Cowper’s Cut 324: Things Can Only Get Wetter

Considering the millions spent creating the high-spec TV studio within Downing Street, one must have a heart of stone not to laugh at the footage of a soaked Prime Minister Rishi ‘The Brand’ Sunak announcing the ‘Genny Lex’ (thank you, Gen Z) outside the front door of 10 Downing Street in pouring rain, as an irksome Brexit protestor blared New Labour anthem D:REAM’s ‘Things Can Only Get Better’ on a nearby loudspeaker.

You’d assume that a consequential general election campaign that started as poorly as this would quickly get booted into serious mode.

And you’d be wrong.

Mr Sunak’s anti-Midas touch saw him ask Welsh brewery staff if they were looking forward to the Euros football tournament (for which Wales didn’t qualify); taking planted questions from Conservative councillors posing as high-vis-clad staff in a distribution warehouse; photographed on the private plane taking him and the press pack around under a prominent ‘exit’ sign; and best of all, doing a media session in Belfast outside the Titanic exhibition centre.

This seems less like electioneering, and more like Dadaist performance art.

We won’t mention the PM’s ‘glaring at bread’ incident.

And that is just the first few days of the general election campaign by ‘the natural party of government’. There may be worse to come: a sense of chaos and disorganisation in a fast-paced election campaign can quickly become self-perpetuating. Failure, like success, can become a habit.

What kind of campaign will we get in GE2024? And how will health, care and NHS issues figure in it?

The national mood appears to make GE2024 a ‘time for a change’ general election. The opinion polling data since the launch on Wednesday do not show any great change. The significant tally of Conservative And Unionist Party MPs in what should typically be relatively safe seats who announced their exit from the Commons tells us that even Conservative partisans recognise that their time is up.

The campaign is sure to see Labour remain cautious and limited in its promises. This is to be expected: they are sitting on a huge lead. Hypotheses that Labour’s huge opinion poll lead will narrow have, to date, been wrong. Ironically, the Conservatives have greater room for radicalism because they are so far behind.

Political priorities

How will Labour conservatism and Conservative potential radicalism play into the health, care and NHS aspects of the campaign?

My guess is, not very much.

Labour: clarity on limits and opacity

The issue for Labour is about raising expectations.

One of Labour’s six GE2024 pledges is to “cut NHS waiting times with 40,000 more evening and weekend appointments each week, paid for by cracking down on tax avoidance and non-doms”. This is based on an assumption that NHS staff will want to work extra sessions in evenings and at weekends.

Come 5 July 2024, Labour will not inherit the strong economic growth that let New Labour more than double the NHS budget between 2000 and 2010. This means that they are going to have to do all they can that doesn’t require throwing huge amounts of money at the problems.

There are options here for the acute sector, including a re-professionalisation of NHS management (remember, the Lansley reforms cut it by 45%) with a rediscovery of waiting list management theory and practice, and a relentless focus on patient flow through systems. This would have to be balanced with increases in social care provision, which will not be cost-neutral.

If they can get the staff to work more, then Labour’s promise of 40,000 extra operations a week will help, somewhat, to bring down the 7.6 million NHS RTT backlog. But this may not make it come down quickly, and they know it.

40,000 extra treatments a week (if achieved) would equal 2 million a year, but structures and systems will need to be put in place to achieve this.

So they will manage expectations of improvement.

Labour will also inherit unresolved pay disputes with junior and SAS doctors, and probable working-to-rule from GPs. Then there are the unacknowledged cost pressures within the NHS, some of which are touched on by this HSJ procurement comment piece by Jason Dorsett.

Once incentivised lying is discounted, the English NHS’s financial situation is bleak, as HSJ news editor Dave West observed.

There is also the issue of vast deficiencies in NHS and medical culture and leadership. This is fast becoming public knowledge, whether through the infected blood scandal; through the grotesque mis-handling of spreading the associate practitioner roles (it is now clear that the Royal College of Physicians had a parallel, secret document in progress); through the GMC’s admission that vexatious references are used as a management technique; through deeply discontented doctors.

I could go on and on about dysfunctional NHS leadership culture, and I do. Labour realise they have a big, ugly problem here.

I am not clear whether they know how to go about changing the incentives that reward bullying, covering up and never, ever embarrassing the health minister.

NHS culture: why it’s so bad

How would Labour go about changing the immensely centralised nature of the current version of the NHS, which is a part of the closed, defensive, hierarchical, lawyered-up culture that prevails widely today?

Many things brought us here: the de facto abolition of FT status; the uber-growth of NHS England; the years of blatant incentivising of financial lying; the ‘more Matt Hancock’ clauses in the 2022 Act re-establishing the Secretary Of State’s primacy in power; the pandemic; the absent or theoretical protection for NHS whistleblowers.

This centralised, challenge-averse, closed, defensive, ‘lawyered-up’ culture will not change lightly. The internal market and greater freedom for providers with FT status didn’t change it: arguably, they made it worse. See also: targets and terror.

If all of the incentives lead you to cover shit up and lie to avoid ‘bad news for the minister/NHSE’, that’s what you’ll do. This isn’t complicated.

There are things that we know don’t work: Duty Of Candour and Freedom To Speak Up, to name but two topical ones. Both are good ideas in theory: both do not happen in practice. They are policies in name only (PINO?). David Oliver’s recent BMJ pieces on Duty Of Candour are worth reading.

The fundamental ideas of candour and safety culture with just accountability are vital, but are neither incentivised nor rewarded.

The behaviours that systems reward and give honours to is the behaviour that these systems get. Bad leaders do not get cleared out of the NHS. If you want different and better processes and results in the NHS, you need different and better leaders - and different and better incentives.

There are no signs of these whatsoever.

Labour for Glasnost

Wes Streeting: Cultural rot means NHS puts itself before the public

Labour will pursue a decade of change including protections for whistleblowers and sackings for those who try to silence them, says the shadow health secretary

The Sunday TimesWes Streeting

Nor did we get much clarity in shadow health secretary Wes Streeting’s NHS culture article for the Sunday Times. It did, however, open with a cracking anecdote: “on the 74th anniversary of the founding of the NHS, the phone rang in my office. It was NHS England calling to complain about research we’d put out showing the number of people dying while on waiting lists.

“They weren’t calling to complain about the accuracy of the story or tell us about their plan to do something about it. They called to complain that we had spoilt the NHS’s birthday.”

Readers are familiar with my delight at the idea that the NHS has ‘birthdays’, and indeed at the general competence of NHS England.

The piece continues, “of all the challenges we face if we win the next general election, it’s the culture that worries me most. We have too often seen NHS leaders become defensive or even blind to its serious shortcomings. Not just historic injustice, but ongoing scandals — from failing maternity units to monsters like Lucy Letby. Recognising failures shouldn’t be regarded as heresy. Yet brave whistleblowers are hounded out, bullied and silenced as heretics.”

So what is Mr Streeting’s actual plan? “For the scale of change and modernisation required, the NHS needs opening up, a culture of transparency and a reforming mindset. We will give power to the patient, so they can easily judge providers by league tables, be told what they should expect from the service, and choose to switch if they want to. Where performance is poor, we will send in turnaround teams of the best performing leaders to improve care. 

“More trust must be placed in staff to try new ways of working, including partnering with the private sector and civil society. Frontline staff will be in the driving seat of the reform agenda — this can’t be done from Whitehall alone.”

There is little that is either new or obviously effective here. Patient choice already exists in theory as a very vague NHS Constitutional entitlement, and when tried seriously in practice under late-period New Labour, had only very marginal effect.

Turnaround teams of the very best leaders? Again, very little evidence of their effectiveness: there are often major negative impacts on the ‘leadership donor organisation’ - Western Sussex and Brighton University Hospitals; UHB and HEFT; Salford and Northern Care Alliance. Mergers often don’t fix things, either.

And sometimes, long-hailed ‘high-performing’ trusts turn out to have been largely triumphs of assertive PR concealing serious wrongdoing - such as West Suffolk, Southern Health or Torbay.

The three unwritten rules

Fixing NHS culture will be a long, tough job of changing the incentives that make England’s NHS a candour-phobic, closed, defensive system. NHS managers work by three unwritten rules:

1. Don’t blow up the money without explicit prior permission.
2. Don’t kill so many patients that people start noticing.
3. Don’t ever, ever embarrass the health secretary/minister.

You can see why the culture is very centralised and candour-averse. The NHS has spent the past couple of decades getting lawyered-up and ruining whistleblowers’ lives a) because they can afford to, and b) because nobody has been sacked for doing it. Not once. Ever. Not even Steve Dunn.

Unwritten Rule Three really works for the people in charge. NHS operational and political leaders’ general and utter lack of curiosity about why this toxic culture exists and persists is really striking.

I’ve said this many times before, and here it is again: the NHS needs a Chief Anthropologist more than it needs any Chief Inspector. Because tribalism is an epic problem, across all of medicine and healthcare.

And NHS England is, as Mr Streeting shows, a huge part of the problem. To be massively over-large and self-important may be considered a misfortune: to be massively over-large and self-important and also utterly shit at system leadership smacks of carelessness.

The NHS in England cannot afford to be led by careless clowns, who believe they can ‘comms’ problems away with their media genius.

But it is led by such people.

It is worth revisiting Nuffield Trust CE Thea Stein’s points on the need for psychological safety to underpin the hard work of culture change, improvement and transparency.

Conservatives for a subterranean NHS

The Conservative And Unionist Party will not be keen to highlight the fourteen years of failure which marks the performance of the NHS under their leadership.

Mr Sunak’s one good health policy - progressively banning tobacco sales to people - was dumped due to the timing of GE2024.

Health and care worker visa applications down 76% this year

The government said the numbers show its plan to reduce migration is working.

SkyAlix Culbertson

Health and care worker visa applications are down 76% this year. Taking back control, baby!

Participants in the New (If Fictional) Hospitals Programme are, one by one, beginning to admit that they will miss the 2030 completion deadline by some years. Primary care is somehow, heroically, doing more with less. NHS dentistry is dying out; pharmacies can’t get the drugs they need; mental health demand is sky-rocketing, and people in crisis are not being treated properly, with risks to life.

What will we hear from them? The [coughs] success of the N(IF)HP makes me believe that similar fictional manifesto commitments may and should be off the agenda, but the Conservative And Unionist Party has managed to surprise the health policy community on the downside for many years now, so who knows?

Certainly, their campaign will be about the increased inputs: indeed, in the past five years, NHS resources have increased. But its productivity has not. The lack of curiosity that the national system leadership has shown about this has been truly heroic. Could they try a manifesto commitment to cut NHS bureaucracy?

Neither main party seems likely to say much about social care, as Andrew Dilnot’s appearance on Friday’s BBC Radio 4 Today programme reminded us.

The NHS’s own lobbying sector have been setting out their stalls: likewise the big three think-tanks. Nuffield Trust’s Thea Stein has this lively blog.

I wonder why all this ‘health manifesto’ stuff seems curiously anachronistic, though. I think it’s because the sector has poured so much effort and so many infographics into this kind of wasted effort lobbying at each of the past four general elections in the last decade. There has been absolutely no obvious result on the quality of health policy and politics debate, legislation or oversight.

I wonder when the penny will drop with the lobbying sector that ‘being inside the tent’ is wildly ineffective with governments that manifestly don’t want to listen. I’m afraid that I think the answer is probably ‘never’.

Public priorities

There is a fascinating gap between what I think is the near-certainty that the two main parties do not want health, care and NHS issues to dominate this campaign (subject to our old friend, ‘events’), and the clear salience of the gradually-growing and unignorable failure of a major public service that every one of us can imagine needing to use in the future.

The mundane apocalypse has been a long time coming, and our NHS expectations and standards have been a long time getting lowered to their current subterranean position.

This gap is interesting, in that public priorities seem to be quite at variance with this political omertà on the subject. Recent polling data from Ipsos’ May 2024 Political Monitor shows that respondents’ stated view is that improving the NHS within six months should be the Starmer Government’s top priority: 63% of those interviewed backed this option.

The Ipsos work finds that “three in four (74%) predict that Labour will be the biggest party after the next election, which is up thirteen points since last September and much higher than public expectations of a Labour victory ahead of the 2010, 2015 and 2019 elections.

“Forty-five percent think there will be a Labour majority government, compared to three in ten (29%) saying a hung parliament with them as the largest party.”

If this is reflected in Labour’s private polling, then we have to wonder whether they have plans that are not going to be discussed at all before they are in office.

Sign of the (Sunday) Times: Spire warn of no quick private fix

Private hospitals boss says they’re not the answer to NHS crisis

Justin Ash, chief executive of Spire Healthcare, said private hospitals were already busy and couldn’t be expected to help cut waiting lists overnight

The Sunday TimesShaun Lintern, Health Editor

Spire Healthcare chief executive Justin Ash sent a helpful signal in his Sunday Times interview with Shaun Lintern. He stated a bit of obvious reality: that given their slender amount of spare capacity, private hospital providers will make only very marginal impacts on the NHS backlog.

The obvious does need stating, sometimes. Ash says that Spire hospitals are running at about 80% capacity. My contacts in the private provider world suggest that this is quite usual, due to the small increase in private medical insurance subscription rates and the not-small increase self-pay driven by NHS waiting lists.

As members of the Paying Attention Community know, most of the 2000s waiting list clearance was done by NHS staff working evening and weekend overtime in NHS facilities.

It will be the same again this time.

Best not piss off the workforce, eh?

Use your operational process muscle!

Use your ‘operational muscle’ to improve performance urges NHSE director

Commissioners and providers must get back their “operational process muscle” and use it to drive improvements to care, NHS England’s emergency care lead has told HSJ.

Health Service JournalMatt Discombe

The NHS seems to need a phrase of the year.

NHS England’s inaugural chief executive David Nicholson gave us the great line on the Lansley reforms being an NHS redisorganisation “so big you could see it from space”. In 2014, Nicholson’s successor Simon Stevens brought us “unleashing the renewable energy” of carers, patients, volunteers and staff.

There has been “support chassis” in 2017.

It’s only May, but 2024’s phrase of the year seems to be “operational process muscle”. And NHS England director of urgent care Sarah-Jane Marsh wants to see more use of it.

Outlining the recent addition of resources, Marsh told HSJ,  “the NHS, as a whole, need[s] to get back our operational process muscle. Increasing capacity and all those things are really important, but we’ve got to make the best use of the capacity that we’ve got.”

“That is about: making sure that our pathways, our processes, that everything, works; that we align capacity and demand; that we have teams in place at the right time; [and] the right IT systems. The answer to every problem cannot just be more capacity.”

In reality, NHS “operational process muscle” (or as it would be better known, ‘management capacity and capability’) was cut by 45% as part of the 2012 Lansley reforms. She is not wrong that this area needs great improvement, but it will take more than exhortation and a catchphrase for this to happen.

In the same interview, she also revealed that 40% of the £150 million NHSE capital incentive funding pot in 2023-24 to incentivise urgent and emergency care improvements was not distributed.

Vennells Times

Paula Vennells clung on to ‘plum’ NHS role after Horizon scandal

The former chief executive of the Post Office was allegedly ‘tin-eared’ to criticism

The TimesTom Witherow

Former Post Office chief executive, the Reverend Paula Vennells has been getting some belated but welcome publicity this week for her role in the Horizon scandal.

The Times helpfully chronicles how Vennells tried hard to cling on to her role as chair of Imperial Hospitals NHS Trust, once her part in the Post Office scandal became widely known.

The article reports that Vennells “was allegedly “tin-eared” to criticism and “her attitude was, ‘It’s time to put on the tin hats and ride this out’”.

“Directors at Imperial Hospitals NHS Trust privately asked her to step back, but she refused until one threatened to resign. The delay meant she remained in the post for 16 months after a judge ruled the Post Office boss’s position amounted “to the 21st-century equivalent of maintaining that the earth is flat”.”

The piece also reports that “sources said Vennells was close to Dido Harding, chair of NHS Improvement and part of the original advisory panel assessing which candidates had the required experience and the leadership quality to take on the role, the trust revealed in response to an FOI request.”

Infected Blood Inquiry final report

The Infected Blood Inquiry launched its final report this week. Medical expert Sir Brian Langstaff has played a blinder by insisting that the Inquiry will not be stopping its existence or programme until the issue of compensation for victims is fully resolved.

In an emotional launch event in Westminster Central Hall, Langstaff tried to defer the audience’s applause for his role, by asking them to applaud one another for their tireless campaigning over decades to pursue justice.

Isabel Hardman’s Spectator piece on the Inquiry hits the right targets about NHS culture’s role in the scandal, as does Martin McKee in the BMJ.

From EveryGrifter to Canary in the goldmine

Introducing Dr Julia Grace Patterson - our new columnist on the NHS

Dr Julia Grace Patterson is the Canary’s newest columnist, and she’ll be updating you with NHS news and the fight to save our health service

CanaryDr Julia Grace Patterson

Covering health policy and politics is often a bit depressing, so it is with joy that I bring you the fantastic news that EveryGrifter star Dr Julia Grace Patterson has been confirmed as the NHS columnist for unintentional comedy Corbynista media organisation The Canary.

It’s great news that the NHS can finally have the columnist it truly deserves. With a bit of luck, she could be as big as Royston.

Recommended and required reading

NHS England’s emergency care lead Sarah-Jane Marsh claimed in an HSJ interview that 40% of those attending Type 1 A&Es don’t need to be treated there.

Tech utopian nonsense from the Tony Blair Institute about how AI can transform public services. Sigh.

Righteous fury in Kamran Abbasi’s BMJ editorial on the medical workforce crisis.

David Oliver in the BMJ on the risk assessment of the NHS Workforce Plan.