Cowper’s Cut 263: Warming to Steve Barclay

The NHS has allegedly "warmed to Steve Barclay".

Has it?

Really?

Climate change is having all sorts of odd effects, but nobody at all has noticed this one, other than Matthew Taylor, NHS Confederation chief executive, writing in Health Service Journal.

This may not be unconnected to that organisation's attempts to get The Banker to confirm a speaking appearance at NHS ConfedExpo in June.

More money

The Banker's quite the man of the moment, fiscally speaking.

Mr Barclay issued a statement that “I’m working with the Treasury to ensure my department has the money it needs to fully fund this pay offer, which will include additional funding and reprioritising existing budgets.”

“I want to be clear – there will be no impact to frontline services or quality of care as a result of this offer.”

Possibly irked by Mr Barclay's briefing campaign, Chancellor Jeremy Hunt confirmed to The Guardian that the Treasury will find some extra money from elsewhere, but the NHS will have to make efficiency savings too.

I'm not saying that Jeremy Hunt might be getting a bit weary with The Banker's repeated, unsubtle briefing of the media on the workforce plan and finance stuff, but a wry smile would play around the corners of my well-chiselled features if the Chancellor were to announce that he's speaking at ConfedExpo.

HSJ's Henry Anderson spotted that Mr Hunt told Wednesday's Treasury select committee that "in exceptional circumstances there can be a discussion" about extra NHS funding: "this is a different situation because inflation was so much higher ... the commitment we've made is that there is no reduction in frontline services.

"Efficiency savings and reprioritisation are very important", the Chancellor who, as Health Secretary, oversaw over half a decade of health and care austerity added, citing the need to be "responsible with public finances".

The Chancellor also asserted that having done a tax-unregistered scheme for NHS staff (as was done for senior judges) would have been "more regressive" and would have cost "potentially as much" as abolishing the lifetime allowance (which now allows multi-millionaires to pass huge sums on and avoid inheritance tax).

The junior doctors' strike

The answers given by Mr Barclay to Labour's Urgent Question in the Commons on Thursday morning made it seem highly likely that these strikes will go ahead as planned.

The Banker told the House that "the BMA’s junior doctors committee’s refusal to engage in conversations unless we commit to delivering a 35% pay increase is unacceptable at a time of considerable economic pressure and suggests a leadership that is adopting a militant position, rather than working constructively with the Government in the interests of patients".

The Banker also repeatedly insisted that the 35% demand was a starting precondition, despite the published statement by the JDC that this is untrue.

And so the slanging match continues ... and then perhaps abates, with another exchange of letters.

The Times seems to be the Government's political strategy over the junior doctors' strikes: it ran an obviously-briefed article about the BMA JDC leaders' negotiating strategies. The piece was lightly amusing on the techniques (WhatsApp messages and Post-It notes passed between negotiators), but it seems unlikely that this process story will move the dial of public opinion.

Its hyperbolic opening line ("The future of the NHS was on the table but across it, facing the health secretary, were scenes bordering on farce") rather undermines the authors' attempts to undermine the lefty tendency currently leading the BMA. But then, you have to be magnificently inexperienced and incurious to fail to find out that having very left-wing people on the BMA Council is Not A New Thing.

The newspaper of record also ran a plea for negotiations to avert the strike from NHS Confed boss Matthew Taylor.

Another obviously briefed Times piece about the PM's and Government's broader political strategy promised/threatened that “policy-wise, the second quarter of the year will feature a huge push on the NHS backlog, with a primary care plan and then a workforce plan a bit later, attempting to bring the same details-focused governance to one of his five top priorities as he (PM Rishi 'The Brand' Sunak) did to the Brexit and illegal migration issues”.

Mmmm. If not mmmmmmmmmmm. This mention of the NHS workforce plan coming “a bit later” is confirmation that our beloved besties, the Treasury Munchkins, are still stalling it.

A money and numbers game

Another parallel battle of the narrative was joined this week: this one being for NHS England's failure to oversee successful delivery of their plans for cutting the RTT backlog has begun.

The New Hopson Programme (also fictional)

NHS England Director of Being Inside The Tent Pissing Out - sorry, I mean of Strategy - Chris Hopson asserted that the system was on target to eliminate 18-month waiters by April 2023. He told the BBC Radio 4 Today programme of the target that the NHS in England "were on target to hit that in April ... if you looked at where we wanted to be in December, we were absolutely on course. But ... we had to reschedule 175,000 appointments as a result of the latest junior doctors’ strike and we’re currently heading for a four-day strike in a fortnight’s time".

Hopson's assertion here is not quite correct, as Health Service Journal's James Illman points out.

What has been achieved is a very significant reduction of the longest bits of the RTT backlog: the number of 18-month waiters peaked at about 125,000 in September 2021, and it currently stands at about 11,000. This is a significant achievement - as was the reduction of two-year waiters by August 2022 "to just 2,777, despite COVID and other pressures, of whom 1,579 opted to defer treatment and 1,030 are very complex cases, as set out in the plan", to quote NHSE's own press release.

Their latest missive tells us that "the number of patients waiting more than 18 months for care has fallen by more than four -fifths since the peak". This release also highlights reductions in the deterioration of cancer care: "the number of people waiting longer than 62 days since their cancer referral has also reduced significantly with 4,868 fewer people waiting last week (19,027 on 19 March) compared to just one month ago (23,874 on 19 Feb) and 14,923 fewer people since September (33,950 on 19 Sep)".

There are a selection of promising one-line summaries of good practice achievements below this press release, which very much do not amount to 'case studies', as they are misleadingly labelled. Julian Patterson's HSJ column takedown of The New Hopson Programme is a delight.

Virtual reality

But the pledge was to 'eliminate' these waiters. Neither has been achieved. Mr Hopson's explanation that the reason for the second miss is the industrial action is frankly, mostly misdirection.

James wrote about the risk that the 18-week target would be missed in HSJ last July. His conclusion is stark: "pre-Covid, there were around 1,500 patients who had over waited 52 weeks on NHS. This was considered an AWFUL situation.

"So, to have 11,000 78-week waiters is a HUGE number, and has massive patient safety consequences".

The 40 or 48 New (If Fictional) Hospitals Programme

Payers of attention (which is all 'Cut' readers, naturally) will recall that the 40 new if fictional hospitals saw a hearty dose of rhetorical inflation, when the promised 40 became 48.

DHBSC and ministers promised us "a further 8 new hospitals to deliver on our commitment to fund and build a total of 40 new hospitals by 2030". Their promise-document states that "we aim to make a final decision in spring 2022".  It is of course now spring 2023, as Labour's health lead Wes Streeting noticed, tabling a Parliamentary Question about when the next fictional eight will be named.

Health minister Will Quince disappoints us, with this timescale of "in due course". Surely if you're going to prevaricate, it should be done with a certain elegance and style: "in the fullness of time" would have been so much better.

Would it be mischievous, by the way, to point out that Jeremy Hunt's fundraising for his local hospital might not inspire the greatest faith in the New If Fictional Hospitals Programme? It is for a scheme that seems to be leaning fairly heavily on the Royal Surrey Charity, and it clearly isn't one of the Fictional Forty.

Poll tacks

I'm not sure who first used the line 'opinion polls are like aftershaves: good to smell briefly, but you don't want to drink them'. I wish it had been me: it's a good 'un. (Perhaps it will become one of mine, in the future.)

The analysis and data from the latest health questions of the NatCen British Social Attitudes survey were released, and to the considerable surprise of absolutely nobody, the population is majorly dissatisfied with their experiences of the NHS.

29% of respondents surveyed declared themselves satisfied with the NHS (in 2010, this was at the all-time high of 70%). This was a drop of 7 percentage points from the data released in 2022, and the fourth largest year-on-year drop ever recorded.

Over two-thirds of respondents cited long waiting times for GP and hospital appointments as one of their top reasons for dissatisfaction. 55% felt staff shortages were to blame: 50% per cent suggested that the Government underfunded the NHS.

Unsurprisingly, given the past few months, 40% said they were dissatisfied with A&E: this was both a record high, an increase of 11 percentage points from the responses published last year.

This does not mean that they feel the concept of a universal, tax-funded health service is at fault: 90% of respondents said the NHS should be “free of charge when you need it”, and more than 80% believed it should be available to everyone and mainly funded through tax.

Dan Wellings, senior fellow at the BSA health questions' co-sponsor The King’s Fund, noted that “the public can see for themselves the results of more than a decade of underfunding and a lack of workforce planning”.

YouGov's latest polling of public opinion on progress with Rishi 'The Brand' Sunak's five pledges is instructive. On the pledge that 'NHS waiting lists will fall and people will get the care they need more quickly', 83% of those surveyed replied that the Government are doing a bad job (including 56% who say they are doing a very bad job): this total was 82% in a YouGov survey at the start of March.

More than three-quarters (76%) of those who backed the Tories in 2019 think the government is handling NHS waiting lists badly.

It's almost as if just announcing policy stuff and briefing the media on your plans doesn't achieve anything tangible that the public notice. Who knew?

Workforce matters

For a man who at one point wasn't asking for an NHS workforce projection plan/report, and who told The Spectator Health Summit that AI and robots could do lots of stuff, Steve 'The Banker' Barclay sure is leaking the hell out of a fairly recent draft of NHS England's efforts.

Barclay's whole speech to last November's NHS Providers conference made zero mention of the workforce plan. Nor did The Banker mention it once in his contribution to December's Commons debate on the NHS workforce: a curious omission.

The Banker's dropping a recent draft of the NHSE workforce plan to The Guardian's Denis Campbell sees the paper report that "the health service is already operating with 154,000 fewer full-time staff than it needs, and that number could balloon to 571,000 staff by 2036 on current trends".

Ahem. Denis does not point out that the 571,000 figure would be a 'if nothing is done' scenario. NHS workforce strategy is spectacularly far from a triumph, but nothing is not being done.

The piece also notes that "spending on bank and agency staff has risen by 51% and 26% respectively since 2020".

Steve Black offers characteristically on-point comments in this Twitter thread, observing that "since 2019 the NHS has added a lot more clinical staff (10-15% more) but seen lower output (productivity estimates suggest a 25% fall!). To number of workers, empirically at least, isn't the core problem ...

"We know from other internal analysis that more staff in some areas make no contribution to output or performance, e.g. more A&E staff have not stemmed performance declines ... there is no relationship at all between staffing levels and performance in A&E".

Former health special advisor Tony Hockley points us to his 2021 Politeia piece on 'The long, dark shadow of NHS workforce planning'.

Value for euros, pesos, rupees, baht, dollars ...

A profoundly weird article in Monday's Daily Mail suggested that the NHS international recruitment process represents wasting money. No: me neither.

There are many hypotheses you could use about international recruitment (such as that it is pretty immoral to take trained staff from countries with domestic health workforce shortages), but to describe it as wasteful of the £100 million a year in the context of an annual NHS budget of £150 billion; ongoing and years-long workforce shortages; a retention crisis; and an RTT backlog of 7.2 million is magnificently foolish.

Of tangential interest are the figures on the extent of our reliance on overseas staff - driven by the austerity decade's cuts to training budgets and exacerbated by the senior staff retention crisis. This article states that "around 220,000 of the 1.4 million staff in the NHS are foreign nationals, the most common non-British nationalities being Indian, Filipino and Nigerian. In 2022, 63 per cent of doctors who registered with the General Medical Council – in both private and NHS roles – were trained abroad, up from 47 per cent in 2017."

As Malinga Ratwatte's recent BMJ commentary observes, the retention crisis is very real: "the percentage of foundation year 2 doctors going straight into training in 2010 was 83.1%, but this was drastically down to 35% in 2019. From 2007 to 2021, the number of doctors taking early retirement from the NHS trebled, from 401 to 1,358".

The data used is rubbish, as the article admits, just near to the end: "in many cases, the vast sums did not include salaries but represented only recruitment and relocation costs". This failure to disambiguate such a key point pretty much makes a total nonsense of the already-silly idea.

How not to support primary care

I can see the original intention as being good, but the delivery of the news that GP practices will have to earn QOF points for "reducing the risk of GP and practice staff burnout ... (and) shoring up resilience and wellbeing ... (and) to take steps to create a compassionate and inclusive culture within general practice" from April  comes with the sound of salt being rubbed into wounds.

Box-ticking, for these things?

Really?

If ever there were a change that needed to have been properly trailed, squared with professional leaders and managed sensibly, it would have been this one.

Ahem.

AOMRC stick oar in: absolutely nobody notices

I have previously giggled about the opulent impertinence of the Academy of Medical Royal Colleges: an organisation whose self-importance is matched only by its superfluousness. They last hit my consciousness and this column when last September, they issued this ridiculous document saying 'oooh, isn't the NHS in a bit of a state?'

You don't say? Needs fixing? Wow. Who knew?

Special stuff. But they've topped it, with a masterpiece of a new statement this week. On the NHS industrial action about terms and conditions. Which is ... absolutely not the AOMRC's remit.

As they state in the opening paragraph: "issues of terms and conditions are not within the remit of the Academy of Medical Royal Colleges or of its member medical colleges. While we fully recognise the right of individuals to take industrial action, it is not for us to comment on the details of the BMA Junior Doctors’ Committee asks".

Quite right. So, the statement just stops there?

Oh no.

No, no, no.

Via a skid-pan handbrake turn of a "however", the statement goes straight on to talk about this very same subject that is not the AOMRC's remit.

Why, yes: it is almost as if their preferred modus operandi of subtly influencing the agenda behind the scenes and from within the tent were utterly ineffective. Bless!

Cronyvirus and coronamillions update

The Daily Record reports that in the wake of last week's National Crime Agency raid on her London address, Tory peer Michelle Mone may face an interview under caution regarding her involvement in the £200 million PPE Medpro VIP fast lane contract for unusable PPE.

I wonder whether Baroness Mone is still believing everything she reads or thinks? Alas, she has protected her Twitter account, so I can no longer link to that remarkable aphorism.

Other media picked up on the latest data of DHBSC's disposal rates of excess PPE stocks. In the period to 28 February 2023, 269,500 pallets of PPE had been removed from DHBSC's stock. Of these, 131,900 pallets were sent to make energy from waste; 19,600 pallets were recycled; and 6,100 pallets were donated.

Recommended and required reading

This podcast with Rory Stewart and Alastair Campbell interviewing Alan Milburn (former Health Secretary and current Wes Streeting influencer) is interesting.

Sam Freedman's new piece on the public sector workforce crisis is excellent.

Tory peer Baroness Camilla Cavendish's FT piece on the value of data sharing re-uses the claim from an NHS England document that the deployment of Palantir cut Chelsea and Westminster NHS FT's waiting lists by 28% . As best as anyone can tell, this claim remains unsubstantiated. (COI declaration: I sit on Palantir's health advisory panel.)

The Observer revealed that ABPI-suspended Novo Nordisk, manufacturer of injected weight loss treatment Wegovy (semaglutide), is sponsoring NHS weight loss services. The paper showed last month that the pharma company paid £21.7 million to UK health organisations and professionals in the three years before the approval of its Wegovy injections for NHS use.

Times summary piece on the pressures on general practice.

'Capacity to deliver: new ways to increase cancer service capacity', a new report by Mike Birtwistle and sponsored by AstraZeneca, highlights required improvements in cancer care.

Health-adjacent, but this FT review of Henry Dimbleby's book 'Ravenous' on food policy and strategy is worthwhile.