Cowper’s Cut 298: Autumn Statement, winter gloom
This week’s PMQs saw Labour leader Sir Keir Starmer use all six of his questions on the NHS.
As we start to hit winter, NHS-themed PMQs may well become a monthly thing.
So too may PM Rishi ‘The Brand’ Sunak’s relaunches of the Conservative And Unionist Party Government, the latest of which landed on Monday in his speech at a college in north London (home turf of the metropolitan liberal elite).
Starmer asked Sunak why his new five priorities had somehow left out the NHS (which had been one of the PM’s January pledges).
Prime Minister’s Office, 10 Downing Street
Since the PM’s January 2023 pledge to cut NHS waiting lists, Starmer noted, they had grown half a million longer. The PM’s response was that “union action, which he fails to condemn, and which his Members of Parliament support from the picket lines, has led to several hundred thousand cancelled appointments, all making waiting lists worse”.
The Health Foundation
Well, it’s a point of view. Albeit not one shared by the Health Foundation’s recent analysis, which found that “industrial action by consultants and junior doctors has so far lengthened the waiting list by around 210,000, just 3% of the overall size of the list, which totalled 7.75 million at the end of August 2023”.
It’s also consequential politically that both in his north London college speech and at PMQs, Mr Sunak pointed to medical militancy as having sabotaged the Department For Health But Social Care and its wholly-owned subsidiary NHS England’s ‘Abracadabra!’ plans to cut NHS backlogs by increasing elective activity to 130% of pre-pandemic levels by 2024-25, in the absolute absence of any credible method, motivation or theory of change. (The English NHS is, of course, nowhere vaguely near to achieving this productivity increase.)
Jeremy Hunt also touched in this in his Autumn Statement, emphasising the role of public sector pay restraint in reducing inflation (an assertion that most economists agree is nonsense).
These have implications beyond the battle of the political narrative (in which the Government can, as ever, rely on its supine media stenographers). They will also influence the pay negotiations currently under way between new Health Secretary Victoria Atkins and the BMA’s junior doctors and consultants committees’ leadership, and it is unlikely that this influence will be positive.
The PM also asserted that “one of the key things that we are doing to bring down waiting lists is expand access to patient choice. It is a very straightforward idea to make sure that patients can choose where they are treated, and in that way we will bring down waiting lists for mental health and other treatments far faster”.
Ahem.
Secondly, for patient choice to be effective, the NHS and its third and private sector suppliers need to have spare capacity. This isn’t really the current situation: that is why RTT lists keep growing. Despite repeated re-announcements of deals with the private sector to use spare capacity there, there is only a finite amount of spare capacity there. (I’ve been writing for some time in ‘Cut’ about the independent sector’s own growing demand pressure problems, and the Financial Times picked up on this in this very decent article, which focuses on the private medical insurance market.)
Autumn statement
Chancellor Jeremy Hunt’s hinterland as the longest-serving health secretary to date cannot be said to have coloured his Autumn Statement unduly.
As mentioned above, among his opening lines was the phrase “we have not made unaffordable pay offers to the unions”. Mmmmmm. Well, not yet.
Mr Hunt repeated his pledge to “maintain a disciplined approach to public spending. As I set out in the spring Budget, resource spending will increase by 1% a year from 2025-26 in real terms, and we are sustaining the record 2020 increase in capital spending in cash terms until the end of the forecast”.
These are interesting numbers, because with almost the entirety of the public sector in or approaching a serious crisis of capital and revenue funding, remarkably few people believe that they will be achievable.
Mr Hunt trumpeted “record numbers of police officers, doctors, nurses and teachers”, without either mentioning the retention crisis among experienced staff in the latter three professions, or discussing the huge number of police officers laid off at the start of austerity.
The Chancellor added that “alongside extra funding and support, we need to see reform. We need a more productive state, not a bigger one. That is why I want the public sector to increase productivity growth by at least half a percent. a year—the level at which the size of our state starts to reduce as a proportion of GDP”. This is an interesting ambition, but as yet one which has no actual delivery plan about how it will be achieved.
The Institute for Fiscal Studies’ analysis is, as ever, worth reading: their slides are particularly illuminating on the impact of inflation, and its conclusions that “no extra money for capital = lower each year in real terms (even Labour’s extra £20 billion not enough to avoid investment falling). Boosting public sector productivity massively important – but only helps public finance if allows for cashable savings” seem unarguable.
Outpatient dept at Stockport hospital immediately closed after 'significant deterioration' to building
— Lawrence Dunhill (@LawrenceDunhill) November 24, 2023
Much of the estate at Stepping Hill is pretty dire & trust has been trying to get towards the front of the Q for capital investment for a new-build.
To no avail so far https://t.co/XmSOWsl71x
Still, thank goodness there’s no urgent needs for capital investment, eh?
Taking a longer view, day-to-day health funding next year is set to be around 150% higher than in 1998. For other departments, the equivalent figure is 35%... pic.twitter.com/pMDLPUZYfZ
— Ben Zaranko (@BenZaranko) November 23, 2023
The IFS’s NHS experts Ben Zaranko and Max Warner provided more useful fiscal commentary on Kiss (formerly Twitter). Warner looks in detail at the funding of the Agenda For Change pay deal, and concludes that it only appears in the current financial year’s accounts.
This is significant. When the Government does a pay deal, such as that with the AfC trades unions which stopped the RCN strikes, you’d 100% expect the funding for this additional pay to go ‘into the baseline’: this means that it becomes part of the new running costs of the NHS.
It looks very much as if the current Government hasn’t done this, which would bake an actual NHS funding cut into future financial years.
Here I am going to focus on nominal (cash terms) budgets because this is how funding is allocated.
— Max Warner (@MaxWarnerIFS) November 23, 2023
Of course changes in inflation will make nominal budgets more or less generous in real terms.
I'm also going to focus on current not capital spending.https://t.co/CkOWMtRKb6
The OBR now anticipate GDP inflation this FY will be 6.1% - significantly higher than the 2.5% figure published by HMT last month. NHS orgs will feel somewhat vindicated about the cost pressures they have faced this year, which are fueling an expected £1.7bn overspend >>
— Sally Gainsbury (@sallygainsbury) November 23, 2023
The Nuffield Trust’s NHS finance lead Sally Gainsbury provided characteristically cogent analysis of the implications of inflation for NHS funding, drawing on the updated Office for Budget Responsibility analysis.
Sally Gainsbury
The NT’s health and care finance tracker was updated accordingly.
Henry Anderson
Health Service Journal’s Henry Anderson and Lawrence Dunhill report on the deteriorating mood music between NHSE and ICS leaders as to recovering the probable half-year deficit of £1.5 billion. The proposed cuts - sorry, ‘solutions’ - are being described as “unpalatable”, “catastrophic”, “nuclear” and “impossible to deliver”.
Palantir consortium awarded Federated Data Platform contract
It’s not news to ‘Cut’ readers, but this week it was officially confirmed that the Federated Data Platform contract let by NHS England was awarded to the consortium headed by NHS Datastore creators Palantir UK (the supporting members are Accenture, PwC, NECS and Carnall Farrar).
My usual conflict of interest declaration here: I am on Palantir’s health advisory panel, which is a paid role.
SOS Atkins’ written statement emphasises that “the provider of the software will not hold or have access to NHS data for any purpose, other than as directed by the NHS; they will not control the data in the platform, nor will they be permitted to access, use or share it for their own purposes. The contract makes strict stipulations about confidentiality. No new data will be collected, and GP data will not be part of the national platform”.
Atkins incants the vague litany of benefits delivered to date by the 26 FDP pilot sites: “clinicians have described the results as “game-changing”. It has helped them to better organise their clinics and waiting lists by integrating and consolidating data from different hospital systems or by creating a single list of information used by everyone working in health and care on discharge of patients from hospital.
“Patients in these vanguard trusts have seen falls in waiting times, discharge delays reduce, and diagnoses speed up. Theatre utilisation has increased by more than 6%, meaning an average of 120 additional patients per month are being treated at each trust.
“A new discharge tool has allowed one trust to reduce unnecessary days in hospital for long-stayers by 36% and halve the number of patients occupying a hospital bed for 21 days or more, compared with the England average.”
All sounds great: has any of it been evaluated?
Joe Talora
Inevitably, these claims are contested: Health Service Journal has an authoritative-looking piece on this. Contacted by HSJ, just four of the (then) publicly-listed 19 participating trusts cited benefits: seven trusts rejected or paused their FDP pilots, with no benefits accrued.
Never done a thread before but making an exception for FDP and Palantir.
— Nicholas Carding (@ncarding) November 24, 2023
My thoughts summarised below, see if you can make it to the end 👇
1: FDP - in principle - is a GOOD IDEA. NHS staff and patients are frustrated by poor access to data on a daily basis.
This Kiss thread from Health Service Journal’s Nick Carding is very fair and even-handed.
VPAS becomes VPAG
Department of Health and Social Care
The 2018 voluntary pricing and access scheme (VPAS) has had a small but important rebrand as the voluntary scheme for branded medicines pricing, access and growth. ‘Growth’ is the bit that the life sciences industry wanted, and has got.
There are the usual spurious claims that the new deal will ‘save’ the NHS £14 billion over the coming five financial years. It won’t be cashable savings, for sure.
I’ve been tracking the belligerent noises of the life sciences industry leaders over VPAS. More details can be found here.
The Alan comeuppance
Andrew Sparrow
The People’s Partridge is due to give evidence again at the Covid19 Public Inquiry, but Sir Patrick Vallance’s evidence this week added to the pile of those who report that Mr Hancock was known for telling untruths: “I think he had a habit of saying things which he didn’t have a basis for.
“And he would say them too enthusiastically, too early, without the evidence to back them up, and then have to backtrack from them, days later. I don’t know to what extent that was over-enthusiasm versus deliberate. I think a lot of it was over-enthusiasm, but he definitely said things which surprised me because I knew the evidence base wasn’t there.”
Matt Hancock gets a full day and a half at #CovidInquiry next week for those who can stomach it: pic.twitter.com/CSg2dA7GG5
— Shaun Lintern (@ShaunLintern) November 23, 2023
Shaun spots that we are to be treated to a full day-and-a-half of The People’s Partridge giving evidence to the Covid19 Public Inquiry next week.
Alan is one of the little helpers for the National Crime Agency’s ongoing investigations into Tory per Baroness Mone’s now-admitted involvement in PPE Medpro.
Harry Yorke and Dipesh Gadher
The article carefully makes clear that Alan (alongside chatty chap Michael Gove and Lords Bethell and Agnew) was “interviewed as witnesses and not under caution. There is no suggestion they were involved in any alleged wrongdoing”.
Toby Helm
Alan has also been briefing the Observer’s Toby Helm on his lines of defence for his appearance at the Covid19 Public Inquiry later this week.
The People’s Partridge clearly plans to try to convince the Inquiry that he was ahead of the curve with his warnings about the urgency of Covid19, and that it was the 10 Downing Street operation’s failures to listen that worsened matters.
How typical of the Grauniad newspaper group that they mis-spelled ‘Alan’ as ‘allies’. The Hancock MO never changes.
Recommended and required reading
Worryingly, it seems that Clostridium Difficil can no longer be removed by bleach.
The Economist reports that the UK is going to try to create a pathway for individually customised medicines.
Steve Black’s latest Mythbuster column for HSJ is, once again, very good.
The Times’ Eleanor Hayward’s analysis and summary of CMO Professor Sir Chris Whitty’s evidence to the Covid Public Inquiry.