Cowper’s Cut 318: The Great Atkins-NHSE Stupid-Off accelerates; Wes Streeting, Wicker Man, opines

For several years, we’ve had few causes of cheer in the politics and policy of the English NHS. Over the past few columns, I’ve chronicled The Great Victoria Atkins-NHS England Stupid-Off to try to leaven the generally Stygian vibe, but I’m becoming uncomfortably aware that both parties may now be leaning into TGVANHSESO.

Little else could explain NHS England’s insanely stupid and stupidly insane decision to stop funding new secondary care staff registrations to the NHS Practitioner Health service from Monday. (Primary care staff access arrangements continue unaltered for another whole year: such generosity.)

This is in the wake of the pandemic’s effects on staff, which we know to have been profound.

Fronting up to the problems: what can be done to improve the wellbeing of NHS staff?

The NHS is not in a place where it can lose staff, but many workers in the health service have faced almost unimaginable difficulties during the pandemic. How worried should we be about NHS staff health and wellbeing? Nigel Edwards and Andy Cowper look at how bad the situation is and what can be done to improve things.

Nuffield TrustNigel Edwards

This policy choice is going to affect the very people who risked their lives to go to work during the Covid19 pandemic, to look after others sick or dying with Covid19. A more emphatic ‘fuck you’ from NHS England to that workforce, it is difficult to imagine.

The announcement states that “NHS England are undertaking a review of the staff support offer for mental health across all staff groups to consider long term sustainable options”: it would be hard to conceive of a less reassuring formulation.

NHS Practitioner Health was set up in 2008, in the wake of a tragedy. As its founder Dr Clare Gerada notes, “more than 32,000 patients later (who’ve) got better and most returned to work, safely. Many tell us we saved your lives. You tell us this publicly and privately & over 90% say they would recommend our service”.

There may be falser economies than this for NHS England to make, but there will surely not be many. The timing is particularly insane, given that the GMC has just published its report on the reasons doctors are migrating out of the UK health system (or planning to).

I wrote on Saturday on Kiss (formerly Twitter) that I suspect this absurd decision will not stand, and indeed NHS England’s well-deserved embarrassment at this epic stupidity is already showing.

Its director of ‘coughs’ strategy Chris Hopson took to Kiss for a thread of quite awesome levels of unreassurance, which fell onto extremely stony ground.

As a segue, Health Service Journal workforce correspondent Nick Kituno relays NHSE’s weekend-issued statement that “we have agreed we will, in partnership, work through how new requests received from Monday may be managed whilst the review is completed, and any alternative service put in place.”

A considerably more absolute U-turn than this is required, and I doubt that it will be long in coming. It certainly shouldn’t.

But who knows? That is to impute rationality to NHS England: an organisation whose leadership keeps on finding impressive new depths of idiocy to plumb. They are the Shackletons of stupidity.

Wes Streeting, The Wicker Man

Sigh. He’s off again, on the Greatest Hits Tour.

NHS warned there’ll be no additional funding without reform under Labour

THE Shadow Health Secretary warns the NHS today that there will be no additional funding without the “major surgery” of reform under Labour. Wes Streeting asks for Sun readers’ backing for a massiv…

The SunHarry Cole, Political Editor

No, not Dame Elton: it’s the health policy nation’s favourite Alan Milburn tribute act, Wes Streeting. He’s got his hits out for The Sun (appropriately enough) with this really rather pointless article telling us that the NHS is “a service, not a shrine” and attacking “middle-class lefties”.

There’s nothing new here at all: it is Mr Streeting’s standard ’we’ll fight for NHS reform blah blah blah only Labour can reform the NHS blah blah blah it’s a service, not a shrine, blah blah blah’. It’s really boring.

The number of people with NHS reform arse-elbow differentiation skills who think that nothing needs to change apart from more cash is literally zero. What’s happening here is less creating a straw man (that the NHS opposes reform), and more building a highly-combustible Wicker Man.

If you create an imaginary enemy whom you can heroically defy (‘The Anti-NHS Reform Coalition’?), then you’ve got what looks to the unwise like a ‘great story’. Political journalists almost all know very little about the NHS in depth, and they’ll probably buy it.

A much harder story to sell would involve having a detailed, data-driven knowledge of why the NHS got this deep into the shit despite big increases in funding and workforce, and what things you could do that will probably over time improve its performance.

The poor national leadership and lack of seriousness in management that bedevil NHS operational performance and hinder durable improvement are very real problems: imaginary cabals of “middle-class lefties” protesting about Labour’s plans for using the limited private sector spare capacity are not. The likes of EveryGrifter are many things, but a serious threat to meaningful NHS improvement is not one of them.

Imaginary foes of NHS reform are to blame, then. But here’s the problem for Mr Streeting: people are watching and listening to this nonsense. And some of them are the people whom he needs to motivate to do difficult things and different things. So this kind of Wicker Man, bullshit-driven analysis really doesn’t help.

Sure, we consider the venue Wes has chosen to get his hits out: The Sun is not where you will go to give a detailed outline of your evidence-based and nuance-rich health policy plans.

Wes Streeting defends Labour plan to use private sector to cut NHS backlog

Exclusive: Failure to do so would betray working-class people, shadow health secretary says

The GuardianPippa Crerar

Streeting gave a follow-up interview to The Guardian to ram the point home, in which he again repeated his imprecations against “middle-class lefties”.

And it’s been clear for years that Labour is desperate to get such a big majority that even internal Corbynite cliques can’t derail their plans.

But the comms strategy on show here is still lousy. Banging on about Labour’s plans to be radical on the NHS with “major surgery” of reform might have been shrewd back in 2020-22, when Labour couldn’t buy itself a hearing on policy issues. This is spring 2024: they are now eight months away from being the next government. The context is very different, but this ‘Milburn or bust’ comms strategy continues undifferentiated.

This doesn’t make Labour look tough on health policy: it makes them look like they don’t know what they’re going to do. That isn’t reassuring, any more than New Labour was in 1997 when their health policy was ‘abolish the NHS internal market’ (they brought it back just two years later). On-the-job training is all well and good, but Labour are going to inherit an NHS stuck in a longstanding performance crisis, and led by people who demonstrably have no idea how to fix it, nor any clarity about what the real problems are.

At some point, there becomes widespread concern in the health policy nation that we’re not hearing about Labour’s evidence-based and nuance-rich health policy plans because they don’t have any.

RCP leadership’s mea culpa over PAs debacle

The Royal College of Physicians’ latest council meeting, in the wake of their debacle of an EGM over physicians’ assistants, must have been lively. The statement from the RCP President (see below) is remarkable.

It promised a “reset … new agreed direction of travel … we will learn from this and do better”.

When a big organisation screws up as comprehensively, publicly and spectacularly as the RCP did, then only one ritual can suffice to appease the angry Gods: “The Royal College of Physicians (RCP) has commissioned an independent review following its extraordinary general meeting (EGM) held to debate the role of physician associates (PAs). The review underscores the college’s renewed commitment to transparency and accountability following the EGM, particularly on the handling of a pre-EGM member survey and how the data were presented to fellows.

“The independent review is being conducted by The King’s Fund, and is expected to report to RCP Council within 4 months. Its mandate is to look at:

• the context leading up to the EGM and the survey data management issues
• the current governance framework of the RCP, including its leadership and internal processes
• identifying areas of strength and opportunities for improvement in data management, governance practices and procedures.”

Much will depend on the credibility of the person who leads this independent review. A whitewash ‘nothing to see here’ approach will not cut the mustard. We shall watch how this one pans out with interest.

The President’s public statement was accompanied by this statement from the Faculty of Physician Associates: “hosted by the Royal College of Physicians (RCP) since 2015 … the FPA Board recently discussed whether the physician associate profession should continue to be hosted by a medical royal college.

“In recognition of recent developments, the FPA and RCP will now work together to develop a clear timeline for an independent faculty of PAs within 12 months. The FPA will work closely with its membership to ensure that PAs are involved and engaged with this process”.

Cass Review

The final Cass Independent Review Of Gender Identity Services For Children And Young People was released this week.

This thorough report should make uncomfortable reading for many who have nodded along with the Gender Identity Dysphoria Service approach to delivering something exceptionally untested under the guise of healthcare to vulnerable children and young people, many of whom were diagnosed with mental health problems and autism.

The lack of curiosity about the contagion effect and threshold-lowering almost certainly at work in England’s gender dysphoria rates remains remarkable. When the Tavistock And Portman’s GIDS opened in 1989, it treated fewer than ten people each year: mostly males with a long history of gender ­distress. In 2009, it treated 15 adolescent girls. By 2016, that figure had risen to 1,071.

Puberty blockers are highly uncertain drugs, first developed to delay very early puberty. When used at usual puberty age, the changes they induce are not necessarily reversible, as many practitioners seem to have promised.

Following a Dutch study which suggested that puberty blockers might improve psychological wellbeing for a narrow group of children with gender issues, in 2011 the UK trialled the use of puberty blockers in an early intervention study. Its results were not formally published until 2020, when they showed a lack of any positive measurable outcomes.

Despite this, from 2014 puberty blockers moved from a research-only protocol to being available in routine clinical practice. “The rationale for this is unclear,” the Cass Report says.

Among the shocking new things in this report is the fact that six of the seven NHS clinics delivering adult gender dysphoria services refused to take part in sharing patient data about children treated by Tavistock And Portman GIDS with the University of York’s safety and outcomes data-gathering work for Cass to help draw up best practice guidelines for how the NHS should help such vulnerable young people. Cass complains in her report that a potentially world-leading research project had been “thwarted” by this refusal to comply. The reasons for refusal, and York researchers’ responses, are listed in Appendix Four.

The last words here should go to Hilary Cass: “this is an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint. The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.

“It often takes many years before strongly positive research findings are incorporated into practice. There are many reasons for this. One is that doctors can be cautious in implementing new findings, particularly when their own clinical experience is telling them the current approach they have used over many years is the right one for their patients.

“Quite the reverse happened in the field of gender care for children. Based on a single Dutch study, which suggested that puberty blockers may improve psychological wellbeing for a narrowly defined group of children with gender incongruence, the practice spread at pace to other countries.

“This was closely followed by a greater readiness to start masculinising / feminising hormones in mid-teens, and the extension of this approach to a wider group of adolescents who would not have met the inclusion criteria for the original Dutch study.

“Some practitioners abandoned normal clinical approaches to holistic assessment, which has meant that this group of young people have been exceptionalised, compared to other young people with similarly complex presentations. They deserve very much better”.

New (If Fictional) Hospitals Programme remains leaderless

New Hospital Programme fails to recruit chief

The government’s New Hospital Programme has failed to appoint a new chief after conducting a recruitment process for a permanent senior responsible officer, HSJ has learned.

Health Service JournalZoe Tidman

Insert your own joke here about Health Service Journal’s revelation that the New (If Fictional) Hospitals Programme has been unable to appoint a leader from among the forty-four applicants.

They could always just make one up, I suppose. Who’d ever know?

Waits and measures

The latest RTT data for England was released this week. While there appeared to be small reductions in the overall list size, this was an artefact of the changes to reporting of community service RTT waiting times, as the explanatory notes of the press release make clear.

England’s NHS total waiting list for procedures and appointments fell from 7.58 million in January 2024 to 7.54 million in February (mainly due to NHS England having removed the waiting list for community paediatric health services (roughly 36,000 entries) from the overall figure).

NHSE saw its crudely-capital-incentivised 75% March 4-hour A&E target just missed: 74.2% of patients were admitted, transferred or discharged from A&E departments within four hours in March (up from 70.9% in February).  On the A&E safety front, the news remains dire: that 147,650 patients who attended A&E were there for more than 12 hours (this is 10.3% of all attendances). 

Wait list (probably) flatlines as community services disappear from data

About 40,000 patient pathways have disappeared. But on the plus side, a new and better data series has begun.

Health Service JournalRob Findlay

As usual, Rob Findlay’s analysis for HSJ is a must-read.

PM Rishi ‘The Brand’ Sunak’s attempts to defend his Government’s failure on NHS waiting reductions were chronicled here by BBC News. I really hope those ‘new Thatcher’ strike-busting vibes were worth it for The Brand: they clearly weren’t for anybody else.

Recommended and required reading

The impressive Jess Morley has written a piece for the excellent ‘Comment Is Freed’ website on AI hype.

Steve Black’s latest HSJ ‘Mythbuster’ column is another banger.

BBC Panorama on Going Private - What Are The Risks?

Hospitals are infested.