Jul 28, 2024 14 min read

Cowper’s Cut 333: Labour’s Back-To-The-Futurism

SOS CQC

An interim report has found significant failings in the effectiveness of the @CareQualityComm

We expect the Care Quality Commission to take immediate steps to restore public confidence.

A full report will be published in the autumn.

Read more: https://t.co/bkF0oh1vDZ pic.twitter.com/7Iq1nSYz7E
— Department of Health and Social Care (@DHSCgovuk) July 26, 2024

Apparently, the Care Quality Commission still exists?

I hadn’t noticed.

Its credibility has certainly not existed for the best part of the last decade: since some point around 2016-17, I’d say. I can’t remember the last occasion I spoke to anybody who took a CQC rating seriously. It was a key player in what I called the “constellation of regulatory Death Stars”.

I recall with amusement talking to a prominent chief executive whose trust had received a CQC appraisal on which the details of what was very clearly another organisation had been left.

Regulation is meant to find problems, to enable them to be put right and to check that this happens. The dreadful state of far too many NHS services, from mental health to maternity, does not suggest that regulation has been working well.

Or perhaps at all, as Penny Dash’s interim independent report for the Department For Health But Social Care found.

Its interim findings describe:

Poor operational performance.
Significant challenges with the provider portal and regulatory platform.
Considerable loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement.
Concerns around the Single Assessment Framework.
Lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections (often several years ago) to calculate a current rating.

So that’s ‘everything the CQC does’, basically.

Let me be briefly fair: regulation of healthcare is hard, and those regulated usually hate it. But if we look at the performance of health sector regulators, there’s a clear problem: the GMC enjoys very low confidence among doctors, while the NMC is pretty clearly falling apart.

And it has been remarkably helpful to the political leaders and system leaders of recent years not to have had a challenging and credible regulatory presence, pointing out the realities of the mundane apocalypse in NHS performance.

Jeremy Hunt’s 2016 cuts to the CQC’s budget clearly made it scale back its efforts.

The DHBSC judges that the Dash Review is serious stuff: “these failings mean the regulator is currently unable to consistently and effectively judge the quality of health and care services, including those in need of urgent improvement. The report also found that social care providers are waiting too long for their registration and rating to be updated, with implications for local capacity.

“The government will now take immediate steps to restore public confidence in the effectiveness of health and social care regulation, including by increasing the level of oversight of CQC, ahead of a full report by Dr Dash which will be published in the autumn”.

Health and Social Care Secretary Wes Streeting commented, “I have been stunned by the extent of the failings of the institution that is supposed to identify and act on failings. It’s clear to me CQC is not fit for purpose.

“We cannot wait to act on these findings, so I have ordered the publication of this interim report so action can begin immediately to improve regulation and ensure transparency for patients … This government will never turn a blind eye to failure”.

Mmmmmmm. That last line’s a bold promise.

Winning the battle of the New (If Fictional) Hospitals Programme narrative

In a spectacular bit of early-week no-shit-Sherlocking, Wes Streeting briefed the Mirror’s John Stevens that he will uncover the fact that the last government’s New (If Fictional) Hospitals Programme will not be delivered by 2030.

Streeting bid, “the NHS is broken, and nowhere is that more apparent than in state of some of our crumbling hospitals.

“I’m just two weeks into the job and it is already painfully clear that the previous government’s repeated commitment to rebuild hospitals in marginal constituencies by 2030 was a cruel and cynical ploy.”

“Every community deserves hospitals and healthcare facilities fit for the future but I am not prepared to make up timetables and offer people false hope around how soon these facilities will be delivered. That is why I have asked officials, as a matter of urgency, to report to me on the status of the programme and a realistic timetable for delivery.”

Mr Streeting pledged to “report back to patients, clinicians and local communities with the truth about how quickly these new hospitals can be built, so we can get on with fixing our health service and making it fit for the future”.

Throughout the week, the narrative was being developed for Monday’s announcement by Chancellor Rachel Reeves that having opened all the books (informally known in Whitehall as the ‘bring out your dead’ exercise), everything is much, much worse than expected.

A bit of detail on this was trailed to some Times journalists, whose piece contained the lines “NHS England this week forecast a deficit of £2.2 billion, while the cost of building new hospitals is also said to be far higher than thought, and is likely to see the programme put on hold”.

One must have a heart of stone not to laugh.

It’s not as if the National Audit Office, House of Commons Library and Public Accounts Committee reports had made this stuff so explicitly clear that you could see it from space (to borrow David Nicholson’s fine phrase).

This all happens in the big scary context of a £12 billion capital and maintenance backlog, 2/3 of which is high-risk.

That has arisen because big capital-to-revenue transfers have been used to mask the real NHS financial position for at least a decade.

I think we may actually need a separate organisation which holds the NHS capital and maintenance budget; assesses its need and use; and has an unbreakable asset and income/revenue lock. Evidence tells us firmly that local organisations can’t and don’t resist the temptation to raid it.

It’s a centralising solution, which isn’t my default mode, but I think it might actually be necessary.

Public think junior doctors underpaid

The share of the public who say new junior doctors are underpaid barely changes when people are told the reality of how much they earn, rather than relying on perceptions alone.

Around half or more also feel newly qualified nurses and healthcare assistants are paid too little pic.twitter.com/CjbDabttC2
— The Policy Institute (@policyatkings) July 22, 2024

In the week when negotiations over pay start between the BMA Junior Doctors Committee and the Government, new research from The Policy Institute and Ipsos reports that half of the general public and three-fifths of Labour voters sampled think that junior doctors are paid too little.

It finds the share of the public who feel new junior doctors are underpaid is virtually unchanged when they are told how much they really earn, rather than relying on perceptions alone. In their study, half the sample was asked (unprompted) their views on pay levels for NHS staff and other professions, while the other half was prompted with the average salary these jobs attract.

47% of those who were not given salary information said newly qualified doctors are paid too little, compared with 48% of those who were told their true pay of £32,398 a year.

Those who reported that they intended to vote Labour at the general election are much more likely than their Conservative-leaning counterparts to feel newly qualified doctors are underpaid, regardless of whether they are told their true earnings:

Without pay information: Labour 62% vs Conservative 39%.
With pay information: Labour 58% vs Conservative 40%.

Talking to folk involved in doctors' talks, they say Wes Streeting has been very present and engaged himself - and feels positive. Expect will be some form of offer within weeks, rather than months.
— Anushka Asthana (@AnushkaAsthana) July 23, 2024

It was interesting to see ITV News deputy political editor Anushka Asthana writing on Kiss of the junior doctors’ negotiations that Secretary Of State Streeting “has been very present and engaged himself - and feels positive. Expect some form of offer within weeks, rather than months”.

Of course, such a putative offer then has to be big and credible enough for a militant set of junior doctors to accept. This topic also cropped up in Commons Health Questions: see below.

Primary care strikes on the way

https://t.co/Bz5O7cMCmF
— Dave West (@Davewwest) July 22, 2024

Health Service Journal’s stalwart Dave West spotted NHS England’s letter to ICB and trust leads to prepare for ‘collective action’ by GP practices over primary care funding .

Since he took office, Wes Streeting has taken a more emollient approach to the medical professions (including this example), but it’s going to take a really serious bung for primary care to head off the prospect of industrial action.

NAO report on NHS financial management and stability

In a timely new report, the latest National Audit Office report on the sector looks at NHS financial management and stability.

Its key facts (above) are striking. 15 of 19 ICB chief financial officers responding to an NAO survey stated that their ICB’s underlying financial position had deteriorated in 2023-24.

The report also offers vital context: “Over the decade from 2014-15 to 2023-24, the resource expenditure of the NHS grew on average by 3.2% a year in real terms, which was less than the long‑term average. From 1950-51 to 2013-14, resource expenditure on health grew on average by 3.6% each year in real terms. In the 10 years to 2023‑24, expenditure increased by less than this and at markedly different rates at different times.

“NHS expenditure rose by 2.0 to 2.9% a year in real terms from 2014-15
to 2018-19. It then rose by 4.9% to 9.9% a year from £136 billion in 2019-20 to
£157 billion in 2021-22. This jump was because of the COVID-19 pandemic.

“Since 2022-23, NHS expenditure has fallen slightly in real terms. Many of
the costs associated with the pandemic have now ceased, allowing funds
to be used for other healthcare and to address rising costs resulting from
inflation and industrial action.”

It also notes that “many NHS bodies failed to break even in both 2022-23 and 2023-24, although NHSE calculates that in 2023-24, after receiving additional funding from the government and re-allocating central funding, it underspent against its overall budget by an estimated £30 million (0.02%).”

The NAO report correctly concludes that “the NHS’s financial position is worsening because of a combination of long‑standing and recent issues, including failure to invest in the estate, inflationary pressures, and the cost of post-pandemic recovery”. It notes the ongoing, though abating, impact of staff sickness and strikes on financial stability; and observes that NHS performance is far below targets and productivity is in decline.

The report criticises the Treasury-influenced delays to planning guidance and budget-setting for making effective financial planning all but impossible. It is also clear-eyed about the service’s views of the quality and value of NHS England’s financial management support and advice.

Its recommendations on prevention and productivity are all sound, in so far as they go. But that isn’t far enough. It does not reflect on whether NHS England’s long track record of incentivising NHS financial lying gives it an irreversible credibility problem as the overall system manager.

Nor does it mess about with its conclusion that “we are concerned that the NHS may be working at the limits of a system which might break before it is again able to provide patients with care that meets standards for timeliness and accessibility". There it is again, the ‘b’ word.

Commons Health Questions

It was interesting to see how ‘minister-y’ Labour’s front-bench team managed to act at their first Commons Health Questions. With their current majority, they had an armchair ride of it, with many members across the green leather benches welcomed to their places, congratulated on their (re-)election, etc.

The first ten questions were all about the parlous state of NHS dentistry. Former orthopaedic surgeon Neil Shastri-Hunt, new Conservative MP for Solihull West and Shirley, looks like a rising Tory star.

SOS Streeting seemed to particularly enjoy the experience. He was particularly robust on the New (If Fictional) Hospitals Programme, hitting back to shadow minister Dr Caroline Johnson that “I say to the Opposition that they handed over an entirely fictional timetable and an unfunded programme”.

Nice to see the adjective ‘fictional’ getting an airing for the N(IF)HP: I wonder what could have prompted that?

He also told Dr Johnson, “the hon. Lady might not know because she was not there immediately prior to the election, but the shadow Secretary of State, who is sitting right next to her, knows exactly where the bodies are buried in the Department, where the unexploded bombs are, and exactly the degree to which this timetable and the funding were not as set out by the previous Government”.

Sir John Whittingdale drew a particularly short straw by getting stuck with the question, “I welcome the suggestion that the Government are considering the possibility of a royal commission on social care and intend to address the issue on a cross-party basis, but that will take time. Can the Minister therefore confirm that, as was suggested during the election campaign, the Government will take forward the Dilnot reforms, and in particular that they will introduce a cap on social care costs, as was planned by the previous Government?”

It is a truly bold move, to suggest that the key thing for 2024’s newly-elected Labour Government must be to implement the Dilnot Commission On Funding Of Care And Support’s plan from, erm, 2011. Makes a person wonder who’d been in government from 2010 to 2024. Amnesia victims might be convinced, at a push. This new piece by the Nuffield Trust’s Camille Oung looks at where all the Dilnot-intended money was actually spent.

Minister Andrew Gwynne’s retort was relatively restrained. This civillised stuff is all jolly nice. Enjoy it while you can: it won’t last long.

The Health Sec described the 35% pay demand from the Junior Doctors’ Committee as reasonable, at a cost of an additional £3bn each year.

He must come clean about if he will ask the Chancellor to raise taxes, or if she will be asking him to cut frontline services to pay for it. pic.twitter.com/e5nxwTTB5s
— Victoria Atkins (@VictoriaAtkins) July 23, 2024

Victoria Atkins is now a shadow of her former self. She wasted the Commons’ time with a nonsense question which pretended there was any prospect that SOS Streeting would give an answer about how any forthcoming pay deal with junior doctors may be funded.

A wiser person than Mrs Atkins might have taken a look at the opportunity and other costs of having these strikes.

Unimpressive in office, unimpressive in opposition: Bob The Whippet’s Emotional Support Human has been nothing if not consistent.

This comes on top of her pretty public meltdown in the Commons last week, which I covered in last week’s ‘Cut’. There have been those who claimed to see Mrs Atkins as Conservative And Unionist Party leadership material. I was and remain not among their number.

Victoria Atkins: I am not running for Tory leader

Shadow health secretary says she wants to help ‘unite, rebuild and renew’ the Conservative Party after election defeat

The TelegraphDaniel Martin,

On this, Mrs Atkins agrees with me: she wrote an article for the Boris Johnson Fanzine to announce that “I am not running in the Conservative Party’s leadership election. I am flattered that many people in the House and beyond have asked me to stand, but it has never been my intention to run in this contest”.

Quite right too: this and the next couple of Tory leadership contests are going to be good ones to sit out, as the party goes through its Kubler-Ross cycles.

Guess who’s back?

Our Joint Chief Executive Officer, Katrina was an NHS CEO for nearly 10 years, winning the coveted NHS CEO of the year and being named amongst the 50 most inspirational women in healthcare. pic.twitter.com/ZoMvCqwZ5M
— NAPC (@NAPC_NHS) July 26, 2024

In response to popular demand from absolutely nobody, the National Association for Primary Care this week announced its remarkable choice of disgraced former Southern Health chief executive Katrina Percy as its new joint chief executive.

I mean, it’s a different sort of appointment. You have to give NAPC that.

It’s as if the Mazar’s report into Southern Health, covering the deaths by neglect of Conor Sparrowhawk and others in the care of Southern Health, had never happened.

Percy was indeed given the black spot of being HSJ chief executive of the year back in 2012. She ‘stepped aside due to media attention’, if you believe the trust’s version of events, which nobody does. Still clung on to her salary, though.

Chief executives carry the can for their organisations’ performance, and sometimes there is a valid case for those who took the blame to be rehabilitated. There does not seem to be any such case in this instance, and anybody who may be planning to do business with NAPC should bear this in mind.