Oct 22, 2023 13 min read

Cowper’s Cut 293: When are 5,000 more NHS beds actually 3,000 fewer NHS beds?

When are 5,000 more NHS hospital beds actually 3,000 fewer NHS hospital beds?

When you let the Department For Health But Social Care and its wholly-owned subsidiary NHS England have anything to do with the matter.

The Royal College of Emergency Medicine have been a busy bunch on the Freedom Of Information front of late.

They placed a story in The Times which revealed that “analysis of NHS England data by the Royal College of Emergency Medicine (RCEM) showed that between January and September, bed numbers in major acute hospitals fell from 100,046 to 97,332”.

This is embarrassing for DHBSC and NHS England. The NHS urgent and emergency care recovery plan, published in January 2023, set out plans to provide over 5,000 additional permanent, fully staffed hospital beds in total.

The Times reports that “NHS England said the baseline for its promise was the 94,500 core hospital beds it had planned to have available last winter, before pressures led to the opening of extra escalation beds across the country. It is still aiming to have 99,500 core beds by winter.”

Demonstrating an approach to understatement that borders on the heroic, RCEM president Adrian Boyle told The Times, “the fact that people have had six months to build that capacity but appear not to have [done so] is cause for concern”.

NHS Wales deceit over A&E data

The Royal College of Emergency Medicine’s next cutting piece of FOI research into NHS Wales’ A&E waiting data was shared with BBC News. It reports that “the true picture of A&E waiting times in Wales has been seriously under-reported for a decade … the Royal College of Emergency Medicine (RCEM) has established thousands of hours are missed from monthly figures.

This report states that senior A&E doctors have been raising the issue for months. The RCEM told the BBC it could not measure how bad things were because thousands of patients subject to ’breach exemptions’ were not included in overall A&E waiting times.

BBC Wales health correspondent Jenny Rees drily writes that “the Welsh government initially disputed the RCEM's claim, but after seeing detailed figures obtained through freedom of information requests to health boards, changed its position”.

Secretary Of State For Looking Baffled Steve ‘The Banker’ Barclay was quick off the mark to seek political capital, tweeting “Labour has said that A&E performance in Wales has outperformed the NHS in England this year.

“But it turns out they were hiding 45,000 patients from the figures. Whether for planned operations or urgent care, patients in Labour-run Wales wait longer”.

CQC State Of Care 2023: not good, astonishingly

Last week, I highlighted the Care Quality Commission’s blog about how they won’t be letting up on inspections.

This week saw the publication of their latest ‘State Of Care 2022-23’ report - and boy, are things in a state.

It found that nearly two-thirds of maternity units provide dangerously substandard care that puts women and babies at risk, having rated 65% of maternity services as either “inadequate” or “requires improvement” for safety of care (in their SOC 21-2 reports last year, it was 54%). Maternity services are struggling with serious staff shortages and internal tensions, the report adds.

The care provided by ambulance services was also getting worse, the CQC added.

Ambulance services have also seen a sharp deterioration in assessed safety of care. 60% of services was rated ‘inadequate’ or ‘requires improvement’ (upo from 30% in the SOC 21-2 report). Although 999 response times have improved since the disastrous state of things last winter, the CQC notes that too many ambulances are taking longer than seven minutes to respond to life-threatening emergencies - and more than 18 minutes to heart attacks, strokes and cases of sepsis.

RCGP wrong on primary care remedy, claims Streeting

Writing for The Times Red Box column, Shadow Health Secretary Wes Streeting fired another warning shot towards primary care.

Last week, Royal College of GPs chair Kamila Hawthorne suggested in her RCGP conference speech that neither the Conservatives nor Labour had credible plans to rescue primary care from what she called “an existential crisis”.

This is not a niche view in primary care. Team Hawthorne also briefed The Times’ Chris Smyth that doctors at the event would call for a “black alert” system that would allow surgeries to turn away less urgent patients when they’re overwhelmed (as hospitals do, although it’s now called something much friendlier, like ‘Opel Fruit’. Oh, sorry, ‘Opel Four’.)

Streeting’s response was to write that the RCGP proposals were “a plan for the managed decline of general practice, not a serious plan to get GPs back on their feet.

“Where will patients go if it is made even more difficult to see a doctor? Those who can afford to pay will go private, hastening the rise of a two-tier healthcare service, where the NHS is left behind as merely a poor service for poor people. Others will go unseen, with undiagnosed conditions left to worsen, sometimes until it is too late.

“At the same time, the royal college says general practice should receive billions of pounds more in funding, but said nothing how the money should be spent. All NHS organisations need to understand that this way of working won’t wash with a Labour government. The era of simply pouring more money into a broken system is over”.

Streeting reiterated Labour’s plans to shift money within the extant primary care budget to incentivise continuity of care. Robbing Peter to pay Peter is, at least, original. It probably won’t achieve much, but Labour is determined to own fiscal rectitude to a point where they may be starting to slam doors in their own faces.

In one of the worst lines I’ve read in some time, Streeting asserted that “a Labour government will take extraordinary practice in the NHS and make it the norm”. He is an ace away from telling the nation that it is a scandal that 50% of GP practices are below average.

Towards an end to consultants’ strikes?

Last week, I was dismissive of a story by The Guardian’s Denis Campbell about back-door communications over the consultants’ strikes. I checked with my sources, and at the time of my writing last week’s column, I was (and remain) confident that it was not well-founded.

Well in one of those ironies that shows your how national media still can move events, it subsequently became accurate.

Kat Lay of The Times was appraised of the development of a move towards talks.

I’m sceptical how long the talks will last, though. The DHBSC statement to The Times was clear that “officials insisted that headline pay was not up for negotiation”, which could prove challenging given that the consultants’ industrial action is about pay.

The consultants’ mandate for strikes was, well, striking: 86 per cent of BMA consultant members that voted (a turnout of 71.07 per cent) backed industrial action.

Oh, and SAS doctors are about to start talks with the DHBSC, with a massive mandate of their own for industrial action. 88% of respondents to an indicative ballot indicated willingness to take industrial action.

The answer is ‘mergers’. Now, what’s the question?

In last week’s column, I expressed modest cheerfulness that Labour’s nascent health policy plans at least did not involve structural redisorganisation.

I should not tempt the Health Policy Gods in that particular way, it seems.

NHS England » Integrated care system boundary changes and mergers procedure

NHS EnglandNHS England

It was a [chef’s kiss to fingers] magnificent moment, when I discovered that NHS England has reached the self-actualising level of irrelevance where it’s considering ICS/ICB mergers.

Ooooops.

ICSs have existed as local administrative NHS structures since July 2022. They are 15 months old.

Mergers in the NHS are almost always what happens when people do not know what else to do. The track record of provider mergers (in reality, usually takeovers) is mostly bad; often awful.

Consider South London Healthcare Trust. Or Good Hope / Heart Of England / University Hospitals Birmingham. Or Brighton and Sussex / Western Sussex. Or Northern Care Alliance. To name but a few.

Naomi Fulop’s work is worth re-reading, as is Colin Talbot’s.

Are local administrative mergers any better? The history of mergers of primary care groups/trusts, strategic health authorities and clinical commissioning groups over the past generation suggests strongly that this is what national leaderships do when they don’t know what they’re doing.

You might ‘go big’ to save money. I’m not aware of much evidence that this really works, as national bodies end up feeling that they need more resources to ‘man-mark’ the newly-merged organisations.

I repeat for emphasis: ICSs have existed for fifteen months. And now mergers are on the table.

In that short time, they foolishly went along with NHS England’s blatant incentivising of financial lying, which is now (to the considerable surprise of absolutely nobody) unravelling.

(Hello to fans of statutory regulation of NHS managers! How would that work when people get leaned on by the national leadership to lie about finances?)

If there is any purpose to ICS mergers, it is for NHS England to assert grip over local spending. That would rely on the same NHS England which made up ICSs so very recently to be good at grip.

Mmmmmmmmmm.

I am amused by section 3.9 of NHS England’s ‘long read’ document, which says that “the process of engaging on, applying for and implementing a change should not unduly distract the existing ICBs from business as usual, including delivering core performance standards”. Well, of course. How could potentially losing your job be a distraction in any way?

I get that local administration of the NHS is an unsexy subject.

But policy about big/small is also a proxy measure for whether national NHS leadership possess arse-elbow differentiation skills.

If their solution is mergers, they have not adequately understood the problems.

(Oh, and on a pedantic note, ICS stands for ‘integrated care systems’. If they merge, won’t that make them ‘disintegrated care systems’?)

Is The Banker really a line-crosser?

I rarely disagree with HSJ editor Alastair McLellan’s editorials, but I was bemused by his latest: triggered by bafflement poster boy and Health Secretary Steve ‘The Banker’ Barclay’s latest efforts to make the world aware he exists, via a showboating letter to chairs in the English NHS about not spending money on EDI leads.

Alastair writes that The Banker “does not carry the statutory accountability for upholding the equal opportunities and race discrimination responsibilities of local NHS organisations – their respective chief executives do. If the health and social care secretary wants to take on that role, he better set about changing the appropriate legislation.

“Just as significantly, Mr Barclay has humiliated NHS England’s leadership by issuing direct instructions to the service – and not telling NHSE he was going to do so. This rides a coach and horses through their accepted ways of working, and through the official process as described in law.

“The service has had to get used to Mr Barclay and his ministers intervening directly with trusts and integrated care boards, and has usually managed to work around it. But this intervention goes beyond the regular stream of questions, often irritating and bizarre, and unhelpful suggestions”.

This marvellous manifestation of management macho got Mr Barclay a favourable write-up in the right-wing media, which was probably its main intended audience. Things will get pettier and stupider yet by a long way, as our Conservative And Unionist Party Government heads towards the rocks of the electorate at ever fuller speed ahead.

But that’s not the key point here.

NHS England chair Richard Meddings went out to bat for perceived NHS independence on Friday, as HSJ’s Nick Kituno reported.

Surely the real issue here is that NHS England lost all its meaningful independence in the 2022 Health And Social Care Act.

As I pointed out when its white paper was leaked to Health Policy Insight, the Act “unambiguously puts the Secretary Of State For Health back in charge, in a massive political land-grab. This is in charge of both the overall system; of each local Integrated Care Systems; and of the NHS Commissioning Board (known now as NHS England).

“The Secretary Of State resumes formal powers of direction: for the SOS to have more power in this way, the chief executive of NHS England must of course have less.

“Ministers get new powers to intervene at any point of an NHS reconfiguration process, with a new process for reconfiguration that will enable the Secretary of State to intervene earlier and enable speedier local decision-making. The SOS gets new powers to transfer functions to and from specified arms-length bodies (ALBs), and the ability to abolish ALBs as a result of doing so. These power to transfer functions and abolish ALBs will be exercisable via a Statutory Instrument (SI) following formal consultation.

“The Secretary Of State’s revived powers of direction include the ability to mandate NHS England to take on public health functions (which were transferred to local government by the 2012 Act) without annual section 7A agreements.”

Frankly, whether The Banker consults Amanda Pritchard before sending a letter is essentially an argument about ceremonial and etiquette. If the NHS is seriously proposing to argue about ceremonial and etiquette as if they were key issues, then it will neither seem to have its priorities in the right place at all, nor be able to fight any effective form of rearguard action.

Pension pain

The Times’ FOI study finds a new increase in the number of NHS staff opting out of the pension scheme. Health Service Journal recently published something along these lines.

Max Kendix’s piece states that “more than 75,000 NHS staff pulled out of the scheme … including 25,000 aged under 30 … an increase of 67 per cent over the past four years, or 40 per cent once a growing workforce is taken into account. More than 10 per cent of those with less than £20,000 in pensionable pay opted out.

“The NHS scheme, despite having moved from a final salary to a career average model, represents a far more attractive structure, with higher employer contribution, than almost any private pension scheme. The government contribution is 20.68 per cent of earnings and the employee contribution rate is a sliding scale depending on pensionable pay, from 5.1 per cent for earnings under £13,246 to 13.5 per cent for those on more than £75,633.“

Kendix adds, “the number of opt-outs rose ... from 3 per cent of the 1.5 million eligible for the scheme in the 2018-19 financial year to 4.2 per cent of the 1.8 million members in 2022-23. The proportions are far higher among the lower paid. Those on pensionable pay of more than £100,000, who would probably only leave the scheme for tax reasons, represent less than 1 per cent of opt-outs”.