institute For Government's Emma Norris offered some pertinent reflections.
The Alan comeback
I was dreading another fallow week for coverage of The People's Partridge's endless efforts at self-rehabilitation. Step forward Jemima Kelly of the FT, whose magnificently titled piece 'What's the story, blockchain Tory?' reveals the source of Alan's crypto-enthusiasm, shown in his classic City AM article.
Ms Kelly reveals that Alan's brother is a Crypto Bro. Chris Hancock is, Ms Kelly reveals, "the founder and CEO of a fintech firm called Crowd2Fund, a peer-to-peer lending company that claims to offer “a new generation of investments to pioneer a cultural shift away from the traditional banking systems”.
She highlights a Guardian piece reporting that "in 2013, Matt Hancock told the House of Commons: “We are supporting crowdfunding on financial terms, not least through the new business bank, but we are also making sure that it can operate in a high-quality framework". On a different occasion, Matt Hancock urged a fellow MP “to look also at peer-to-peer finance, whether equity or loan, because that is a small but growing part of the market that companies can look to when trying to access finance”.
Ms Kelly notes that Hancock’s Parliamentary peroration was in October 2013. According to Chris Hancock’s LinkedIn and Companies House records, his innovative fintech firm Crowd2Fund was founded just a few months later.
Asked to comment, Alan's office's told the FT "this factless insinuation of wrong doing is not only false and baseless but embarrassing. Matt has a long-standing expertise in digital matters and the idea he shouldn’t talk about something he has detailed knowledge of because his brother is an entrepreneur is clearly absurd. This is unfounded speculation not journalism".
Gina Coladangelo's "communicating in an emotional intelligent way" training of Alan has clearly worked wonders.
And just when you though you couldn't love The People's Partridge any more, he comes up with this corker of a NIMBY article for The Mail against a proposed new solar farm and battery storage development in his constituency.
Ooops.
Has Wall Street rumbled Ali Parsadoust's, erm, promotional tendencies? And does app-based access to primary care look like a highly contestable niche?
Cronyvirus and coronamillions update
In a major exclusive for Beckie Smith of Civil Service World, we learned that seven billion items of pandemic PPE are now deemed not fit for NHS.
Ooops.
Nearly one in five PPE items that the Government bought since February 2020 are marked "do not supply". This includes 1.2 billion items that can't be used in any setting (a figure is up from 1.9 billion items last June).
Ms Smith notes that the DHBSC "hasn't said how much was spent on the seven billion items of PPE that can't be used by the NHS. But we do know the value of the 1.9 billion items marked "do not supply" last June was £2.8bn... so the number will be high".
According to Ms Smith, "this "wastage" – which accounts for 3.3% of pandemic PPE – includes around 800 million aprons that DHSC is now looking to recycle, permanent secretary Sir Chris Wormald said in a letter to the Public Accounts Committee, which was published without fanfare this week".
Good Law Project boss Jolyon Maugham QC has a startling update on the profit level made by PPE suppliers during the pandemic. Uniserve sold facemasks bought for to the UK government at 87p. "And you can work out the per unit gross profit: 41p/mask. Multiply that by 80 million units, and you get Uniserve's gross profit of £32.8 million".
There were, of course, administrative, transport and delivery costs to come out of that 47% gross profit margin. But as Maugham notes, "if extrapolated across the £12.5 billion we spent on PPE, it represents £5.875 billion of profit, much of which will have gone to associates of Ministers who were glad-handled through the sleazy and illegal VIP lane".
The Mirror's Mikey Smith got a fascinatinh revelation of how far the Department for Health But Social Care will go to avoid answering FOIs: it took eight months to agree to publish a single text message related to a meeting between then-Health Minister Lord Bethell, Tory peer Lord Feldman and a firm handed £160m of Covid contracts.
Recommended and required reading
The Financial Times' article on how pharma industry business models are impeding the development of new antibiotics.
Publication of the Ockenden Report has been delayed by Parliamentary prodecure requiring a 14-day objection period regarding the DHBSC's proposal to seek liability insurance.
The Saj made a smaller but probably more important speech to open the CEPI Global Pandemic Preparedness Summit 2022 in London.
It's worth reading '“It’s been ugly”: A large-scale qualitative study into the difficulties frontline doctors faced across two waves of the COVID- 3 19 pandemic', in the International Journal of Environmental Research and Public Health.
The Lancet has had a go at comparative international mortality stats for the pandemic
Interesting Times piece on the use of machine learning / pattern recognition software in cardiac MRI scans.
Author and Spectator assistant editor Isabel Hardman, researching her forthcoming NHS book, found this 1976 gem of a note for the PM in the National Archives.