Cowper's Cut 271: The Keir Starmer speech on NHS reform

If it's Monday, it must be Opposition leader Sir Keir Starmer's NHS reform speech day - and the Government tried to spike the media guns with this curious briefed story about patients using the NHS app to book private care to cut NHS backlogs, given to Times Whitehall editor Chris Smyth.

The thinking behind this founders on three obvious points. Firstly, there is no guarantee that expanding the NHS app will intrinsically drive patients to choose private providers. It may, or it may not.

Secondly, we know from the Kings Fund research evidence that patients usually choose their nearest hospital.

And thirdly, the independent sector has limited spare capacity. If you put these things together, you don't have a clear recipe for shorter waiting lists and times. You do have a headline for a day, though.

The Starmer speech

Labour rolled the pitch was rolled for the Starmer speech by giving The Sun its extrapolated research showing that over 23,000 people died in A&E last year (an annual number up from below 9,000 in the years preceding the Covid19 pandemic.)

Interviewed on BBC Radio 4 Today (2 hours 10 in), Labour's leader dropped a potentially big line about the GP partnership model "in many cases is coming to the end of its life, and we need to have more salaried GPs".  This is the opposite of the message that Labour's shadow health secretary Wes Streeting gave in his Kings Fund speech last month.

Starmer made a pledge that all existing NHS targets will be met by 2030, which is ... shall we say, highly ambitious: “the next Labour government will deliver an NHS that is there when you need it. No backsliding, no excuses. We will meet these standards again. We will get the NHS back on its feet”.

Health Service Journal reports that Starmer is to promise to cut “deaths from heart disease and stroke by a quarter within ten years”. He also promises to “reverse the rising deaths from suicide, so they are declining within five years ... (and) hit all NHS cancer targets, so patients are seen on time and diagnosed early”.

Starmer promises a “fundamental and sustained change to the NHS”, involving “three ‘big shifts’ in approach: analogue to digital; hospital to community; and sickness to prevention”.

Labouring towards talking about funding

Will there be more money? For the first time, Starmer hinted at a possible increase, telling the Today programme that "money is part of the answer and the NHS is always better funded under Labour”.

The actual speech

Eventually, the pre-briefing media fluffing stopped, and 10.30 am arrived. The actual speech was reasonably well delivered. Presentationally, Starmer is no Blair (although in the Q&A, a reminiscent "Look, ..." preceded many of his answers).

But Labour's leader doesn't need to be a presentational star: he simply needs to know what he's going to need to do.

So does he?

The thirty-minute speech had four main aims (which is at least one too many): to set out Labour's distinctive health policy; to cement NHS reform as a key Labour goal; to do the obligatory 'tech utopianism' bit which all senior politicians' NHS speech must by law contain; and to deliver some 'Starmer NHS story'. It didn't strike me as wholly successful in any area, but the 'personal story' bit was probably the most complete.

The tech utopianism bit was painfully bad: it always is. It was been chunked out into this Guardian comment piece, and it is no better on the page than it was read aloud.

Little of the actual content is really new, if you've been paying attention. Streeting's 'neighbourhood health service', and the greater emphasis on prevention and personalisation, were all present and correct.

The philosophical approach that the opening outlined is not foolish, and does show some analytical reasoning: "it starts with the cause, the central project – “how do we serve working people”, and then it asks – “what do we value; what do we conserve, cherish and protect The answer: a public and universal health system, free at the point of use, paid for by general taxation, the NHS.

"But then it asks – what do we need to change, what are the challenges, the opportunities, how can we save lives, improve lives, provide more dignity? Innovation – where can it be found? People – how do we unlock their purpose? Technology – how do we make it work for us?"

(Clearly, there are not a few people at senior levels in the NHS whose purpose should be locked at the earliest opportunity, and the key thrown away. And the passage about walking towards the light should have been cut at first-draft stage: it smacks of near-death experience, which isn't a great allusion.)

Inequalities and gimmicks

The most interesting section was on health inequalities: "we will improve healthy life expectancy for all and we’ll halve the inequality gap between different regions of England". There were pledges on the three biggest killers: "One – cardiovascular diseases: heart attacks and strokes – we will get them down by a quarter, within a decade. Two – cancer: we will make sure 75% of all cancer is diagnosed at stage one or two." For the third - suicide - there was sensibly no numerical target set, other than "to get it down".

There were also sensible broader commitments on public health, with misogynist content from social media companies put on notice, and bans on advertising vaping and junk food to children announced.

There were gimmicks, too: "to cut waiting lists more quickly, patients should be able to visit nearby hospitals when faster treatment is available, and Labour will give them that choice". Announcing something that is already patients' NHS Constitutional right is probably smart, and most of the media will miss it.

The emphasis on patient choice rather ignored the research evidence showing that even when this was a shiny new placebo, most people chose not to choose and went to their local provider.

Starmer also promised "we’ll make good on the integration of health and social care. Backing successful community models like the centre at Bromley-by-Bow where they bring together in one place – doctors, nurses, physiotherapists, social carers – to provide joined up care in the community, keeping people out of hospital. And we will recruit and retain more carers with a fair pay agreement".

Integrated care is probably right, but certainly not easy. Starmer isn't the first politician to be impressed by Sir Sam Everington and team's Bromley Centre; nor will he be the last. But it would behove Labour's leadership to be curious why the Bromley-By-Bow model hasn't been adopted elsewhere - which is probably because it's very hard, and needs consistent, ultra-motivated leadership.

The tech utopianism bit was truly poor: "This is the game changer. The light at the end of the tunnel. This is what will make the NHS fit for the future". Tech is necessary but not sufficient: certainly not without broader reforms, greater change/improvement management and analytical capacity and capability.

In the Q&A following the speech, Starmer won a few 'Cowper's Cut' Brownie Points by referring to the 40 new hospitals as "largely mythical". I'll take that as a win for the 'Forty New (If Fictional) Hospitals' line.

A lot of important things were missing, of course: this was a speech aimed at the national media and Westminster political discourse.

There was nothing on culture - either on the NHS's overall problematic centralising and bullying tendencies; on target culture and its perverse incentives; nor on the culture change needed to turn integrated care and partnership working with local government, social care, the third sector and other parties into something real (as opposed to rhetorical).

There were bits about public health, but it wouldn't be your main take-away.

And there was very little on workforce, or how actually to deliver sustainable improvements in NHS management systems.

I'd like to feel more confident than I do about Labour's leadership understanding the importance of all of these issues.

As for reactions to the speech, I recommend Isabel Hardman's piece in The Spectator.

'Build An NHS Fit For The Future', Labour's policy document accompanying the speech, is here.

Iron while the strike's hot

It seems that PM Rishi 'The Brand' Sunak is actually quite fond of NHS backlogs. He has promised to reduce them by an unspecified amount by an unspecified date, but continues to fail to come to a pay settlement with a key part of the NHS workforce which can and will make these backlogs grow.

BMA junior doctors committee co-lead Rob Laurenson's tweet about this is incendiary. He asserts that "we have been clearly told by DHSC that doctors wages are being suppressed and withheld by Rishi Sunak himself".

Laurenson is pointing the finger in the most unambiguous way at the political leadership of the Department For Health But Social Care. He might, of course, be bluffing here - but if so, he knows that the same social media space that he's using to do this is available to the person whom he is dropping in the brown, sticky, malodorous stuff.

Over to Health But Social Care Secretary Steve 'The Banker' Barclay (or team), who responded in kind, anonymously telling The Times' Eleanor Hayward that the BMA JDC leaders “have collapsed talks by calling strikes. The BMA never shifted from their 35 per cent demand, and in fact upped their proposal to 49 per cent. That is not how negotiations work. It is completely unaffordable and unrealistic”.

And SAS doctors?

Yep, there's an overwhelming vote to hold a strike ballot over pay there, too.

The situation in Scotland provides a vivid contrast: junior doctors there will vote on an offer of 14.5% staged over two years. BMA Scotland are just presenting this proposed deal, rather than advocating it to their members.

Strike: Inside the Unions - Series 1: Episode 1

Charting the start of the historic wave of strikes.

BBC iPlayer

It's about political attitudes, beliefs and choices. RCN general secretary Pat Cullen told a revealing anecdote about these in the BBC documentary 'Strike: Inside The Unions', revealing that a health minister had told her that they were surprised nurses needed to live off their salaries: "ministers coming into the room saying to me that they're shocked that nursing staff may be the main breadwinner in the family. Because they believe that it's a second salary that we don't depend on. They are totally out of touch".

Aren't they just. This is almost a callback to the beautiful moment when The People's Partridge told the 2019 Chief Nurses Summit "nurses were expected to stand up when a doctor entered the room ... I find that's still the case in some antiquated, archaic corners of the NHS". (As with so very many things that Alan asserted, this was unmitigated bullshit.)

It feels as if the Conservative And Unionist Party's health team is struggling to make its way into the 1980s.

A Department For Health But Social Care spokesperson said they 'did not recognise' Cullen's claim (this is Not A Denial), and had "utmost respect" for all staff. Mmmmmmmmmmmmmmmm.

The opening credits of this programme report that “the government departments ... featured in this series declined to take part”. This is telling, as is Cullen's information: it all sits squarely with everything I've observed and heard about The Banker's and the Government's 'parent-child' approach to these pay negotiations.

There will be a lot more strikes ahead.

The politics

Reliable pollsters Ipsos' Political Monitor for May 2023 finds that "63% of Britons expect Labour to be the biggest party after the next General Election ... 43% expect a hung parliament with Labour as the largest party and 20% think Labour will win a majority.

"25% expect a Conservative victory (8% expect a Conservative majority and 17% a hung parliament with the Conservatives as the largest party).

"In September 2019, 23% expected a Labour victory at the coming election, and 58% a Conservative one (12% expected a Conservative majority; 46% expected a hung parliament with the Tories as the largest party)".

Ipsos' global chief executive Ben Page highlighted another Europe-wise survey which found that "while cost of living is number one most places, in the UK it is the future of  public services".

Workforce

General practice tracker

Our GP tracker monitors selected NHS data on general practice appointments and workforce in England.

The Health FoundationThe Health Foundation

The Health Foundation's latest GP workforce tracker data shows that the increasing trend in appointments in general practice continues, with 29 million appointments in January 2023. (This compares with 25.4 million in January 2022, and 24.7 million before the pandemic in January 2020.)

It alsos shows that while the total number of GPs has increased since 2015, there are fewer qualified and permanent full-time equivalent GPs: "the total number of fully qualified and permanent GPs by headcount has only increased slightly from 34,828 to 35,198. Due to a reduction in working hours by GPs over time, the number of full-time equivalent fully qualified permanent GPs has in fact decreased from 28,590 in 2015 to 26,631 in 2023 – a fall of 1,959.

"The number of full-time equivalent, fully qualified permanent GPs is the best measure of GP workforce capacity".

More choice (that you already have)!

This amusing piece in the Boris Johnson Fanzine suggests that "private health companies will run cancer check centres as part of efforts to clear NHS backlogs".

But there's a catch! Members of the Paying Attention Community (such as 'Cut' subscribers) will spot that further down the story, it suggests that "the first chain of diagnostic cancer centres is planned for the South West, which has some of the longest waits, where a single provider will be asked to operate about a dozen centres. The “test case”, currently seeking Treasury approval, will be followed by the rollout of such centres across the country".

Mmmmmmmmmmmm. Treasury approval. For more spending on health.

Still maybe they could try buying out the Rutherford Diagnostics Centres set up by 'Positive Professor' Karol Sikora. They were A Triumph.

As was Cancer Partners UK.

Oh, is there a pattern developing here?

40 New (If Fictional) Hospitals update

Look, I know it's not new news to any of you. But - sigh - the Government's been at the Forty New (If Fictional) Hospitals hopium again. Do you think it's time we should stage an intervention?

I'm distressed to report that The Banker made a statement on the subject.

There are not going to be 40 new hospitals by 2030. This is an obvious untruth. To keep trying with it begs the question of whether the Secretary Of State is a fool, a knave, or both.

Life sciences

Chancellor Jeremy Hunt's got the national credit card out to whack £650 million at the life sceinces. The press release tells us that his "multi-faceted ‘Life Sci for Growth’ package brings together 10 different policies including £121 million to improve commercial clinical trials to bring new medicines to patients faster, up to £48 million of new money for scientific innovation to prepare for any future health emergencies, £154 million to increase the capacity of the UK’s biological data bank further aiding scientific discoveries that help human health, and up to £250 million to incentivise pension schemes to invest in our most promising science and tech firms".

Mmmmmmm. Note the repeated use of 'up to' there.

Apparently it "also includes plans to relaunch the Academic Health Science Network as Health Innovation Networks to boost innovation by bringing together the NHS, local communities, charities, academia and industry to share best practice". That'll be nice, if it actually happens: the AHSNs have become sadly bereft of real purpose.

Speaking at the launch, Health But Social Care Secretary Steve Barclay said, "we will take forward Lord O’Shaughnessy’s recommendations to speed up the delivery of clinical trials and boost patient involvement in research, so people getting NHS care can benefit from cutting-edge treatments faster, supported by £121 million in government funding".

The financial incentives for GPs to enrol patients in clinical trials caught the media's attention: it'llo be interesting to see what this amounts to in practices.

Eli Lilly doesn't seem to have got the memo, and is now reconsidering its plan to invest in lab capacity in London because of the "stifling commercial environment", due to the VPAS.

Recommended and required reading

Professor Steve Black's latest HSJ column is a good read on the need to genuinely understand what's needed in NHS reform.

Chris Morris speech at the BMA's LMC conference https://www.youtube.com/watch?v=vECEz1E0HWg

Sensible Economist editorial on NHS reform. https://www.economist.com/leaders/2023/05/25/how-to-fix-the-nhs

Amazing story about a spinal injury sufferer's successful experimental treatment.

Dentistry remains in crisis.

BBC Newsnight follow up on new controversy about the GIDS reform.

My latest column for the Pharmaceutivcal Journal.