Apr 23, 2023 12 min read

Cowper's Cut 266: Activity speaks louder than words

We start, like last week, with an opinion poll on the NHS industrial action.

This one, like last week's, brings good news for those doing the striking, and bad news for the Government. The new YouGov polling for The Times released on Monday showed that of the group surveyed, the majority of voters continue to back the strikes, with nurses enjoying 67 per cent support and doctors 59 per cent.

This level of public support "has remained stable", the article notes.

YouGov's latest weekly tracker poll on how well the Government is handling the NHS (10 April datapoint) found that 82% of respondents believe the Government is doing badly, with 13% saying it's doing well. (The 5% who don't know are intriguing.) It's worth noting that YouGov use online surveys, with active sampling.

The implications of the RCN's rejection of the proposed pay deal that they recommended continue to reverberate. At the Lobby briefing on Monday, the PM’s spokesperson said that negotiations with the RCN would not resume: "I think the RCN themselves, Pat Cullen herself, said this is the final offer. We agree. The Royal College of Nursing was clear that talks will not be reopened if members reject the pay offer, and we agree".

On the topic of these strikes, shadow health secretary Wes Streeting's Urgent Question to Health But Social Care Secretary Steve 'The Banker' Barclay on Monday afternoon was underwhelming all round.

The Banker protested that the junior doctors’ leaders' 35% pay demand was the issue blocking progress: ironic, coming from a SOS whose Government keeps pushing the fictional figure of 40 new hospitals.

Fictional numeracy is where health policy is at in 2023, it seems.

Mr Barclay also sought to pretend that 78-week waiters were the result of the pandemic: this is not so. Neither was his attempt to convince the Commons that the NHS backlog was down to Covid. The backlog was 4.4 million in January 2020 before the pandemic hit; and now stands at just over 7.2 million: it’s been rising by about 100,000 a month, averaged out.

That same morning, PM Rishi 'The Brand' Sunak had warned of an "anti-maths mindset": surely the perfect cue for Mr Streeting to have had a comeback on the inability of the Government to calculate the losses (both actual and intangible, in goodwill) caused by their unwillingness to resolve the strikes.

The "anti-maths" numbers game

The Department For Health But Social Care's wholly-owned subsidiary NHS England published data on the operations cancelled due to last week's junior doctors' strike.

There were 195,000 cancellations. At the peak of the action, 27,361 staff were not at work due to industrial action. (There were a high number of nil returns on the workforce data collection, so these figures are not the full picture.)

In the previous junior doctors strike, there were 175,000 cancellations across three days.

The primary care campaign

Labour resumed their primary care attack, pledging "thousands more GPs" and to "bring back the family doctor and guarantee face-to-face appointments to all who want them".

Labour will make sure you can see your GP quicker and in person. pic.twitter.com/ye6QUiWSz2
— The Labour Party (@UKLabour) April 17, 2023

Labour's research highlighted how 1,209 GP practices had shut or merged since 2015. NHS data from February 2023 states that 6,414 GP practices were open. There are 2,000 fewer full-time NHS GPs in England than there were in 2015: the average GP is now having to look after an extra 348 patients, compared with eight years ago. The number of patients per practice increased from 7,465 in 2015 to 9,722 in February this year.

Quoting a recent ONS survey on the impacts of NHS winter pressures, Labour suggested that almost one in four patients could not get a GP appointment last time they tried to book.

Of course, Labour offered no clarity on the near-term source-to-be of the thousands of more GPs who will be required. Nor did they show recognition of the fact that Improvment Analytics Unit research from last year found that just 10% of patient care requests made to GP practices indicate a preference for a face-to-face consultation.

The opposition claims that almost three million patients have seen their practice close or merge in the past five years. It is rather a call-back to shadow health lead Wes Streeting's robust position-taking on primary care around the turn of the year.

Labour need proper analysis. They'd do well to look at Steve Black's latest 'mythbuster' in Health Service Journal, which looks at the major problems facing primary care, and observes that to some of them, the solution is far from straightforward.

Labour primary care policy: a little more detail

"In its 75th year, it is time to make it a neighbourhood healthy service as much as it is a national health service. Labour’s three principles: healthcare on your doorstep; there for you when you need it; patients in control".

Wes Streeting's Friday speech on primary care at the Kings Fund was teed up in an interview with the Boris Johnson Fanzine mid-week, in which Labour leader Sir Keir Starmer acknowledged the staggeringly obvious fact that the NHS is broken.

“I think the NHS is broken ... there’s been one way of doing things for the last 13 years, and this is where we’ve ended up now with the NHS.”

Starmer also claimed to see “no political advantage” from the strike action, showing that his deftness of touch when running for the Labour leadership and promising that Labour must not "lose sight of our values or retreat from the radicalism of the past few years" has not deserted him.

He concluded by pinning the blame on the Conservative And Unnionist Party Government: "if they carry on like this, it can’t survive – the biggest risk to the NHS is another Tory government”.

Streeting: fighting man

In this Kings Fund speech, Mr Streeting tacked hard away from his autumn 2022 stance of throwing out undercooked ideas with an apparent view to antagonising the medical professions.

Specifically, he repeatedly emphasised that he did not plan to nationalise GPs: “contrary to reports, I have absolutely no intention of nationalising GPs.

"But we are exploring how to make the future of general practice sustainable so patients aren’t left without when more and more GPs are choosing to take the salaried route, and partnerships are forced to close because fewer GPs want to take them on".

He was likewise careful to avoid committing news by setting out timescales for delivering access improvements; emphasising instead the party's longstanding plans increased training of 7,500 more doctors and 10,000 more nurses each year, to be funded by the abolition of the 'non-dom' tax status.

Instead of fresh commitments, Streeting sensibly played the three-cup trick by calling for the NHS workforce plan to be released "from Steve Barclay's top drawer".

Streeting's calls for more continuity of primary care, face-to-face appointments for those who want them (while stressing that he himself tended not to), more district nurses and a shift to a "neighbourhood health service" all sounded attractive and seemed sincere.

It was, of course, very light on the 'how'. And the 'how' very much matters.

But he made repeated commitments to work with the professions to develop this 'how'. That, at least, is progress: it is impossible to imagine Lansley, Hunt, Hancock, Javid, Barclay, Coffey or Barclay doing the like. Mr Hunt learned his lessons the hard way, but seems now tragically to have been stricken by Treasury Amnesia Syndrome: the others learned nothing at all.

That Streeting is a confident and fluent performer is no surprise: perhaps his choice line being line that "the Conservatives have sounded so positive about the NHS this week, you'd think it was 2009". And his move away from performative policy pyromania is sensible: he explained having "deliberately upset the apple cart" with his past comments as motivated by a desire to fuel debate and drive fresh thinking.

Beyond mere investment

Taking journalists' questions after the event, Streeting said that the NHS “requires more than just investment”. To a question from HSJ on whether this meant a return to austerity, he said: “the reason why we’re going so heavy on reform is in part because public finances are in a mess: there's just a practical constraint that we need to be honest about.

“There is a perception in the electorate that Labour’s answer to problems is always more money. In this case, I don’t think the answer is just more money. I think investment does matter, but we’d be kidding ourselves if we thought that if we just put more money into the system as it is, everything will be fine.”

He suggested that it would take a “decade to get the NHS back to where it was under the last Labour government”. That timescale sounds about right - but public, professional and political pressures for delivering short-term experience and performance improvements will not abate.

Challenges to industrial action

Well! If it isn't our dear old pals the Academy Of Medical Royal Colleges, indulging their public self-shaming kink in style again this week, with what they perhaps naively saw as an authoritative intervention.

As previously, their latest statement should have stopped at the end of its first line ("issues of terms and conditions are not within the remit of the Academy of Medical Royal Colleges or of its member medical colleges").

So, have they learned? I mean, they're an academy: that should be learning-prone.

Alas, they have not learned.

Instead, the very, very, very, very, VERY grown-up AOMRC decided to show themselves to be the decisive intervention-makers calling for the involvement of ACAS, for which the BMA and NHS Confederation had already called a week ago.

NHS Employers make themselves redundant

The NHS Confederation's sub-set NHS Employers (funded by its work for the Department For Health But Social Care) decided to give itself an interesting week and an unlikely future by getting actively involved in the RCN strikes planned for the turn of the month.

To be precise: NHS Employers are trying to suggest that these next RCN strike dates are not covered by the extant strike mandate.

Its chief executive Danny Mortimer wrote that NHSE has "legal advice, including from lead counsel, that indicates that the six month period in which industrial action can be taken expires at midnight on 1st May 2023 ...

"Given the concern that the RCN may be asking its members to take strike action which does not enjoy legal protection, I have this afternoon written to the Secretary of State for Health and Social Care asking him to intervene and to seek the view of the courts as to whether the notices of action issued to relevant NHS organisations for 30th April to 2nd May 2023 fall within the law governing industrial action”.

As made clear by NHS Employers in their letter to me today seeking my assistance and support 👇 (2/2)https://t.co/BNrreTwdAI
— Steve Barclay (@SteveBarclay) April 21, 2023

Surprise, surprise: Steve 'The Banker' Barclay finds this very helpful, and is proceeding with legal action on NHSE's advice.

The RCN's legal advice based on precedent is orthogonal to NHS Employers', and they plan to contest this legal action.

NHS Employers "manage the relationships with NHS trade unions on behalf of the Secretary of State for Health and Social Care". They don't seem to have thought about this very carefully.

They are dealing with an RCN whose membership chose to reject the pay deal that its leaders negotiated with the Health Secretary.

It's obvious why The Banker wants this challenge, but very hard to see why NHS Employers is so enthusiastically playing along with and up to it. One lesson from the junior doctors' contract dispute is that fighting your workforce is a profoundly bad idea. Jeremy Hunt has for some years been particularly clear about this.

Nor can they claim that this is them 'just doing their job': they were superseded from that job once Steve Barclay became directly involved in the pay negotiations (having somehow overcome his deep reverence for the indpendence of the independent pay review body).

So NHS Employers' action seems like a deeply stupid move. Do they seriously doubt that, should it prove necessary, the RCN will get a majority for further industrial action? What is the actual proposed win here?

Because if NHS Employers continues to exist, it will have to negotiate with staff trades unions in the future. And they have long memories.

I've heard theories that the RCN leadership secretly welcome this challenge, because they don't really want more strikes. This hypothesis smacks hard of motivated reasoning. The RCN leadership came out fast and hard in response to the NHS Employers challenge: it needs to show its members that it is up for their expressed wishes not to settle on the proposed terms (that they leadership had concluded was the best deal likely).

Stevens on the strikes

Lord Stevens of Birmingham has been keeping himself well out of the health policy fray, but in an elegant piece for The Spectator, he aimed a potent blow at the Government's inpet conduct of the industrial strife.

With epic understatement, the noble Lord wrote, "it’s clear the health department’s industrial relations strategy isn’t going to plan. Having tried to tough it out, their attention switched to the Royal College of Nursing, hoping other union dominoes would then fall. But the RCN is still reeling from a CBI-style sex scandal, and its members have ignored their own leaders and narrowly voted no to the latest pay offer".

He characterised the junior doctors' pay dispute as "a rear-view-mirror claim for pay restoration after a decade or more of real-terms erosion ... unlike the nurses, improvements in the forward inflation outlook make less difference to their negotiating stance".

Stevens suggested that "the current lose-lose standoff" might have been avoided by the independent pay review body ancknowledging the exceptional inflation: "they could have been asked, exceptionally, to make an improved 18-month pay recommendation. That might have drawn the sting, while preserving their legitimacy. Had it been coupled with the Government’s long-awaited NHS workforce plan to expand and reform training, frontline staff might have seen light at the end of tunnel.

"Now if further strikes drag on, at the very least waiting lists will worsen. The nuclear option of withdrawing cover for emergency services and urgent cancer care would be unconscionable".

The Artist Formerly Known As Simon Stevens is Not Wrong here: the current Mexican standoff is ugly all round. And there are no negotiations.

NHS England to set up new national improvement board

(No, really)

I feel mildly sorry for NHS England: they've been reduced to satirising themselves with this new plan reported in HSJ to set up a national improvement board.

Maybe they could call it NHS Improvement?

Summer-y execution

HSJ also reported NHS Engroovement's plans to "virtually eliminate" 78-week waiters by the summer.

Unhelpfully, we didn't get a definition of which summer.

The Summer Of Love? Donna Summer? Summer 2023?

But I'm getting quite fond of the phrase "virtually eliminate": I read it as virtual in the 'virtual reality' sense. Two-year waits have stilll not been eliminated in actual reality.

Activity speaks louder than words

NHS Providers' deputy chief executive Saffron Cordery told HSJ that NHS Engroovement's failure to act on the BMA unofficial 'rate card' for extra work was not helping the current situation.

As James Illman's piece explains, this 'rate card' is the subject of separate controversy between the BMA and NHS Employers.

Ms Cordery also said that the Prime Minister's pledge to to have NHS waiting lists falling was "in the balance" due to various factors, but mainly the industrial action. And Henry Anderson's story that forty provider trusts (including some huge ones) have been set targets to deliver 103 per cent of pre-covid activity levels in 2023-24 (NHS Engroovement's national ambition for providers post-Covid was 130% of pre-Covid activity, albeit without any real plan as to how it'd happen) further confirms the jeopardy in which the PM's promise remains.

Perhaps it's time for the Government to have a look at the Institute For Government's sensible piece on finding an approach to ending the strikes?

The Alan comeuppance

The least self-efffacing man in Britain, your People's Partridge and mine, was back in the news in this extract from The Times' serialisation of Anthony Seldon's book on Boris Johnson's tenure in Downing Street.

The contempt in which Johnson (and his shit Rasputin, Dominic Cummings) held Matt Hancock is striking. That's the man who they (re-)appointed as Health Secretary, and left in the post during a pandemic. "Fucking useless" is one of the gentler phrases they used about Hancock: it cuts both ways, really.