Mar 24, 2024 11 min read

Cowper’s Cut 315: Hanlon’s Razor cuts and burns

Most of you are familiar with (William of) Occam’s Razor: the hypothesis that the simplest explanation for something is usually correct.

I was delighted to learn of a contemporary counterpart: Hanlon’s Razor, which proposes that one should ‘never attribute to malice that which is adequately explained by stupidity’.

Ahem.

I was reminded this week of my previously proposed ‘Senior Healthcare Job Exit Loghorrea Syndrome’, when the outgoing NHS Ombudsman Rob Behrens suddenly become very vocal about poor NHS cover-up trends over care standards, just as he gave media interviews around his departure.

This is not a thing about which ‘Cut’ readers are unaware. It is depressing to read that “in an interview with The Guardian as he prepares to step down after seven years in the post, Rob Behrens claimed many parts of the NHS still put “reputation management” ahead of being open with relatives who have lost a loved one due to medical negligence.

“The Ombudsman said that although the NHS was staffed by “brilliant people” working under intense pressures, too often his investigations into patients’ complaints had revealed cover-ups, “including the altering of care plans and the disappearance of crucial documents after patients have died and robust denial in the face of documentary evidence”.”

There’s nothing like really good timing of your intervention, and this is nothing like really good timing of your intervention.

The utter stupidity of people who believe that what they say on their way out of the door acquires instant credibility and gravitas is just breathtaking. It’s also depressingly common.

The time you have to make an impact is the time when you are in the job. That’s it. It is depressing that the penny is yet to drop for so many, that becoming loquacious on your way out the door simply makes you look foolish, and lets The Powers That Be Unchallenged simply laugh at you, unchallenged.

Junior doctors’ industrial action mandate renewed

To the considerable surprise of absolutely nobody, the BMA junior doctors’ committee won a renewed six-month mandate for industrial action, with a majority of 98% on a 62% turnout.

Specifically, 98% of voters backed further strike action and 97% backed ASOS (no, not the cheap fashion retailer): action short of striking.

That is going to be important. The junior doctors’ resolve is impressively durable (and vice versa), but their desire to undergo the ongoing losses of income from more longer strikes must surely come into play.

An interesting question that they should now be considering is how to make ASOS effective. Their ability to avoid the pointless and useless stunts of the 2015-16 ‘new contract’ campaign has thus far been a considerable strength of their approach.

Text here on the Government’s Stakhanovite efforts since the last strikes ended to resolve the industrial dispute with junior doctors, so that NHS service provision can resume at full capacity.

New (If Fictional) Hospitals Programme in ‘is fictional’ shock

Imagine my surprise to read that the New (If Fictional) Hospitals Programme is, well, fictional.

Health Service Journal’s Zoe Tidman reports that the N(IF)HP is short of £4 billion of requisite funding. Even the Department For Health But Social Care have had to admit that there is indeed not enough money

What a shock. Who could possibly have predicted this, all the way back at the very outset of the mythologising?

Oh yeah, me: that’s who.

The story reports that “Ministers have so far pledged £22 billion to the New Hospitals Programme, but well-placed sources told HSJ that a full business case is now requesting £26 billion from the Treasury. The Department of Health and Social Care is thought to have added its support to the bid.

“HSJ understands the cost has increased due to a change in approach to bed numbers, with the NHP now proposing to maintain existing numbers rather than reduce them. It is understood NHS England felt it was too early to assume reduced demand for inpatient beds. Concerns were also raised last year that the standard designs being considered could result in new hospitals that were too small.”

In the words of fragrant satirist Julian Patterson, what the N(IF)HP lacks in buildings, it more than makes up for in fabrication.

NAO report on NHS Long-Term Workforce Plan

This Year’s Model?

Mmmmmmm. If not mmmmmmmmmmmmmmm.

The National Audit Office is, alongside Private Eye, one of the reliable routers that we still have to some certainty about what is actually going on in The Real World.

Accordingly, the NAO’s latest report on NHS England’s modelling assumptions for the NHS Long-Term Workforce Plan is a very useful read.

I might well say this, as it coincides quite strongly with the critique of shaky assumptions that I was enabled to make by smart colleagues and ‘Cut’ subscribers here, back when the NHS LTWP first saw the light of day.

The NAO’s report rightly does not piss about in its verdict: “this first version of the modelling pipeline as a whole has significant weaknesses, including the lack of integration between different parts of the pipeline and the manual adjustments to balance supply and demand gaps in the triangulation models.

“We found that limitations in documentation and the use of manual processing meant we were not able to fully replicate the results of the modelling as an independent reviewer.

“Some of the assumptions used in the modelling may be optimistic, and the model outputs were weakened by the limited extent to which future uncertainties were communicated. NHSE needs to address these issues in order for the modelling to be a reasonable basis for regular strategic workforce planning.

“Workforce modelling is highly unlikely to produce a single ‘correct”’ answer on how many health professionals will be needed in future. In this context, modelling is really an evidence-based and transparent tool for beginning a conversation, including with external stakeholders, about the desirability and feasibility of different approaches and policies.”

Nobody was expecting the LTWP to be perfect. But I’d say that quite a few people were expecting that it might include uncertainty ranges, and some acknowledgement that scenario-planning in healthcare should tend to try to remember how both the Wanless and Dilnot scenario-planning approaches actually panned out in The Real World.

RCP leadership find selves in hole, continue digging

We now know that senior officers presented a flawed and distorted version of the findings at the Extraordinary General Meeting on 13th March 2024. Here’s my thread on that presentation (from before I’d seen the actual results).
2/https://t.co/gQ7r2eXC9W
— Trisha Greenhalgh (@trishgreenhalgh) March 18, 2024

The Royal College of Physicians’ current leadership seem to be a bunch of sleeper agents sent in, Trojan Horse-style, from the Royal College of Physicians of Edinburgh. The data behind the shockingly-presented physicians associate (PA) survey for last week’s EGM has now been released, and oh boy, can you see why the RCP leadership tried so desperately to gerrymander it.

Professor Trish Greenhalgh narrates us through this ably on Kiss (formerly Twitter). Of the MRCPs who feel able to comment (73% of the total sampled), 61% say that having a PA on the team impacts negatively on their own training opportunities. For speciality trainees, this figure rises to 63% (of the 88% who feel able to comment). For internal medicine trainees, this figure rises to over 80% (of the 96% who feel able to comment).

For those not consultants or in trainee roles to become consultants (SAS; locally employed doctors,; GPs), 69% (of the 75% who feel able to comment) believe that their own training has been negatively impacted by introduction of PAs.

When asked if the introduction of PA roles had impacted on the training of other doctors in their team (i.e. not just on their own training), the figures were even higher. Of the 80% of consultant respondents who felt able to comment, 53% felt that PAs had had a negative impact on training opportunity for others in the team.

The irony of the Royal College of Physicians having been used as the location for the police station in ‘Paddington 2’ is delicious.

Mind you, the General Medical Council seem determined to provide the RCP with some stiff competition in the current ‘who-can-piss-their-members-off-most-a-thon’. Their medical director and director of workforce and standards Dr Colin Melville, has written a remarkable new blog, which directs us to this statement.

In a footnote, the GMC statement says, “our responsibilities will soon extend to regulating Physician Associates (PAs) and Anaesthesia Associates (AAs). Our initial focus will be on ensuring the right pre-qualification structures and processes are in place to assure ourselves of a consistent standard for them to be included on the register. Once brought into regulation, the principles in this statement will apply to these professions as well.”

These principles mean that post-grad MAP training will be exactly the same as it is for doctors.

But what they really mean is non-doctors educating, supervising, training and mentoring doctors.

I am absolutely not averse to other members of the MDT being involved in post-grad teaching and training. Groovy! Should be more of it.

But supervising and mentoring??
5/ pic.twitter.com/mF6pcPuxmg
— Louella Vaughan (@DrLKVaughan) March 19, 2024

As Dr Louella Vaughn notes, “what they really mean is non-doctors educating, supervising, training and mentoring doctors.

“I am absolutely not averse to other members of the MDT being involved in post-grad teaching and training. Groovy! Should be more of it. But supervising and mentoring? Professions train, supervise and mentor their own. That's part of what being a profession is all about.

“Then they want to change medical schools. Again, nice idea. But they are clear that they want to shorten courses and use more online teaching … I am especially concerned by the statement: 'outcomes ... basis for career development ... for all professionals'. Remember, they stated at the start that this document is NOT just for doctors. Are they implying that anyone who can function at the level of a doctor and prove competencies and satisfy their employer IS a doctor?”

Where the EGM vote lands the RCP leadership

The RCP’s EGM vote massively rejected the current RCP leadership’s recommendation that the meeting’s vital fifth proposition, on caution over scale and pace of associate roles roll-out, be opposed: instead, this was supported by 79% of respondent RCP voters (on a 32% turn-out).

The RCP’s leadership now look out-of-touch, and silly - and very exposed indeed.

They’re going to have to go. The only question is how, and how soon.

Wes Streeting re-states his position to the FT

Labour’s shadow health secretary Wes Streeting has re-stated a bunch of things he has previously said.

This is Not News.

However, he did so in an interview with the Financial Times, which is one of the few remaining credible national news media publications. There is therefore a reasonable likelihood that because the FT is credible and media attention spans are short, this will inadvertently become News.

A couple of Streeting’s quotes bear repeating: “I can simultaneously want to reduce our reliance on the private sector by making sure the NHS has the staff, the equipment, the technology it needs to treat patients on time, at the same time as recognising that there is currently some capacity in the private sector and we should seek to use it.”

He’s said every bit of that in interviews before, more than once. But in the words of the classic song, ‘T’Ain’t What You Do, It’s The Way That You Do It’.

There is, however, a new bit, and it may get missed completely, because it’s important: “I’m less persuaded by the ideological conviction of New Labour — even though Tony always says he wasn’t ideological — that competition in public services necessarily drives up standards”, Streeting told the FT, noting that the evidence to support that view was “patchy … the private sector fell off a cliff under the last Labour government, because the NHS was so good that people didn’t feel the need to go private … and that’s my ambition again: to make the NHS so good that no one feels forced to go private”.

The important bit here is that Streeting has become interested in the evidence that competition drives (or drove) up standards in our system of publicly-funded and largely publicly-provided healthcare. There is some (Cooper, Van Reenen and Propper are the main academic proponents), but it isn’t overwhelming.

Nor has the New Labour health competition playbook been widely imitated elsewhere. There tend to be reasons for that.

I’ve been critical of what I see as Streeting’s Alan Milburn tribute act tendency (attention-paying readers will remember that I mentioned that I wrote about Streeting being advised by Milburn many months ago). But Mr Streeting is evidently a bright and capable bloke, and it’s actually both interesting and not only News, but Good News, to hear that he is thinking seriously about serious issues.

Why you’d never do PFI again, ever

Apart from being basically financially literate?

See HSJ’s coverage of an ongoing legal case where administrators for the collapsed PFIco of the Whittington is trying to sue a former advisor on fire safety.

These same administrators are already suing Whittington Healthcare Trust for £56 million, claiming subsequent payments it withheld because of the provider’s inadequacies caused the company to collapse.

Funny old world. Those were days.