Cowper’s Cut 236: Grate Expectations

Kami-Kwasi economics

'The Growth Plan', Chancellor Kwasi Kwarteng's Budget-but-not-really on Friday was a radical event, albeit perhaps not in the way Team Truss intended.

The notoriously left-wing bond and currency markets promptly administered a therapeutic kicking to gilts and sterling, and are sticking with their judgment call on the 'Growth Plan' throughout this morning's trading - hence the later publication for this column than usual. (Unpatriotic bastards, talking Great Britain down with their so-called 'trading'. Enemies Of The People, I'd say.)

This ramps up inflation, and so interest rates will rise further and faster than otherwise. I suppose you might call that growth.

If you wanted confirmation that sanity has done an Elvis and left the building, it arrived in the shape of this briefing to The Times (evidently Mr Kwarteng's leak-receptacle of choice) that the Spending Review settlement will not be re-opened in the light of the inflation the Chancellor has just avoidably caused.

Mr Kwarteng has set fire to the Conservative And Unionist Party's reputation for economic competence and fiscal prudence with the verve and elan displayed by his predecessor Norman Lamont on and around Black Wednesday. 'Je ne regrette rien'? Mmmmmmm.

So it currently looks as if we will head into the next General Election with both the economy and the NHS in avoidably bad states. And as John Appleby and Sally Gainsbury of the Nuffield Trust showed last week, high UK inflation was already a massive hit to NHS spending power even before The Kwarteng Pyromania.

Dr Tiz prescribes a cloud

So how has 'Our Plan For Patients', the Truss administration's health policy relaunch, gone over, then?

Ahem.

In golfing terms, Dr Therese 'Tiz' Coffey's NHS reform drive has been sliced into the long grass, right off the tee.

Once again, a strong briefing to the media (on this occasion, that GPs MUST see patients within two days) turns out in the rather more mundane real world to be merely an "expectation". Grate expectations, I suspect.

The proposals overall represent what the introduction by NHS England's Pope Amanda Pritchard describes as "ambitions".

How will this be done? A million more GP appointments a year are to magic-ed up out of the ether. We do not know how.

Wonderfully, we learn that there will be 'cloud-based GP telephone systems'. (Henceforth, let these be known as the Carly Simon Reforms: "I had some dreams: they were clouds in my Coffey, and/You're so vain, you'll probably think this song is about you".)

Oh, and the vaccination volunteers will be encouraged to re-enlist in this "national endeavour". It's a missed opportunity that Team Truss and Dr Tiz have not promised to re-open the Nightingales.

A national endeavour

The most basic principles of economics suggest that if you are going to satisfy higher demand (or meet existing un-met demand adequately), then you need to increase supply.

Pensions tax reforms were promised in Dr Tiz's statement. Alas! The detail in the published plan make it clear that these will be optional, not mandatory. The Kwarteng Pyromania was silent on mandating change here.

The BMA's pensions tax expert Dr Tony Goldstone picked this up within minutes:

£500 million extra for adult social care is not new money

In perhaps the least surprising element of the presentation, Dr Tiz's promise of "£500 million of additional funding into adult social care to help people get out of hospitals and into social care support" turns out not to be new money.

It will have to be found and re-purposed from existing budgets, as Health Service Journal's Henry Anderson got our dear chums the Treasury Munchkins to confirm.

It is genuinely remarkable that, as we head into a winter about whose awfulness the only real question is will it be catastrophic or merely appalling, that there is no serious plan to prepare or mitigate the predictable problems.

The Great Resignation

Dr Tiz was also bidding to get people to believe that GP numbers have been "stable".

This is not true.

Health secretary claims GP numbers are ‘stable’

New health secretary Dr Thérèse Coffey has confounded GPs by claiming their numbers have been ‘stable’ since the last general election.

Pulse TodaySofia Lind

The most recent GP workforce data also published by NHS Digital last month showed that the number of fully-qualified full-time equivalent (FTE) GPs continues to fall.

There were 27,507 fully-qualified FTE GPs in July, down from 27,558 the previous month and 27,750 in July last year.

Overall NHS vacancies rose to over 130,000. The Great Resignation, driven to no small extent by the pensions issues, continues unabated.

Time for structural change, argues Lord Lansley's former  special advisor Bill Morgan

It takes some neck to argue that structural reform is needed right now, but dear old Lord Lansley's former special advisor and Incisive Health senior counsel Bill Morgan has a go in this Times opinion piece.

Bill's hypothesis is that physically co-locating NHS England's senior leadership team in the same building with the Department For Health But Social Care would fix problems. It is a bold and entertaining hypothesis.

I like Bill: he's a nice chap. And he correctly identifies the major tensions between ministers (especially under Steve 'The Banker' Barclay, who brought Bill back in to help) and the current NHSE leadership.

Yet some of his argument is demonstrably factually untrue. He claims that the NHSE independence was of an era before the current point when "basic levels of performance — on ambulances, cancer and waiting times — are not being met. These issues, largely but not solely due to the pandemic, rightly invite ministerial attention and require a performance-focused department working hand-in-glove with the NHS".

These issues are not remotely "largely but not solely due to the pandemic". NHS performance on cancer and waiting times have been deteriorating over many years. There is a better case for the collapse in ambulance performance having a big impact from the pandemic, but the RTT waiting list was already 4.4 million in January 2020, before the pandemic hit.

There are well-known issues with the NHSE leadership. It is not unusual to hear senior figures in front-line operational jobs in the NHS complain of insularity and group-think in the NHSE senior management.

Overall, what I hear from contacts is some respect for Amanda Pritchard's having avoided the deepest bear-traps of promising the utterly undeliverable in negotiations with Government and Treasury. It could have been worse.

However, my contacts' experience also suggests that there is not widespread belief across the service nationally that the scale of the current plans for NHS recovery - basically, 'do everything' - will be deliverable. You hear the phrase 'to govern is to choose' a lot.

(The service also understands well that Amanda's period of 'new in post' political immortality is now over. It is less clear that NHS England is alert to the risk that, as NHS performance deteriorates yet further, it will become abolition-prone. NHSE would do well to wake up to this very quickly.)

This is at odds with Bill's contention that "there is belief inside the NHS that the plan to cut waiting times is tough but achievable and the milestones are indeed being met". But then, it's also rather at odds with his own hypothesis that ministers have lost trust in NHSE.

As HSJ chronicles regularly, the money is already off-course in many places.

Bill's argument gets yet more tendentious when he claims that "the NHS has at times overpromised in exchange for more money, and has then blamed external factors for failing to achieve what it said it would do. National targets are habitually missed because there is little belief within the NHS locally they can be met".

This is not the case (indeed, it's basically the 1980s/1990s argument that England men's international football teams play badly because of a lack of "passion"). National targets are not being missed because of a lack of belief, but because of lacks of resources - workforce, capacity and planning skills.

Oh, and social care, more resources for which Amanda's predecessor Simon Stevens continually advocated.

Social care cap - still here

And social care is in crisis, according to those notorious pinkos, erm, the Conservative-led County Councils Network, which represents 36 mainly Tory-run authorities.

“We face the perfect storm of staffing shortages, fewer care beds, and higher costs – all of which will impact on individuals waiting for care and discharges from hospital,” said Martin Tett, the Tory leader of Buckinghamshire council.

The Guardian's Patrick Butler and Pippa Crerar report that "although social care budgets have been under strain for years, the past few months alone have added an extra £1.4 billion to the already hefty funding deficit faced by English councils, according to a new analysis carried out by the network, pushing many services to the edge of viability".

Thank goodness that the Mail reports that, having dumed the Health And Social Care Levy NI increase to pay for things, Team Truss plan to retain the social care cap. Shall we call this Making Inheritances Great Again?  

Workforce

The Guardian reported that two-thirds of GPs in training told a Kings Fund study that they plan to work part-time.

It's also worth reading this powerful comment piece by Andrew Goddard, past President of the Royal College of Physicians.

Quiet, behind-scenes private influence-peddlers in 'fail to realise own utter inefficacy' shock

One must have a heart of stone not to laugh at the finger-wagging bathos of the new document from the splendidly-pointless Academy Of Medical Royal Colleges.

This AOMRC report, 'Fixing The NHS: Why We Must Stop Normalising The Unacceptable', is a masterpiece of far-too-little-far-too-late lobbying.

Its introduction states, without any apparent irony, “collectively, we are not known for vocal campaigns and of necessity much of our work takes place behind the scenes. The ability to be quietly influential is a precious commodity and not something to be given away lightly.”

This document does nothing but repeat what everybody serious has been saying for years: that the health and care system is in crisis. The AOMRC's late realisation of this inescapable fact is not a thing to which a serious organisation would draw people's attention.

The BS hypothesis

The ‘quiet behind-the-scenes influence’ theory among foolish sector leaders in health and care (the BS hypothesis, for short) has been an obvious bust in policy and political terms since the Lansley reforms.

Were that alone not proof enough, the set of failed intercessions during the junior doctors' contract dispute should have made this glaringly obvious, even to the remedially shrewd.

The sector’s tendency to self-censor under the guise of the BS hypothesis is profoundly self-destructive. Long-time policy analyst and former special advisor Tony Hockley rightly notes that politicians love it:

What’s really going on behind the scenes, quietly, is not effective advocacy and lobbying: rather, it is preserving access and perceived status.

It is pitiful that the AOMRC cannot even see that their utter ineffectiveness has played a role in the political ecosystem that has enabled and permitted this crisis.

The Alan comeback

Our Hero promptly scampered into LBC to make some fabulously misleading claims about the pensions tax changes he achieved.

The People's Partridge also told listeners that the Kwarteng Pyromania had "landed well", which is nice.

Obesity strategy reprieve?

Denis Campbell of The Guardian, who last week reported the Truss administration's aim to abolish the Government's obesity strategy, has a further update that the Sugar Tax's introduction as part of a Budget may make its removal complicated.

Towards the Covid19 inquiry

The Guardian's Jessica Elgot points out the farcical conflicts of interest for PR firms used by DHBSC during the pandemic potentially bidding to provide services to the Covid19 inquiry. Marking one's own homework much?

Rosie Cooper MP to step down

One of the Commons' shrewdest and best-informed MPs on NHS and care issues, Rosie Cooper, is stepping down as an MP to become chair of MerseyCare NHS Trust.

Her statement is here.

Recommended and required reading

IT publication The Register reports further delay to the NHS England Federated Data Platform procurement. This article again pre-supposes that Palantir are the candidate in the box seat, and notes the company's hiring of Global Counsel consultant and former NHS England deputy chief Matthew Swindells. (My usual COI declaration: I sit on Palantir's health advisory panel.)

Statistician and NHS waiting list expert George Donald has produced this helpful and interactive NHS workforce data visualisation.

Patient safety advocate and cover-up opponent Minh Alexander has learned from FOI requests that North East Ambulance Service failed to act on legal advice to ensure it complied with coronial legislation to disclose evidence, and vilified its staff who followed the law.

Former SOS and Health Select Committee chair Jeremy Hunt MP has launched a weekly blog for his charity, Patient Safety Watch.

The FT reports that the Novo Nordisk Foundation is to spend $200 million over seven years on superfast quantum computing devices for biomedical research, and will evaluate competing technologies before deciding which of them to green-light.

Now that mourning has broken, we have Julian Patterson's latest HSJ column, and it is magnificent.

Think-tank Reform has a new consultative report on Reimagining Health.

This is an extraordinary advertorial from the Boris Johnson Fanzine, masqurading as a interview with the boss of an imaging firm.

New Chartered Society of Physiotherapy report on rehab services.

Gorgeous Fail idiocy piece about 'broken' primary care.