Cowper’s Cut 239: To Truss - to tie up the legs and wings of a bird before cooking

"Prime Minister Liz Truss allowed a smile to play around the corners of her mouth.

"Leader of the Government, First Lord of the Treasury: everything she touched was going perfectly."

No, sorry: I just can't do it. My contract with The Boris Johnson Fanzine for opinion pieces will have to wait.

It's highly likely that Liz Truss will no longer be the leader of the Conservative And Unionist Party by next weekend (the time I will next be writing this weekly column).

Her entire leadership platform, summarised helpfully in this Public First document, has been binned due to the absolute and very public failure of her mini-Budget.

PM Truss' mandate to lead her party, and therefore the country, is accordingly gone. It is an ex-mandate: it has ceased to mand.

Ms Truss' sacking of her weak pound provider and political soulmate Kwasi Kwarteng as Chancellor, replacing him with Commons Health Select Committee chair and longest-serving Secretary Of State For Health But Social Care Jeremy Hunt, probably won't save her from a Parliamentary and national political party that is evidently no longer lead-able.

(And this is so even were they able to find and elect a leader who did not prove themself blatantly incompetent.)

If you're feeling a bit gloomy, you can cheer yourself up by reading the PM's Sun article for a deeply funny take on her sacking of Kwasi Kwarteng.

'What will Jeremy Hunt do?'

We could, if we wish, play parlour games of analysis about what history suggests that Mr Hunt will do in his second Great Office Of State role.

At present, he is making noises about taking tough decisions and asking every department (including health) to make cuts.

This is, I guess, what you are required to do when you agree to become the Chancellor in these circumstances.

These are the terms of the trade. Even if (or perhaps particularly if) you are basically there in the job as a human shield.

There's just one problem: in meaningful terms, a Hunt Chancellorship probably isn't going to happen.

"When the public gives a verdict on this Government, they will judge us much more on what happens in the next 18 months than on these 18 days", Mr Hunt told the BBC's political editor Laura Kuenssberg.

Mmmmmmmmmm.

We'll see, but I hope for Mr Hunt's sake that he will be regarded as highly as an ex-Chancellor (the Government's fourth in four months) as he has become as an ex-Health Secretary.

Will Mr Hunt's willingness to serve The Truss Supremacy stand him in good stead with a party whose MPs ejected him from the leadership contest at the first deliberative stage?

Only time will tell, but the current Parliamentary party's record for gratitude - let alone rationality - is not strong.

The £60 billion pound man

Among Mr Hunt's problems is that objective analysis by the Institute for Fiscal Studies suggests a financial hole in the mini-Budget fiscal plans of £60 billion: one that he will have to fill with tax rises, or spending cuts.

The new Chancellor can cosplay the 'tough-guy' all he wants in media interviews, as his former mentor George Osborne did over austerity. But come Halloween, Mr Hunt will (if still in post) have to credibly make significant tax rises; spending cuts; or more probably, do both.

The bond and currency markets will look at Mr Hunt's words this weekend, but they will be most attentive to (and thus wary of) his actions. Media briefings will not cut it: they will want to see what he does.

So realistically, both the pound and gilts are likely to start paying a significant uncertainty premium once the markets open.

Nothing left to cut

Here is Mr Hunt's major problem with making further 'efficiency savings'.

A decade of austerity has left very little to cut that will not be a) immediately obvious to voters, and b) wildly unpopular to the same; as well as to the health and care producer interests, whom voters demonstrably trust.

The breaking of social care, due to the huge 2010-19 cuts to local government funding, is a huge contributory factor to the current troubles of an NHS that cannot get its main user base of frail older people out of hospitals in a timely way. This is driving our huge current problems with admissions and A&E/ambulance handovers.

UK interest rates are rising faster than even inflationary pressures was making them rise, due directly to last week's chaotic and reversed mini-Budget: this makes the required income tax rises to help fill the Government's self-inflicted hole almost impossible.

The Institute for Government's Nick Davies rightly pointed this out.

He is spot-on. Their new Performance Tracker is a must-read.

The £20 billion 'Nicholson Challenge' (named by then-Health Select Committee chair Stephen Dorrell for then-NHS Commissioning Board CE David Nicholson) was mostly achieved by many years of NHS wage restraint.

That is evidently not a goer in an NHS with over 130,000 full-time vacancies in late 2022.

So how are the finances going currently?

I'm glad you asked. NHS finances have become a hotly-discussed topic.

And that is, as ever, Not A Good Sign.

There have been significant discussions throughout the service on the issue of finance. NHS England's Pope Amanda Pritchard told service CEs that the state of the money is "fucking shit", Health Service Journal reported.

These frank leaked messages have not, however, been going down terribly well.

People in the service leading ICSs are expressing concern about being verbally asked by NHS England regional teams to blatantly mis-represent the position of their organisations' finances. This would by no means be the first time that this has happened, as longstanding observers know.

NHSE boss Amanda Pritchard told Shaun Lintern in her first major national news interview to promote new community falls and respiratory hubs services (which are to be staffed how, exactly?) that “transparency is good”, calling for a “culture that seeks to know and doesn’t try to hide away from bad news.

"The fundamental learning from things like the [Shrewsbury and Telford maternity scandal] is that these are highly toxic environments where things have gone horribly wrong, but it could happen anywhere. We have to show by the way that we behave that we are expecting organisations to take action, but I start by expecting them to be non-defensive.”

Mmmmmmm.

Some people who've been around the block a few times (and are non-exaggeration-prone) say that the NHSE back-channels suggestions - that this is all about current transparency of how bad things really are - don't accurately represent what they are experiencing.

This mis-match seems like a basic, if important, fuck-up.

Pritchard also told participants that “we must not collude with defeatism” which the multiple pressures facing the system might engender, urging local bosses to seek out “marginal gains” from improvement programmes, HSJ reported.

There is also some post-Covid slack to mis-represent in-year finances, as HSJ pointed out back in September.

Even allowing for this, I've heard discussions about a figure significantly above the £12 billion efficiency savings that the NHS promises DHBSC.

I have been told that NHS England modelling reports that a £14 billion overspend in 2022-23 is considered a feasible worst-case scenario.

HSJ editor Alastair McLellan's editorial on how the service might bid for more funds is a strong read. Events, of course, have overtaken it somewhat (as no doubt they will do to this column later today).

Performance: surely that's going OK?

With grinding predictability, the RTT backlog soared by double its long-habitual 100,000 a month, doubling that to go past seven million in the August data. 387,257 patients were waiting more than 52 weeks, and 2,646 patients were waiting more than 104 weeks.

Just as tellingly for fans of nice, big round numbers, the latest ERIC figure for the capital and maintenance backlog rose past £10 million. This is an 11% increase on the 2020-21 data.

This isn't all: FOI work by New Civil Engineer further confirmed the enormous cost of replacing all the vulnerable RAAC roof technology in NHS hospitals.  

What doesn't go up must come down

But hang on: surely post-pandemic, NHS capacity is meant to rise by 30% by 2024-5, by an unspecified set of mechanisms?

Who among us could forget that NHS England's ambitions are "that the waits of longer than a year for elective care are eliminated by March 2025 ... by July 2022, no one will wait longer than two years.

"We will aim to eliminate waits of over 18 months by April 2023, and of over 65 weeks by March 2024".

How splendid!

Returning to the real world, we find that BBC News research reveals that NHS capacity has in fact gone down by 12%.

"Dr Tiz - hey! Dr Tiz!"

So, Dr Therese Coffey, Deputy PM and Secretary Of State For Health But Social Care will be on it like Gromit, right?

Ahem.

Dr Tiz has certainly been busy ... telling Nursing Notes that nurses can leave to go and work overseas for better terms and conditions if they want: “it is their choice of course if they want to do that, but then we also have an open route for people to come into this country who are professional staff”.

A peerless bedside manner, I'm sure you'll agree.

And she's in such a strong position to piss the professions off, too.

I mean, virtually nobody in the trade saw the BMA survey suggesting that almost half of hospital consultants are considering leaving the NHS in 2023.

Helpfully, the Nuffield Trust this week updated their thorough piece on the NHS workforce numbers.

Yeah, but Dr Tiz's priorities?

The Drugs Don't Work (Dr Tiz remix)

Dr Tiz chose this week to tell the Boris Johnson Fanzine that, following her rejection of the anti-smoking and anti-obesity strategies, she will now liberate antibiotic prescription.

This plan, and its impact on the global issue of antimicrobial resistance, did not land well among members of the arse-elbow-differentiating community.

An actual professor of microbiology took time out of his busy day to try to educate Dr Tiz about just how stupid a plan this was:

Team Dr Tiz are also allegedly looking at the hot-button topic of hospital parking.

It's all going tremendously well.

The Johnson Government culture

I wrote extensively in these columns past about the dysfunction of the Downing Street culture and practices in Boris Johnson's administration: Dame Kate Bingham's latest interview with The Times to promote her book is even more starkly clear about this.

“I wasn’t allowed to brief the opposition, so it was being politicised, even though it shouldn’t have been,” she told the paper. “If you are getting vaccines to help the vulnerable not get really seriously sick and die, it doesn’t matter what walk of life you come from, or who you vote for, that is a national issue. And that is what was missing. Everything was seen through a political lens.”

The Dame delivered, and the Johnson Government tried to shaft her.

Bingham's view on how PM Truss would handle a pandemic? “I’ve switched off. The current chaos is all political.”

Your reminder that Liz Truss was a Cabinet Minister throughout that time.

The Alan comeback

The People's Partridge was on the BBC's Laura Kuenssberg Show, laying down three conditions for PM Truss' survival.

Bless! A mere week and two days after he told LBC that he thought the mini-Budget had "landed pretty well".

Alan is a deity. We are not truly worthy of his greatness.

Recommended and required reading

The Guardian was leaked the report into bullying, sexism and discrimination in the Royal College of Nursing senior leadership.

'The Positive Professor', Karol Sikora, talking nonsense in the Mail about why his Rutherford Health business tanked? Colour me surprised.

Dame Kate Bingham 's book launch Telegraph interview is also eye-opening

The Health Foundation’s analysis finds that by the second quarter of 2022, 200,000 older workers (age 50–69) had left employment due to ill-health since the start of the pandemic: the biggest contributor to the recent rise in economic inactivity for that group.

The state of the adult social care sector and workforce in England 2022 report has been published.

New Nuffield Trust/QualityWatch analysis on the causes of delayed discharges from hospitals

Probable federated data platform bidder Palantir (COI declaration: on whose health advisory panel I sit) has U-turned on proposals to alter pension arrangements for its UK staff, following a backlash, the FT reports.

Disgraced fomer Randox lobbyist and former MP Owen Paterson may be fined £7,500 for his undeclared lobbying.