Cowper's Cut 267: Banking on ambiguity with Steve Barclay

Tuesday's meeting of the NHS Staff Council now looks certain to accept the Government's AfC staff pay offer. As BBC News reports, Unite's rejection of the deal on offer was outweighed by the GMB's acceptance, and they now certainly have over the required 50% for acceptance.

What they're accepting is not, as Health Service Journal's Alison Moore notes, a wonderful deal: as she says, it "embeds a real terms pay cut of about 6% from 2023-24. The lump sum brings pay roughly into line with inflation, but only for 2022-23. The starting point for 2023-24 is 6% lower".

The RCN lost their court case about the extra day of striking, but are on strike at the time of publication (an exception to their 'no derogations' approach for this action has been made for Great Ormond Street Hospital).

This seems set to prove a Pyrrhic victory for the Health Secretary and his minions NHS Employers, who will still have to negotiate and transact with these people in an atmosphere of much-reduced trust.

Moreover, the possibility that the RCN may vote to extend their industrial action is surely not small.

Tuesday also looks set to see new in-person negotiations between the Secretary Of State and the BMA Junior Doctors Committee leaders.

On Sunday afternoon, HSJ's Dave West highlighted that the RCN agreed a form of blanket exceptions for critical care.

Faster, Steve: kill, kill!

Health But Social Care Secretary Steve 'The Banker' Barclay has been much in the media this week, for non-strike-related reasons.

Specifically, The Guardian ran this piece flagging his brusque personal style at work, with allegations that some civil servants have privately described his approach as "bullying".

As well as these angry outbursts, The Banker reportedly deliberately ignores some DHBSC staff who are trying to talk to him.

This is not news to 'Cut' readers, who will recall that at the start of the intriguing reign of Liz Of The 49 Days last September, I shared an anecdote of the newly-appointed Barclay coming up with some crackpot idea (unspecified): when told by his DHBSC minders that he couldn’t do it, he lost his temper, and started shouting, “WHAT DO YOU MEAN, I CAN’T DO IT? BUT I’M THE SECRETARY OF STATE!”

Likewise, last year I shared an anecdote about Barclay keeping Amanda Pritchard and colleagues waiting outside his office for hours for a scheduled meeting until they could come up with specific data that he required.

The DHBSC's worst-kept secret

Barclay's bad-tempered demeanour in the office has been scant secret, in other words. And the penny now seems to be dropping (if not yet reverberating) in the service that NHS England boss Amanda Pritchard has taken significant amounts of the brunt on this.

(To be fair to Barclay, he does have some fans. But they are not many in number. And the Health Service Journal editorial 'welcoming' his appointment was genuinely unprecedented.)

The Times' write-up on these matters has a truly pitiable briefing barney over whether there are enough staplers and meeting rooms for the NHS England senior staff now co-located in the DHBSC offices, and about the nature and pigeon-richness of their view.

Steve's indecision is final

A more cogent critique of Mr Barclay than his anger management is that he is dilatory and incompetent. He fails to take important decisions - and it's not just one or two, such as the NED board appointments to the Care Quality Commission that the NAO flagged were well overdue, as reported by Health Service Journal.

The incompetence critique has come to the attention of Times Whitehall editor Chris Smyth, who reports a DHBSC source as saying “he creates a very unpleasant atmosphere — it’s definitely a very unhappy environment and vastly different in terms of morale to previous secretaries of state, but I don’t think this is going to end up in some kind of bullying thing”.

The ongoing situation over Royal Free CE Caroline Clarke's appointment to run NHS England's London region is a fine example. People were congratulating Caroline on getting this job back at the Nuffield Trust Summit in early March. It's now touching May, and no formal announcement has yet been made.

Barclay's indecision may not yet be final, but it's certainly a long-term condition. Civil servants in the Department For Health But Social Care have a tally of progress-chasing emails that they've sent The Banker about the overdue decisions that he called in for his sign-off, as well as those he actually should be making. It's their equivalent of asking for a Ministerial direction.

If we must have them, then interventionist ministers should surely be competent and purposeful.

Ahem. I invite you to go back to the speech Mr Barclay gave at Policy Exchange at the end of his first tenure as SOS, and my review of it.

Barclay's indecisiveness is not a bug: it's a feature. Not for nothing did I term him a Banker: this is a numbers and structures man.

Remember his DHBSC, NHSE and ICS organograms fetish?

His gorgeous call for "consultancy, professional spend and labour contracts" spending cuts of 20%, but which he "feels" could go up to 80%?

When still a Treasury minister, he refused sign-off for the Covid19 vaccines programme on the grounds that it was not value for money, only giving in once more than a million people had been vaccinated.

Then there were his "urgent hackathons" to fix the ambulance crises: they really worked well ...

The Banker is an angry man because his chosen toolkit and vibe are no way to try to run a system that is in longstanding and profound chaos: a chaos now exacerbated by the Government's choice to fight and stonewall industrial disputes over pay.

To quote former DH Director of Finance (from competent times) Richard Douglas' words (to Chris Hopson of NHS England) at the Nuffield Trust Summit: “you’ve confused accountability with the illusion of control … you think that by having templates and spreadsheets, you think you’re in control, and you’re not”.

The Banker has made just this mistake. He came in with his fantasy about the NHS being a 'bottomless pit' for taxpayers' money, and he has found that his organograms, spending cuts (20%? 80%?) and urgent hackathons have proved neither use nor ornament.

He probably thinks of himself as an alpha male type, who should be the chief executive of the service, leading to disappointment with his actual role. I'd say The Banker's more of an alpaca male: alpacas communicate through body language; most commonly by spitting, to show dominance when they are in distress, fearful, or feel agitated.

This week's media reports about him are also now going to make him paranoid: this may not improve matters.

In a time of chaos, you need three main things from leaders: clarity, priorities and leadership by example.

It would be fair to say that Mr Barclay delivers on zero out of those three.

An example

Secretary Of State Barclay pushed matters fairly firmly this week with his laudatory claim that "more people than ever are surviving cancer, but we know there is more to do. That’s why it is encouraging to see the NHS hit the new Faster Diagnosis Standard for the first time. Cutting waiting times for diagnosis means faster treatment".

I mean, that's lovely, as far as it goes. Which isn't far.

Because the facts are that "fewer than 3% of England’s NHS trusts met a key waiting-times target last year for cancer patients to be treated within two months of an urgent GP referral.

"Of 125 hospital trusts in England analysed, only three (2.4%) hit the standard of treating 85% of patients within 62 days after an urgent referral in 2022. Some trusts have not hit the standard for at least eight years."

Still, mustn't grumble: it takes some nerve to promote your own longstanding failure, but to each their own kink. We're all open-minded people here.

HSJ saw this turn into a bollocking exercise - sorry, learning opportunity - for six health systems over the performances of their community diagnostic centres, which had diagnosed or ruled out fewer than 70 per cent of urgent cancer referrals within 28 days in February, thus failing to meet the “faster diagnostic standard”.

Medexit: why staff are leaving

It's that Banker again, shilling the excellent progress with medical recruitment. The People's Steve is evidently yet to realise that you can't recruit your way out of a workforce retention crisis.

And as John Burn-Murdoch's excellent piece for the Financial Times maps, that is very clearly where we are. "Despite steady upward trends in the numbers of new doctors and nurses, vacancies continue to rise. The NHS has developed a leak.

"And it’s not an easy one to mop up, since it frequently drips into other countries. According to the latest figures, there are now an estimated 18,000 UK-trained doctors practising overseas ... a 50 per cent increase since 2008

"One in seven practising doctors who trained in Britain is now working elsewhere ... almost three times the average rate among peer countries".

Burn-Murdoch quotes NHS data "which shows that the huge increase in voluntary resignations over the past two years has been driven by people citing problems with their work-life balance".

And he draws attention to this 2022 General Medical Council survey on 'Understanding Doctors’ Decisions To Migrate From The UK'.

The GMC piece shows the multi-factorial causes driving the UK's Medexit. Interestingly, recent LCP research based on the latest NHS Staff Survey, shared with HSJ, finds that "discrimination and inequality are bigger factors for staff wanting to leave acute trusts than burnout".

Workforce issues just cannot be left in the present plan-free, unmitigated mess. Going through the back issues of 'Cut' to find something I wrote about Barclay, I found the following few tweets, including a brief coda from my friend, the late Andrew Foster.

Re-reading it was a lump-in-the-throat moment.

There used to be some actual grown-ups in charge around the place.

Hopefully there will be again, in the not-too-distant future.

NHS England new tech committee

NHS Engroovement, the wholly-owned subsidiary of the Department For Health But Social Care, continues to let its public self-humiliation kink hang out big-time.

Following last week's triumphant reinvention of not-long-merged/abolished NHS Improvement, NHSE will reinvent the even-more-recently-merged/abolished NHS Digital and NHS Kiss (the latter created and used by Simon Stevens to distract People's Partridge and tech magpie Matt Hancock).

Of course, they're not being quite that frank. They are looking for a 'key senior leader' in digital (offered salary a risible £100,000). I think these people used to be just called leaders: inflation's everywhere now, including in nonsensical job title inflation such as this.

And the successful candidate will need to be "confortable with ambiguity". As opposed to "uncomfortable with clarity"?

Recommended and required reading

An un-named person in a fairly senior role tried taking on national diabetes lead Partha Kar for fulfilling his portfolio role on bullying and harassment. They might make a worse decision this decade, but it won't be easy, as Partha's blog attests.

Michael Marmot piece in The Guardian about Wes Streeting's NHS reform proposals.

'Healthy people, prosperous lives: the first interim report of the IPPR Commission on Health and Prosperity', the new IPPR report, is now out.

Ben Clover's latest HSJ commentary makes a plethora of smart points about the Lloyds PFI £56 million lawsuit agasinst the Whittington.

DHBSC briefed The Times that the VPAS medicines pricing rebate scheme has saved £7 billion. Love to see the numbers to stand this up, please ...

The British Medical Journal has joined the profusion of other organisations doing a commission on the future of the NHS. Perhaps Health Policy Insight should do a commission on NHS commissions?