Cowper’s Cut 248: Whose Chief Nurse is Ruth anyway?

The first RCN members' strike went ahead, and as far as we can yet tell, nobody died as a direct result.

The blame game

The blame game continues, as we head towards the second day of RCN striking, and the ambulance walkouts.

RCN boss Pat Cullen has made few mis-steps so far, but I sense that she and her union need to do more with the data about the fall in NHS staff pay since 2010. This needs to be at the core of every quote.

Health But Social Care Secretary Steve 'The Banker' Barclay continues to refuse to negotiate about pay, hiding behind the independent pay review body which delivered its verdict before the full impact of inflation had hit.

This is in contrast to the view of former health minister and health select committee chair Steve Brine, who told the BBC Radio Four's World At One that "sending it back to the pay review body to have a look would be a sensible answer."

For now, The Banker's boss Rishi 'The Brand' Sunak is backing him, calling the pay award "appropriate and fair". For some context and facts, it's worth reading Delphine Strauss' sensible piece for the Financial Times about the affordability of public sector pay increases.

The battle for public opinion will intensify, as industrial action continues. Ben Page of Ipsos noted that a survey this week had found a fall in public support. Other polls found public support remaining a bit stronger, with this Opinium research for The Observer finding support for nurses at 60%.

Matthew D'Ancona's observations for Tortoise  seem right to me: he suggests that beyond the client media, ultimately, the PM and his Government will end up with the blame.

The question is, more broadly, whose NHS is this anyway? The vast majority of the voting public have no idea of who NHS England are or what it does: the wiring arcana of the system is simply irrelevant to them. They know that they pay their taxes to the Government machinery, and they see the public services that those taxes should fund being degraded.

Who are the public likely to blame for the state of the NHS?

Whose CNO is it anyway?

Chief Nursing Officer Dame Ruth May visited the picket line at St Thomas' Hospital, to show her support for nurses and to urge a resolution of the dispute. Dame Ruth's correspondence with the RCN about derogations during the strikes (which was leaked to The Times: hello, James Lyons!) made this choice slightly surprising, but it's very much the right one. Health Service Journal covered the expansion of derogations.

The Government said that Dame Ruth does not speak for them, which at one level is obviously the case.

At another level, it's at the heart of the issue about NHS leadership and the plan-free nature of the current system.

The 'more Matt Hancock' provisions in the 2022 Act sit alongside the recent aspiration to relocate the senior leadership of NHS England into the same DHBSC offices where ministers and SpAds work.

(This is Bill Morgan's idea from his September Times op-ed, basically. I like Bill, but in that Times piece, he also asserts that "there is belief inside the NHS that the plan to cut waiting times is tough but achievable": this is the polar opposite of my experience.)

In the first place, the need for physical co-location to achieve change speaks of a lack of management capacity and capability by the political leadership that is quite heroic. It suggests that The Banker and co can use neither the Mandate nor the 'more Matt Hancock' powers to intervene: that'll be because they have no ideas of how to improve things.

Or at least, no good ideas, which would be likely to work if implemented correctly.

The Banker is largely spending his time asking the local Integrated Care Systems for organograms. He might as well ask for Bananagrams: they'd probably be more useful.

More broadly, it denotes the fact that nobody whatsoever has a realistic operational plan to deal with the backlog.

This also came through loud and clear this week.

Leaked Kings Fund 2021 report states obvious, is right

In autumn of 2021, someone in the DHBSC had a sudden fit of intellectual honesty and commissioned a report from the Kings Fund on what had worked in the past with cutting waiting times. This report, 'Strategies For Reducing Waiting Times For Elective Care' was leaked and briefed to The Guardian, who splashed with it.

The new report by Nicola Blythe and Shilpa Ross is a useful but predictable canter through points that were, frankly, first and better made in the Kings Fund's 2011 analysis of the New Labour health reforms, edited by Nick Mays. It is supplemented by interviews with 'anonymised' figures from the New Labour era.

This report phrases it's 'we're doomed!' in a bet-hedging manner: "the improvement in waiting times performance of nearly 20 years ago took place in a very different political and economic context; a stable government and strong economic performance meant that the NHS received record levels of investment that could be sustained over a decade.

"It is unlikely that applying individual policy initiatives from the past would be effective today unless shortages of health care staff and physical resources are urgently addressed".

Yep. There is no plan.

Strike out

The strikes are drawing attention to the appalling state of the NHS: The Guardian published a decent long read on this by Andrew Gregory and Denis Campbell.

The bad state of the service has become a double-edged sword: public expectations have been lowered, such that a chaotic, inaccessible and long-waiting environment is normalised.

However, these strikes will make obvious to the voting public what has long been obvious to experts: that neither NHS England nor the political leaders in Government have anything approaching a realistic plan to turn things around.

Speaking of which ...

Health reform

I first observed that Rishi 'The Brand' Sunak's habit of briefing The Times rather unsubtly had become manifest when he was having his rows with Boris Johnson and Sajid Javid about the now-abandoned Health And Social Care Levy to fund the also-now-abandoned social care £85,000 lifetime contribution cap (once it had funded helping to cut the backlog).

The Government's U-turn on, ahem, 'fixing' social care gives us a strong clue of the seriousness of their thinking about public policy. The Levy policy was not about improving social care in any way: it was about protecting inheritances within the families of those with significant wealth.

Charmingly, the PM's latest briefing went to The Spectator's deputy political editor Katy Balls (writing in The Times), rather than The Speccie's political editor James Forsyth (Sunak's friend and best man).

The resulting article on the Tories' comeback plans suggests that Mr Sunak "is sceptical that economic growth will deliver big results for voters by the time of the next election, instead viewing public service reform as more likely to deliver quick results.

"Top of the list is the health service. The NHS has more money and more staff than ever, yet is performing worse ... his allies wondered whether the national insurance rise — to be used to clear the NHS backlog and fund social care — for which he argued to the point of resignation, would highlight to his party the political pain of pretending money was always the solution".

One must have a heart of stone not to laugh at such utter intellectual incoherence. If there is one area which has no track record of delivering quick results, it is health and social care: the Blair reforms cost many billions and took almost a decade. Moreover, the confusion over whether a hypothecated tax rise to fund increased spending shows "the political pain of pretending money was always the solution" is genuinely impressive.

You might think that the article's arguments could get little worse, but you'd be wrong: it bids that "the chancellor, Jeremy Hunt, was the longest-serving Tory health secretary. The health secretary, Steve Barclay, is a former chief secretary to the Treasury and a veteran of funding rows with the NHS. Hunt takes the view that the health service can learn from education, where there is more freedom and less high command. In place of top-down targets, managers should be given more powers to run their hospitals as they like. Sunak believes Michael Gove’s education reforms offer a blueprint for how modernisation rather than more money offers the answer".

Where to even start? With the same Steve 'The Banker' Barclay who, when at the Treasury, refused to approve funding for the Covid19 vaccine roll-out? (Simon Stevens simply went ahead anyway.)

With the tension between The Banker's organogram-obsession and the proposal that the system needs greater devolution of powers?

Magnificently, we learn that PM Sunak's proposal for the new “elective recovery taskforce” to clear the NHS backlog "is modelled on the vaccine taskforce where the public and private sector worked together".

Ahem. Vaccines Taskforce boss Dame Kate Bingham has had a great deal to say about the Government's conduct, and the word "bollocks" was prominent in it.

Dame Kate also noted that Mr Sunak, when then Chancellor, had not had the Vaccines Taskforce on his radar: "the VTF had submitted a business case and initial budget to the Treasury, but when she asked the then Chancellor, Rishi Sunak, why approval had not yet been granted, he “had no idea” what she was referring to"."

Return of The Saj

Sajid Javid: ‘Current NHS model is not sustainable for the future’

In an exclusive interview with Beth Rigby, Mr Javid said radical change was needed and urged the country to have an honest debate about its future.

Sky News

If we want some more dismal Tory ideas about what the NHS needs, who could be better than everyone's favourite Blockbuster ex-SOS in an age of Netflix, Sajid 'The Saj' Javid?

I agree. Nobody.

The Saj told Sky News, "I don’t think the NHS will survive many more years in the way it says on paper it’s supposed to deliver unless we start making fundamental reform."

Right. Because all of the real issues affecting the NHS and social care are about the funding system.

"It’s not going to be ‘let’s give it an extra £5-10 billion’. Whilst that might help at the margin without looking at the model of delivery, I’m afraid it’s not going to make enough difference."

The funding system (you're proposing social insurance) and the delivery model are two utterly different things, The Saj.

“People are queueing for their operations, for their diagnostics, for ambulances, they are queuing for GPs, and I don’t think anyone thinks that’s a sensible way to go forward.”

They weren't queueing significantly before 2010.

The Saj added, "I don't think the model of the NHS as it was set up 70 years ago is sustainable for the future. The world has changed and the NHS has not moved on with that.

"Even before the pandemic, it was heading in that direction because of the changing demography, people living longer, and therefore needing more healthcare, and social care for that matter, new medicines and needing that of course. Everyone rightly wants to get access to new medicines and treatments.

"Also, the changing burden in disease. We have a lot more obese people today, a lot more problems with addictions."

He said nothing about how social insurance funding would help with any of these things.

John Redwood

The finest minds of the Conservative And Unionist Party are all over NHS reform, clearly.

John Redwood's is, too.

It's all about the furniture. Thanks for that, John. IKEA, here we come.

Recruit more people. So beautifully simple. The man's a organisational genius.

Helpfully, he is also a workforce genius:

Alas, John was not paying attention to the longest-serving Health Secretary, Chancellor Jeremy Hunt's November 2020 revelation that our dear chums the Treasury Munchkins are the people impeding NHS workforce planning.

In November 2020, Mr Hunt wrote in his Patient Safety Watch newsletter, "but where is the workforce plan that was supposed to accompany the 10 year plan? Not in the People Plan, as I challenged Prerana Issar about at the Select Committee.

"The truth is the Treasury are refusing to let DHSC publish the projections submitted by NHS England until after the Spending Review (and maybe not even then if they don't agree to fund the necessary training places).

"If you want to see why I smell a rat on this, listen to this non-answer to my question to Matt Hancock on Tuesday."

Productivity

The NHS's failure to increase productivity is at the heart of Tory concerns outlined above, however incoherent and weak their associated reform ideas may be.

Thois issue was again foregrounded in 'NHS Funding, Resources And Treatment Volumes': new research by Max Warner and Ben Zaranko from the The Institute for Fiscal Studies, which was helpfully described by data expert John Burn-Murdoch in this Financial Times piece.

Some of Warner and Zaranko's data is really striking: "the number of A&E arrivals in November was 1% above its pre-pandemic level, and the NHS carried out substantially more GP appointments (4.0% more in the latest month of 2022 data compared with the same month in 2019) and first cancer outpatient appointments (8.6% more).

"The increase in GP appointments is particularly striking, as the number of GPs has fallen while the number of hospital staff has increased".

The authors conclude that "the NHS is delivering substantially less care than it was before the pandemic. And, this exercise almost certainly understates the actual pandemic impact on treatment volumes, because we would in normal times have expected treatment volumes to grow as the population grew larger and older. For example, the number of patients treated from the waiting list in 2019 was 8.4% higher than in 2016, equivalent to 2.7% annual growth in treatment volumes.

"The NHS is treating fewer patients than it was in 2019, but even fewer than we would have expected it to be treating had the pandemic not occurred."

Whew.

Warner and Zaranko hint at the possibility that the withdrawal of goodwill (in the form of unpaid overtime) by NHS staff may be a contributing factor to lower productivity: rightly, they note that (whatever anecdotal data might say) there is no empirical evidence for this.

They also suggest (but cannot definitively conclude) that the loss of more senior and experienced staff may well be another contributing factor. They observe that "it seems clear that the NHS is struggling and that there is no simple, one-size-fits-all explanation or solution. Our analysis suggests that while funding and staffing levels are higher than in the past, the number of beds available for non-COVID-19 treatment is not. Staff undoubtedly feel stretched.

"But it is not obvious that (somehow) adding more staff or money would immediately unclog the system."

They add, "there are some clear signals in the data that NHS hospitals are struggling to discharge patients ... although there are concerns about the quality of delayed discharge data (Discombe, 2022), the latest data suggest that 40% of those still in hospital for more than 21 days are medically ready to be discharged, compared to 34% at the same point last year."

The IFS research's pay-off line is that "to improve NHS productivity in the coming years, it is necessary to know what the largest actual underlying problems are, and not just those that that are the most salient".

Their work does stress the importance of managers and management: a point highlighted in this unusually sensible, well-researched and evidence-based comment piece in The Times by Emma Duncan.

Cronyvirus and coronamillions update

The Mirror reported that the 22nd Earl of Shrewsbury, Charles Henry John Benedict Crofton Chetwynd Chetwynd-Talbot, used his contacts in Parliament to promote a Covid firm that paid him £57,000. The hereditary peer (who lost the Tory whip in October) “clearly” breached the Lords Code of Conduct by “seeking to profit from membership of the House”.

Although the Lords Standards Commissioner ruled he was not “deliberately dishonest”, it concluded that “ignorance is no excuse” and recommended a nine-month suspension.

In a witty move, The Sunday Times parodied its annual Rich List with this summary of the biggest earners from Government PPE contracts.

The Alan comeback

Nothing to report.

Recommended and required reading

Timely Times piece on the cancer backlogs.

The Guardian had this strong piece on medics and comedy.