Cowper’s Cut 264: Banking on Imperceptible Industrial Action

The unedifying propaganda war over NHS industrial action stepped up some gears this week.

The RCN alerted The Guardian about suspected fraud by the anti-agreement 'Vote Reject' grouping (why didn't they call themselves 'Vote Leave It?), who counter with allegations of bullying.

The RCN leadership told Denis Campbell that they have "asked the police to investigate a petition to hold a vote of no-confidence in its leadership, while reporting the behaviour of other members to social media platforms and the nursing regulator ...

"Vote Reject campaigners claim they are being bullied and intimidated by union management".

Meanwhile, the shocking revelations in The Times from last weekend that left-wing people sometimes get elected to BMA Council and talk bollocks on Reddit got their predictable echoes throughout the Conservative-supporting nationals.

As the bank holiday weekend hove into view (with the now-traditional port log-jam at Dover), there appeared to be an equal gridlock between the Secretary Of State For Health But Social Care Steve 'The Banker' Barclay and the BMA junior doctors' leaders.

The JDC leadership's latest epistle stated that The Banker's latest communication required new preconditions, of the kind he had been alleging they had established, and continued bluntly that "without any credible offer, next week’s strikes will continue". Would a credible offer ensue from The Banker?

Well ... and well some more. The Sunday Times's impressive data editor Tom Calver filed this fact-packed piece on why junior doctors are striking.

Based on calculations using the sensible consumer price index inflation, Calver concludes that "junior doctors’ pay fell 16 per cent in that time, meaning it would take a 19 per cent pay rise to restore it ... figures on average earnings since 2010 suggest junior doctors have lost out considerably in comparison to the average worker".

The Banker's Sunday Telegraph op-ed stated that "it is deeply disappointing that this industrial action has been timed by the BMA Junior Doctors Committee to cause maximum disruption to both patients and other NHS staff".

This is quality stuff. The People's Steve would clearly prefer Imperceptible Industrial Action: a platonically perfect strike that causes no disruption to anyone anywhere, and which is in fact not even noticed by the strikers themselves.

That would be bound to prove highly effective at getting the junior doctors' pay dispute fixed: ‘Imperceptible Industrial Action - as approved by Steve Barclay’.

We can safely assume that the strikes will go ahead.

You can't wave a shroud without rending garments

There has been much weeping and rending of garments about this strike among system leaders, on the grounds of the risk of harm to patients.

Mmmmmmmmmmm.

If not mmmmmmmmmmmmmmmmmmmmmmmmmm.

So where were these system leaders during the many maternity scandals of recent years?

Or when young people needed access to adequate mental health services?

Or during the collapse of ambulance and A&E services at the end of last year?

Oh, and how about the latest sitrep data showing that 13,000 beds are taken up by patients who no longer need to be in hospital every day last week, and more than 19 out of 20 adult beds being occupied?

In Professor Sir Steve Powis' own words, "Norovirus and flu cases have continued to put strain on services with hundreds of patients in hospital beds across the country, and a further 7,556 in hospital with Covid, while our NHS 111 service received over 440,000 calls last week alone".

But yes, of course if harm or deaths happen during this week's industrial action, it'll be the very first time there has ever been a risk to patients using NHS services in recorded history.

Of course it will.

Junior doctors are what we might call Schrödinger's Trainees, to borrow Mike Reynolds' line: too unimportant to pay fairly, but too important to strike.

Splitting off the consultants?

Meanwhile, the ballot for BMA consultants on industrial action was delayed for a month.

The BMJ reports the BMA consultants' committee announcement that "while these talks are still at an early stage, the union agreed to pause the ballot to allow the talks to take place,” observing that the delay gave the Department for Health and Social Care “ample time” to engage with the BMA and “work towards an offer that will reverse the erosion of consultant pay and restore the pay review body (DDRB) to its original purpose and independence”.

Mmmmmmmmmm. While some may think that the Hunt Budget's removal of the lifetime allowance cap followed by this can allow the Government to split off the consultants from the junior doctors, others may note that the use of "towards" in the language ablout a pay offer here is rarely a reassuring sign in the world of health policy.  

The Hewitt Review

This week saw the arrival of The Hewitt Review.

What to say about it?

Well, the Chancellor likes it, saying that his fellow former Health Secretary "is absolutely right to say the NHS should scrap most national targets and move its  focus to preventative care. If that now happens, it will have a profound and positive impact."

The "if" is quite telling, isn't it?

As indeed Jeremy Hunt should like it, since there is a fairly huge overlap with the conclusions of his book 'Zero'.

This review hasn't landed well with The Powers That Be For Another Eighteen Months, as HSJ's Lawrence Dunhill notes: "absolute minimal enthusiasm for the Hewitt review from DHBSC - ministers will review in 'due course' (i.e. not a priority) and no quote from Barclay NHS England says it's very very grateful & the review v important -but stresses ICSs are 'already' taking significant action".

HSJ's editor Alastair McLellan weighted in, with some sharp observation about the Hewitt review's reflection of the dynamics between the two big representative bodies of NHS management: Confed (hosts, supporters) and Providers.

It's accurate, but misses an important point: Alastair wonders about something that would never have happened, namely a 'stop Barclay' recommendation to prevent the growing SOS interventionism.

A ‘stop Barclay’ recommendation would never have made it into print in the Hewitt review, because of the “more Matt Hancock” stuff in the 2022 Act. Any real devolution of more power from Whitehall was never going to happen: neither the year after the 'more Matt Hancock' provisions

were written into statute in the 2022 Act; nor in the 18-month run-up to the next General Election, by when PM Rishi 'The Brand' Sunak has promised falling NHS waiting lists.

Because neither the Government, DHBSC nor NHS England neither have any credible plan whatsoever for getting the NHS out of the mess in which it remains, nor any credible plan for ramping up its productivity.

And because of the proximity of the next General Election; there is going to be one clear outcome: A Lot More Top-Down Shouting.

All of the policy and political action from now till GE24 is going to be about making NHS waiting lists fall. Nothing else whatsoever is going to matter. It’s going to be Duke Of Wellington Management all round: “SHOUT, SHOUT AND SHOUT SOME MORE!”

The historical effectiveness of a combination of no credible plans and A Lot More Top-Down Shouting is, shall we say, a triumph of optimism over experience

Helen Buckingham's Twitter thread on the Review is well worth reading:

Adam Briggs' views are also useful:

Towards 2006 ambitions, with 2023 resources

And those with functioning longer-term memories such as Richard Humphries point out that the Department of Health's 2006's Our Health, Our Care, Our Say made many of the self-same promises on prevention.

Patricia Hewitt's introduction to that document is poignant: "year on year, as health and social care budgets continue to rise, we will see more resources invested in prevention and community health and social care than in secondary care.

"Previous governments have aspired to parts of this vision. But we are the first government to lay out both a comprehensive and compelling vision of preventative and empowering health and social care services and an effective programme for making this vision a reality. This White Paper truly represents the beginnings of a profound change: a commitment to real health and well-being for all."

As the French have it, autre temps, autre moeurs. And, of course, that was written a couple of years before the global financial crisis.

The hell of well-meaning

The most damning adjective comes to mind having read this Review: it is well-meaning. Many of the ideas it promotes are Not Wrong.

Nor is a document one of whose chapters is called 'Why it can be different this time' guilty of complete self-unawareness.

Its 'six principles' of "collaboration within and between systems and national bodies; a limited number of shared priorities; allowing local leaders the space and time to lead; the right support, balancing freedom with accountability and enabling access to timely, transparent and high-quality data" sound lovely, and would probably be lovely. I just can't help wondering what happened to 'God is love' and 'please adjust your dress before leaving'.

We must also pause briefly to reflect on the likelihood of the current system leadership - The Banker and Co; DHBSC and their wholly-owned subsidiary NHS England - doing these things.

OK: that's long enough.

The problem is not only that there is no national policy plan with which this can align (beyond 'cut waiting lists'; see the More Top-Down Shouting section above); but that there is simply no driver towards making such a plan; nor towards delivering a sustainable increase in capacity in almost any sector that can cut the backlogs and keep them down.

ICBs/ICSs are in reality nascent sets of should-be collaborative relationships, born into a system whose longstanding motivations have been competitive. They have little sooner created in law than they are being required to cut their management/workforce spending by 30%. Oh, and their projected overspend in 2023-4 looks to be somewhere about the £6 billion mark (yes, of course it will come down).

Integrated care may, nonetheless, turn out to be the right approach. But it's a 'hit-and-hope' approach to system redesign.

Nor is the Review decisive (nor even descriptive) about the trade-offs that real change requires: "the share of total NHS budgets at ICS level going towards prevention should be increased by at least 1% over the next 5 years" sounds fine, but we do not know what budgets should be cut to fund this.

Likewise, it's fine to read that "we should encourage and deliver subsidiarity at place, system, regional and national levels. We are currently one of the most centralised health systems in the world, and ICSs give us an opportunity to rebalance this". But why did past efforts at decentralisation fail, and how will it be different this time?

Hewitt writes of "real concern that the transformational work of ICSs and specifically the opportunity to focus on prevention, population health and health inequalities might be treated as a ‘nice to have’ that must wait until the immediate pressures upon the NHS had been addressed and NHS performance recovers. That is what has always happened before, and must not happen this time". In the absence of any 'how', to explain convincingly how what has always happened in the past will not happen this time, this is just well-meaning verbiage.

The Hewitt Review is well-meaning, but it is a 'how'-free zone.

Mo' money, mo' problems

As we covered in last week's sermon, there are allegedly new Treasury Euros for the AfC staff pay deal. Next stop: it's the old New Labour question: 'yeah, but is it really new money, or just another re-announcement or re-prioritisation?'

HSJ's Henry Anderson reports that "DHBSC (are) only saying that money will come a combination of reprioritisation and new money - so some of the cash has come from internal health budgets DHBSC also denying that this is linked to the social care funding cut confirmed yesterday".

New (If Fictional) Hospitals Programme update

HSJ's Zoe Tidman and Nick Carding report that "the Government’s flagship hospital building programme will cost an estimated £35 billion to complete, almost twice the amount of original estimates".

Flagship may be a euphemism for fictional, I suppose.

The article adds, "in 2020, the Government allocated £3.7 billion to the NIFHP to cover spending up to 2025, but no information has ever been officially released about the total cost of the programme ... internal NIFHP documents estimate it will cost £27.3 billion to build the 40 already-designated projects by 2030.

"The documents were drawn up late last year, amid the process of NIFHP submitting its business case to the Treasury for funding the remainder of the programme 2025-2030. They show it would require £2.3 billion capital for the eight pre-existing schemes and 10 new smaller schemes (known as cohorts 1 and 2) ... the total capital spend on the much larger projects in cohorts 3 and 4 would be £22.3 billion".

You're right: that IS an awful lot of fictional money that won't ever be made available; nor will ever be spent in the real world.

I'm sure you're just as shocked as I am to learn that the total cost of the New (If Fictional) Hospitals Programme - total number 40/48; total yet completed = 0; target date 2030 - has doubled.

That's fictional inflation for you, I guess. We'd better raise fictional interest rates.

Recommended and required reading

Nuffield Trust deputy director of policy Natasha Curry's response to the DHBSC's confirmation of social care's financial shafting.

Via the Nuffield Trust's Louella Vaughan, a Millbank Quarterly article showing that bigger hospitals are not better.

Craig Nikolic's piece on over-efficiency, NHS brittleness and monolistic structures is thoughtful.

Sam Freedman's latest piece on public sector workforce and Tony Hockley's on NHS workforce planning are both fine reads.

Tony Hockley is also among the co-authors of a new book on behavioural public health policy, 'Steering For Health'.

'Evaluation of the national governmental efforts between 1997 and 2010 in reducing health inequalities in England', a new paper in Public Health, shows that "the National Health Inequalities Strategy (NHIS) coincided with a reduction in inequalities in YLL (premature mortality) rates. Broadly, total inequalities in YLLs remained relatively stable between 1990 and 2000, significantly improved over the following 10 years, and began to plateau in the years following the end of the strategy".