Cowper’s Cut 256: Everything you know may be wrong

The Government's line on the NHS strikes this week is as intriguing as it is intransigent. And at the time of writing, it is very intransigent.

What happens next with the strikes is interesting.

Sunk cost, Treasury Brain and Thatcher cosplay

The Government's position is defined by a cocktail of the 'sunk cost' fallacy (just as true of the trades unions); a chronic case of Treasury Brain (price-knowing-value-ignorant remix); and Thatcher Cosplay - a desire to be being seen to be tough. What a surprise to see the latter prevalent, in the week of a Liz 'The Lettuce' Truss comeback.

Monday morning's Government line for the media round (astonishingly, echoed to perfection in that day's Boris Johnson Fanzine and Mail op-eds) was that 'if the nurses/ambulancefolk/whoever really heart the NHS, they'll call off the strike'. It's a niche line to take, and one that highlights quite how long a time it is since a government's had to deal with a major industrial dispute.

Among the group which still support the Government passionately is a majority of the national media. You would expect there to be a plethora of 'The Government Must Hold Firm!' articles this week: nor were we disappointed.

And on the staff side? Opinion polling data suggests that public support remains firmly with the health staff/trades unions. This isn't surprising: Ipsos' long-running Veracity Index still finds medical staff poll very highly on public trust, and politicians rate very low. (And, yes, journalists rate very low too.)

In a belated hit of common sense, the RCN leadership appear to have shown some willingness to move from demanding a 19% settlement that they were never going to get. The RCN leadership probably now need, in the words of health policy guru (and Zoe's dad) Johnny Ball, to 'Think Of A Number': the Wales deal might help with this.

Another are where the workforce should think is the role of discretionary effort. The NHS probably used to partly run on this, but over the past decade-plus of the annualisation of winter and the permanence of workforce shortages, I'd say that it's been gradually, quietly withdrawn.

I absolutely think that removing discretionary effort is the right (though difficult) thing to do, by the way. No system can be run, planned or managed on the basis of that intangible and uncertain element.

The down-side of this is that once the system has become accustomed to staff mainly leaving work when their shift ends, escalating industrial action becomes harder. Working to rule, or refusing overtime, is (as train drivers have shown) an effective tool to ramp up pressure.

Among the first rules of effective campaigning is that your opponents need to be hurting on a regular and very public basis. It feels as if the RCN and its fellow trades unions need to do some more thinking about this.

The position that the RCN have reached is to brief the BBC thay they will escalate strike action. This tellingly-unbylined BBC News report states that "a Royal College of Nursing source said NHS leaders are "fearing this escalation" and "must bring pressure to bear on government to get it stopped".

The BBC News piece also correctly notes that "the union would have to give two weeks' notice for any action. Dates have not yet been set, it is understood, but could be announced within days."

Urgent Question on Monday

The Government's revealed preference in handling the strikes over recent weeks has been to designate Health Minister Will Quince (who sounds like a character from A Midsummer Night's Dream) as Minister For Awkwardness And Stuff.

Quince was the face of the last round of 'negotiations' with the trades unions, and was sent to the Despatch Box to answer Labour's Urgent Question on resolving the strikes. He bid that "about 88,000 procedures or outpatient appointments have been postponed as a result of industrial action over the last eight weeks, so I am disappointed and concerned that patients are facing disruption once again, especially because strikes by Royal College of Nursing members have now come together with action by GMB and Unite members in eight ambulance trusts.

"I recognise that there have been efforts on behalf of unions to ensure that derogations are in place to keep people safe, and I acknowledge that some aspects of that can indeed be challenging, but it is essential that all unions adhere to a set of derogations at a national level so that we can plan and act with certainty."

In a festival of non sequiturs, Quince continued, "both staff and the public should no longer be in this situation, because we all know that industrial action is in nobody’s best interests, especially given the collective challenges we face to help the NHS recover from the pandemic." At some point, a classical scholar should sit the Minister down and explain to him the difference between post hoc and propter hoc, not to mention Occam's Razor.

Noting that "there has not been a single minute of negotiation on pay", Labour's Wes Streeting set the cat among the pigeons in his reply, by openly discussing Chancellor Jeremy Hunt's briefing war with Health But Social Care Secretary Steve 'The Banker' Barclay: "perhaps the Health Secretary is busy briefing against the Chancellor, just as the Chancellor is busy briefing against him. All the while, the Prime Minister is too weak to do anything about it."

It is notable that Quince did not deny the briefing battle between the Chancellor and his boss.

Jane Merrick of i news has been given unattributable briefing from unions and Government, but it amounts to nothing more than hoping that a pause in the strikes will lead to actual negotiations and some kind of miraculous breakthrough. Mmmmmm. As I wrote last week, optimism is not a plan.

Might there be just a hint of movement in Chancellor Jeremy Hunt's interview comment to Sky News' Paul Kelso on Friday, as economic data showed that the UK (probably) avoided recession?

Asked what he'd say to striking public sector workers, the Chancellor said, "we’ll talk about absolutely anything to resolve these strikes – except measures that will entrench high inflation ... we think the best way to resolve these issues is to sit and talk and find a solution which doesn’t entrench the very inflation that is upsetting so many people."

Asked if this was a “no” to more money, Mr Hunt replied, "it’s not a no, it’s saying we’ll talk about absolutely anything, except things that will dig in the very high inflation that is causing people to see the cost of their weekly shop go up and the value of their wages erode."

Performance, finance and the backlog

The latest NHS England data showed some improvements, although also a small further increase to the total RTT backlog, rising back up to 7.2 million. Specifically, urgent and emergency care saw welcome improvements, with shorter waiting times at A&E and for ambulances. The number of emergency care attendances dropped by 14% but remain close to 2 million.

The latest NHS England board paper on finance has some key points. The overspend is evident, although its size is uncertain: "systems have overspent against plan by £870 million for the first eight months of the year ... the majority of systems are forecasting that these overspends will be recovered in the latter months of the year resulting in a forecast position in line with plan.

"... A number of systems are currently formally reviewing their forecasts and as a result we expect that systems will report total overspends against their plans of around £500 million by year-end."

What a surprise to see that capital budgets are taking a hit: "to month 8, providers have spent £2,602 million in Capital Departmental Expenditure Limit (CDEL) terms (excluding IFRS 16 expenditure). This represents 35% of the full year budget. This compares to 39% at the same stage in 21/22. Primary care spend was £25m meaning total CDEL spend was £2,627m to month 8.

"Based on provider and commissioner reports at Month 8 we are currently forecasting expenditure to be £314 million below the CDEL allocation for the year." Good old underspending on capital budgets: what could conceivably go wrong?

So NHSE calculate that this capital underspend, plus their recruitment freeze (and no doubt a few other wheezes), will prevent the DEL from being breached.  This might work, if the year-end position in local health systems doesn't appreciably worsen. Which it might.

NHSE tries to 'comms it' with a re-brand

Last week's sermon was (in part) a warning of the 'comms-ing it' approach to things. I might as well have saved my words, as a fascinating story from Health Service Journal editor Alastair McLellan highlights.

NHS England is going to have a comms 'glow-up' and makeover.

Branding agency Thompson has been hired to help everybody's favourite national regulator and wholly-owned subsidiary of the Department Health But Social Care to "cultivate the right personality" as an "empowering coach-like leader", in part to "rebuild lost trust" with the service.

No, really.

NHSE has hired in Thompson to help “position” its “future role” and put forward a “central narrative” and “messaging framework” for the “new NHS England”.

I initially wondered if an editorial mix-up at HSJ had put Alastair's byline onto Julian Patterson's latest comic genius. Then I checked that it wasn't 1st April.

Apparently not.

Because of course, the problem with NHS England is the branding and the comms.

Of course it is. Not the consistently laughable behaviour, nor the demanding of surreal pledges of financial balance. Nor the pledge to hit 130% of pre-pandemic activity, divorced from any idea of how.

No: the problem is the branding and the comms.

This is a perfect example of Cowper’s PR Fallacy, whereby a depressingly large number of individuals and organisations believe that they are the sum of the things that they say about themselves.

This is wrong. The things that you say about yourself are just public relations.

You are what you consistently do.

Towards self-reflection with NHS England

This re-branding exercise has really triggered some people: I've been getting a lot more emails, WhatsApps and Twitter Direct Messages from contacts and strangers across the service than usual.

The lack of meaningful NHSE self-reflection as to why the current leadership team has lost the trust of the dressing room is almost, but not quite, impressive.

It comes on the heels of the emerging 2022-23 overspend, which is is central to the prevalent bad atmosphere. ICSs have been, erm, 'encouraged' by NHSE regional teams to submit wildly unrealistic forecasts of year-end financial position. I thought we learned that this doesn't work all the way back in 2006.

I've also been hearing A Lot Of Complaints about highly tokenistic front-line 'visits' from the NHSE SMT. I've been sent this link a lot.

The NHSE senior management team's absorption into the Department For Health But Social Care? The Borg? The Collective? You might think that (and quite a lot of my correspondents clearly do): I couldn't possibly comment.

Now on one level, you can understand this. The 'more Matt Hancock' reforms in the 2022 Act really ended NHSE autonomy in any meaningful way.

At another level, NHSE's SMT do not appear to be sighted on the massive opportunity they've created for the Government to blame them for the NHS's failure to miraculously recover.

It's a frightening thought that the NHSE leadership might actually believe that by being 'collegiate' (i.e. loyal) with The Banker and company, the result is that they won't get shat on should that become politically expedient.

Mmmmmmmmmm. If you want loyalty, get a dog.

Because it is now politically expedient for the Government to blame the NHS. 'You've had all the extra money, so where's the improvement?' couldn't be any more obviously on the way. So NHSE leaders must expect it to happen, and prepare accordingly ... oh.

NHS England » Amanda Pritchard’s response to the autumn statement

NHS EnglandNHS England

The Great Restructuring (of NHSE)

A good row about NHS England was probably inevitable, in advance of Thursday's announcement of The Great Internal Restructuring.

These internal announcements about the money-saving restructuring plans (which will in time affect NHSE/HEE/NHSD/NHS Kiss/Old Uncle Tom Cobbley And All) do not strongly suggest that NHSE's leadership have developed a clear view of the unique contribution that they want Neo-NHSE to make within the health and care system.

Fellow transparency fans will be entertained that the NHSE powers-that-believe-they-be have finally realised that this restructure would promptly be leaked, and so put each separate directorate's plan on a separate password-coded internet microsite. This makes it impossible to screenshot the new orgasmatron - sorry, organogram - which I'm sure will give Steve 'The Banker' Barclay nightmares. Or kittens. Maybe nightmare kittens.

Nonetheless, it's quite funny how many sub-teams in certain directorates are set to grow in number.

And as the people affected start absorbing what lies in store for them, we can safely expect that greater levels of back-door transparency about NHSE's past and present deeds and misdeeds will emerge. NHSE board members who worry about this sort of thing (hello, Chris!) should just think of it as a de facto unofficial FOI spree.

IFS backlog report

The latest NHS backlog report from Ben Zaranko and Max Warner of the Institute for Fiscal Studies presents helpful analysis and modelling of the waiting list data.

The IFS report rightly credits the (very near) achievement of the two-year maximum waiting target, and suggests that on the current trajectory, the 18-month maximum may also be achieved.

The report notes that "the ambition is to increase treatment volumes to 30% above pre-pandemic levels by 2024–25. As it stands, our judgement is that this is highly unlikely to be achieved – not least due to the lingering effects of COVID-19 and other pressures on the system. As a result, waiting lists are – in our view – unlikely to start falling rapidly any time soon.

"Instead, our central expectation is that waiting lists will more or less flatline over the next year, and fall only gradually from mid-2024."

The report notes that "more concerningly, there has been little sign of a surge in elective treatment volumes, which puts at risk the headline ambition to increase elective activity levels by 30% above pre-pandemic levels, and makes the next round of long-waiter targets more difficult to achieve."

Stuck Outside The Treasury With The Pension Blues Again

At the launch of this IFS report, I asked NHS England national director and Northumbria Healthcare CE Sir Jim Mackey about the impact of the pensions taper tax and annual allowance disincentives on experienced senior NHS staff's willingness to work extra elective backlog sessions in NHS hospitals in evenings and weekends.

Longstanding readers already know that this was how the bulk of the 2000s backlog was cleared.

Mackey said, "that does make people hesitant about doing something, then tripping over a barrier and then getting a big tax bill. It's a natural thing to feel very anxious about.

"I remember speaking to clinicians who were getting bills of thirty, forty, fifty thousand pounds, having to think about whether they have to sell their house to be able to pay their tax." No shit. But Mackey was clear that he doesn't expect our beloved amigos The Treasury Munchkins to change their adorable little minds on this issue.

It was consequently unsurprising to see this Observer FOI piece covering how senior clinicians have developed an 'insourcing' private provision model, which will have the effect of removing earnings from that specific disincentive.

Off your block

Sir James also addressed the role of the change away from block contracts back to Payment By Results, answering HSJ's James Illman: "it’s a painful transition [from block contracts on to payment by results, and] we will have to iron some wrinkles out before it goes live. That’s a live conversation around that. But we have to recognise that we need to do more work, we need to be more productive, we need to get the transition out of the old world."

Addressing concerns that trusts could cease treating patients from commissioning bodies that have already hit their activity targets (as incentive funding may already have been used, Sir Jim said: “The idea that an FD (a) would have that much control and (b) anyone would listen to him or her if they said to clinicians ‘don’t see those patients because we’re not going to get paid… [is] absolute nonsense … there is an argument that block arrangements contributed to a loss of productivity. That is something we need to confront”.

Prerana Issar hearing

Appointed by everybody's favourite noble Baroness Dido Harding, Prerana Issar talked a very good game about the importance and value of the NHS workforce. Her delivery was somewhat less impressive, and stories about her inability to get on with her colleagues in NHS England (not to mention rows about having a physically big office) were legion.

One of the workforce tribunals involving allegations of misconduct against Ms Issar (whowas technically still an NHS employee until February 2022, signed off with long Covid) has just concluded, and Nick Kituno of HSJ has covered its events.

Judgment is expected in the spring.

Consultancy spree

Last week's column covered the abolition of 'Crown Consultancy', the in-house effort by the Government. As I predicted, the consequence is going to be jolly good for the Big Four (and who can say, for any former ministers heading towards the shiny revolving door).

The Guardian revealed this week that at the end of January, ministers quietly dropped restrictions introduced by former PM David Cameron on Big Four and suchlike management consultancy spending controls. This will inevitably allow Whitehall departments (and indeed) ALBs to spend millions more on external consultants.

Spin like a Big Four Door!

Recommended and required reading

The second part of the Financial Times' NHS 75th anniversary piece served to remind me that the utterly un-transparent NHS Assembly still exists. Why?

"At the moment, I’m a bit worried about the lack of space and it’s only 9 am.” Very good piece of reality-based journalism in The Times about the A&E crisis at The Royal London. This is ugly stuff: “it’s distressing for the mental health patients because they’re not getting their treatments. The longer they are here in this environment, the longer they are at risk. It compromises patient care. Unfortunately this has been normal for a long time in a lot of other places, but it’s a new normal for us here.”

The Institute for Fiscal Studies' podcast on the current state of the NHS is thorough and thoughtful.

Judith Smith and Ruth Thorlby reflect on the ten years since the publication of the Francis Report of the public inquiry into Mid-Staffordshire NHS Foundation Trust. What progress has been made (or not) by the NHS?

One the above topic, Shaun Lintern interviewed Sir Robert Francis about what has or hasn't changed since his report. Fascinatingly, the Times and Sunday Times did not run this.

The Daily Mail being bemused by capitalism (here, over GP salaries, which are - shock horror! - higher elsewhere in Europe) is never not funny. It's almost as if there were a free market in operation.

The Life Sciences Exit continues, with AstraZeneca announcing that they will shift plans for a $360 million investment in a new manufacturing facility from Britain to Ireland, due to tax changes.

New report from think-tank Reform on 'The A&E crisis: what’s really driving poor performance?' basically goes over ground well covered here by Monitor in, erm, September 2015.

Of much higher value, a fascinating transcript of a Reform event with two senior civil servants on why the civil service can be so poor. Key quote: "what we've witnessed is a steady degradation of the authority of the Civil Service: the authority of the Civil Service in the interactions with ministers it sort of granted us. It's sort of the status within the constitutional framework that's unwritten constitution, clearly. So this is a thing about perception rather than changing statute, the rules. But over time, I think the place that the Civil Service has in the running of the country has diminished."

Staggering Boris Johnson Fanzine story about French paedophile doctor Joel Le Scouarnec, to whose activities health authorities turned a blind eye, despite an FBI tip-off in 2006.

Sunday Times previews a new book on the scandalous care delivery of the gender identity development service at the Tavistock and Portman.

Striking preview of a film adaptation of Alan Bennett's play 'Alleluia', set in an NHS geriatric ward.