Cowper’s Cut 334: A possible deal on junior doctors’ pay, but a doughnut for Dilnot

Racist riots

Rioters throw rocks at ‘terrified’ NHS nurses on way to work as emergency cover

The Filipino NHS workers were targeted by rioters in Sunderland, leaving them “terrified” as they headed to work in taxis to provide emergency cover amid violence breaking out

The MirrorJeremy Armstrong

It isn’t sensible to write about politics and public policy and not acknowledge the fact that we have just seen a number of days of emboldened and explicit racist rioting in several British cities.

Because I am not a complete idiot, I am not going to refer to these riots as ‘protests’ in response to the appalling multiple child murders in Southport. They are nothing of the kind.

I don’t think of myself as someone well qualified to write about racism in the NHS, but I think Professor Partha Kar is, and he agreed to write this piece, which I hope you’ll read.

Showing us that the NHS is anti-racist

Professor Partha Kar is a diabetes consultant in Portsmouth, and author of the first plan for addressing racism in and affecting the NHS medical workforce. He is writing here in a personal capacity. Let’s be honest about what we have seen over recent days in the UK. Under the

Health Policy InsightMr Andy Cowper

The upshot of these events will be a climate of greater fear, in which black and minority ethnic NHS staff may or will be affected, as some already have been. I definitely don’t have to tell ‘Cut’ readers that racism is bad, but I confidently hope that those of you in leadership roles will take some time this week to check in on and reassure your staff as best as is possible.

Inheritance tacks

Chancellor statement on public spending inheritance

Chancellor of the Exchequer Rachel Reeves statement to the House of Commons on 29/07/2024.

GOV.UKHM Treasury

Chancellor Rachel Reeves’ ‘financial inheritance’ statement to Parliament and ‘Fixing The Foundations’ public spending audit returned the compliment that the Conservative And Unionist Party paid Labour in the wake of the 2008 global financial crisis: firmly pinning on it the label of fiscal irresponsibility, and in the 2024 remix, of leaving behind a £22 billion in-year overspend.

Will this charge that you can’t trust the Tories with the economy stick?

It’s too early to tell, although Reeves delivered her Commons speech with great verve: ‘boring, snoring’ no more.

But her central allegation - that Chancellor Jeremy Hunt and his party were not honest about the genuine fiscal position - gained some traction from the reactions of both the Office for Budget Responsibility and the Institute for Fiscal Studies.

She announced that the next Budget will be on 30 October, and that the public sector pay review bodies recommendations (on whose affordability the last government had given no guidance) would be accepted in full, as would the deal proposed to junior doctors.

Reeves’ rationale for this was that the costs of ongoing industrial action were worth avoiding: “industrial action in the NHS alone cost the taxpayer £1.7 billion last year … today marks the start of a new relationship between the government and staff working in our National Health Service – and the whole country will welcome that”.

How will the Chancellor pay for this? Tricky bit here. Accepting the pay review recommendations “come at an additional cost of £9 billion this year. So, the first difficult choice I am making is to ask all departments to find savings to absorb as much of this as possible, totalling at least £3 billion.

“To support departments as they do this, I will work with them to find savings ahead of the Autumn budget, including through measures to stop all non-essential spending, such as on consultancy and government communications. And I am asking departments to find 2% savings in their back-office costs”.

Efficiency savings? Mmmmmmmm.

It didn’t stop the Bank of England monetary policy committee cutting interest rates by 0.25% later in the week.

A doughnut for Dilnot

Social care got it, or rather didn’t. The 2011 Dilnot proposed cap on lifetime care costs (albeit the greatly raised Osborne version) is no longer pushed off ever-further into the future: it is now officially dead and buried.

This simply shifts the location of the financial risk back from councils who could not conceivably have afforded this without significantly more funding, and onto individuals. Rarely can the Department For Health But Social Care’s name have felt more ironic.

And the New (If Fictional) Hospitals Programme is to get the long grass of a review: “since coming into office, it has become clear that the previous government continued to maintain its commitment to 40 hospitals without anywhere close to the funding required to deliver them.

“We need to be straight with the British people about what is deliverable and what is affordable. So we will conduct a complete reset of the New Hospitals Programme, with a thorough, realistic and costed timetable for delivery”.

The Chancellor also removed the winter fuel payment from those not on pension credit. This will increase the number of people just above the threshold who go into fuel poverty, or who will be at higher risk of winter respiratory diseases. But then, this coming winter’s already gone: we know that.

Money blowing up - latest

Health Service Journal’s Henry Anderson’s latest tally of ICS deficits shows that 3/4 plan to overspend their budgets, to a cumulative £2 billion total, after just four months of the current financial year.

A deal for junior doctors?

A deal in principle has been reached between the Government and BMA junior doctors’ leaders, which the latter are recommending to their members.

This contains a significant pay rise, of between 20 and 25% over the course of the current and previous financial years. It also contains commitments to changing the DDRB pay review body’s remit to include making medicine an attractive career, and for work to go ahead to change rotational training and to exception reporting (to make this easier).

One of the quids pro quids is that the BMA ‘rate card’ for extra work will be withdrawn with immediate effect.

BMA JDC co-chairs Dr Robert Laurenson and Dr Vivek Trivedi‘s statement said,“we are announcing that almost two years into our dispute we have received an offer from the Government that our committee thinks merits consideration by our membership …

“This offer does not go all the way to restoring the pay lost by junior doctors over the last decade and a half. However, we have always said that we did not expect to get there in one go. This offer, combined with the recommendation of the pay review body today, changes the current trajectory of our pay, even though there is further to go yet.

“We are recommending that members vote for the deal. We believe that this is the best offer available at this moment in time and that the inclusion of the additional reforms make the package a good step forward for our profession, acknowledging there is still more work to be done in the future.

“We recognise the speed and effort put into this round of negotiations which we believe shows the beginning of a Government that is learning to treat doctors with more respect. There is a catastrophic NHS workforce crisis that needs addressing and they at least appear to recognise that fixing pay must be part of the solution.” 

Resiling from the deal you just made

The BMA junior doctors’ leaders have been far more basically competent and smarter for most of their conduct of this dispute. Good media training and well-prepared answers to obvious questions have given them the chance of a decent outcome, in vivid contrast to the hydra-headed leadership experiences of the 2015-16 new contract disputes, which gave Jeremy Hunt an easy victory.

Junior doctors’ leader threatens more strikes after NHS pay deal

Robert Laurenson has suggested that the union should prepare to strike next year when Labour’s honeymoon period ends

The TimesEleanor Hayward, Health Editor | Poppy Koronka, Health Correspondent

It’s telling that shortly after having publicly supported the deal that they negotiated, the JDC’s outgoing co-lead Dr Robert Laurenson GP was trashing his own deal on Times Radio and on junior doctors’ WhatsApp groups.

He writes that “the last two years the strategy was based on a general election and trying to extract a deal from a desperate chaotic government in decline. I think the only way to extract a better deal would be to take long sustained action [strikes] for probably the next 12 months. I could not in good conscience ask people to invest their money in that kind of action without clarity on what return they might get from it”.

Arguing that the 22 per cent deal is the best the BMA could get at the moment, Laurenson told junior doctors that “the Labour government is “utterly ruthless at the moment as they establish themselves in government and the power dynamic has swung too far towards them for us to successfully achieve anything via strikes right now”.

“I would consider striking with a low threshold for 25/26 when Labour’s honeymoon period ends and they make some sort of mistake that leaves them politically vulnerable.”

Laurenson acknowledges that his political strategic reasoning “may be wrong”, which is sensible. And since he is no longer a junior doctor, he is no longer eligible to lead the group.

In time, he may come to realise that this kind of resiling from the deal you just negotiated and recommended will come back to bite you. Isabel Hardman’s piece for the Boris Johnson Fanzine accurately outlines how and why junior doctors’ leaders get such a poor reputation.

BMA Council likes to look ridiculous

BMA to undertake an evaluation of the Cass Review on gender identity services for children and young people - BMA media centre - BMA

Press release from the BMA

The British Medical Association is the trade union and professional body for doctors in the UK.BMA media team

The BMA’s recent better performance as a campaigning organisation to improve its members’ pay starts to look like a mirage, when you consider its Council announcement that its Council wants to not just review, but “publicly critique” the Cass Review. And voted accordingly.

The full motion reads: “this meeting recognises that the provision of gender identity services in the United Kingdom is inadequate, and that transgender people should be treated with compassion and respect for their bodily autonomy.

“Following the publication of the Cass Review on Gender Identity Services for children and young people, this meeting is concerned about its impact on transgender healthcare provision because of its unsubstantiated recommendations driven by unexplained study protocol deviations, ambiguous eligibility criteria, and exclusion of trans-affirming evidence.

“Therefore, this meeting calls on the BMA to: 
i. Publicly critique the Cass Review;  
ii. Lobby and work with other relevant organisations and stakeholders to oppose the implementation of the recommendations made by the Cass Review;  
iii. Lobby the Government and NHS in all four nations to ensure continuity in provision of transgender healthcare for patients younger than 18 years old;  
iv. Lobby the Government and NHS in all four nations to ensure continuity in provision of transgender healthcare for patients aged 18 or older;  
v. Publicly state support for transgender people, particularly transgender youth, and provision of prompt access to gender identity services and treatment at all ages;  
vi. Condemn the increasing political transphobia which is ostracising transgender people and discriminating against them by blocking their access to healthcare’.”

It couldn’t be more explicit that this is about BMA Council members’ take on gender politics, rather than medical politics. Its phrase about the absence of “trans-affirming evidence” makes the agenda unambiguous. The Cass Review remains a balanced and considered piece of work: it has published its evidence reviews and engaged with its critics.

A kick up the ARRS

An unstated but evident goal of the 2019 Additional Roles Reimbursement Scheme (rather brilliantly, ARRS) was to fund the expansion of physician associate roles by primary care networks. Other roles, including physiotherapists, were also funded, but this money absolutely could not be spent on GPs.

This has now been overturned by Wes Streeting, and the Department For Health But Social Care’s announcement confirms that “more than 1,000 newly qualified GPs will be recruited thanks to government action to remove red tape currently preventing surgeries from hiring doctors.

“Bringing back the family doctor is central to the Government’s plan to rebuild the health service, and the changes being made to cut through the current rules will help more patients get access to GPs, and ensure more GPs are able to find roles, so that people in communities across England will receive the timely care they deserve this year.”

Well. ‘This year’ is a euphemism for ‘this financial year’, so it won’t solve imminent problems, as the statement adds “this is an emergency measure for 2024-2025”. It also confirms that “the Government will ensure the NHS has the funding it needs to deliver this, paid for by £82 million from the existing department budget”. It’ll be interesting to see what gets cut to fund that.

Industrial action by GPs

To the considerable surprise of absolutely nobody, GPs voted by a vast majority to take collective industrial action over 2024-25 funding. On a turnout of 68%, 98% of those who voted endorsed the union’s proposals for taking industrial action on one or more of the ten non-contract-breaching grounds.

SSOS Atkins lies as she tries to fight the last war on the New (If Fictional) Hospitals Programme

Bob The Whippet’s Emotional Support Human and shadow health secretary Victoria Atkins took to Kiss to attempt a defence of the New (If Fictional) Hospitals Programme.

Alas, Mrs Atkins mired herself in mendacity.

She started weakly, with the bold claim that the Conservatives’ N(IF)HP “was set to deliver 40 new hospitals for communities by 2030”. As the NAO, PAC and Commons Library reports all show, this assertion was and is utterly untrue.

Did Bob the Whippet’s ESH let this stop her?

You will not be astonished to hear that she did not, going on to claim that “for the record, the New Hospitals Programme has seen 6 hospitals open, with another 2 opening by the end of this financial year, and a further 18 under construction or with work ongoing to prepare the sites”.

This is quite, quite untrue: only one of the six cited was anything to do with the N(IF)HP: the other five were already in progress before its fiction was launched. Liverpool and Sandwell were both delayed by the collapse of Carillion, and nothing whatsoever to do with the New (If Fictional) Hospitals Programme.

Poor Mrs Atkins. Losing the last war can’t be nice.

The cost of negligence

NHS Resolution’s latest annual report shows that half of the £2.87 billion in negligence claims relate to maternity. While allegations of negligence in obstetrics accounted for 13 per cent of clinical claims not involving general practice, they resulted in 57 per cent of the overall value of NHS payouts

Recommended and required reading

Institute For Government webinar on Labour ‘s public spending inheritance.

Financial Times article on the shortage of actinium 225: a nuclear isotope used in precision oncology.

Interesting paper on public service delivery and support for the populist Right.

Coroner issues Regulation 28 POFD Notice over an avoidable death caused by a physician’s associate, citing the lack of national regulation over training, supervision and oversight of PAs.

FT long read on how medical research is failing women.

Wellcome Trust chief executive claims to the Sunday Times that NHS resource constraints are cutting clinical trials, and thus access to new drugs.

Steve Black in majestic form in HSJ on why AI is not the new oil, but the new snake oil.

Julian Patterson likewise on the very successful history of NHS long-term plans.