Cowper’s Cut 336: Rumsfelding the NHS
It’s been another fairly quiet week in health policy and politics. After the past few years, that’s not unwelcome.
Department of Health and Social Care
We’re obviously in The Drop Zone, waiting for the September birth of the new baby that is Lord Darzi’s ‘Buying Time For Making An Actual Plan’ NHS Review.
So one option would be to speculate about that. Will The Noble Lord Darzi Of Denham still think what he thought in 2008, albeit with added doses of Artifical Intelligence on steroids, courtesy of the Tony Blair Institute?
(As best I can tell, the TBI has completely failed in its duty of publishing its statutory dull fortnightly simper about how AI is going to save the NHS/education/public services/the universe (delete as applicable). If this woeful failure continues, Larry Ellison of Oracle will be asking for his money back. If you want to read something about AI in health that isn’t snake-oil-vending bollocks, Dr Jess Morley has written this useful piece for the Nuffield Trust.)
Instead of second-guessing the Darzi BTFMAAP Review, I thought I’d look at a few key issues. I’m not quite going full Donald Rumsfeld, and putting them into the categories of ‘known knowns, known unknowns and unknown unknowns’. The Johari Window is an interesting ‘2x2 matrix’ heuristic, but things are a little more complicated than that.
I will score these issues for importance; solubility; and current priority.
Workforce morale
Importance 10/10; solubility 5/10; current priority 2.25/10
I’ve tracked Health Secretary Wes Streeting’s Alan Milburn tribute act in these columns for some time: ‘the champion of service users, not producers’, and all of that weary, tabloid-friendly cack. And I was clear that he probably felt that he had to do this, starting back in a time when Boris Johnson seemed to be electorally popular and Labour couldn’t buy itself a hearing.
Times have changed quite a bit since then. Beyond giving the Department For Health But Social Care a cop-out line for every media quote, the official statement of the obvious that the NHS is “broken” hasn’t really achieved much.
A significantly more pertinent question would be what the NHS is doing about the staff that it’s broken. (Answer: not much, and certainly not enough.)
Now, older hands can wearily sigh that ‘NHS staff morale is always the worst it’s been since 1948: haven’t you read any BMA press releases?’ And fine: that raises a cynical grin.
But we do have data: the NHS staff survey. And it’s not good.
The movement that the government had made on staff pay deals was necessary and sensible. The likelihood of movement on the ‘global sum’ pay deal for general practice would fit into that category, too.
But there is a broader issue: the service has more staff now, yes, but the new arrivals are not experienced. Experienced staff are gold, and know how to make systems work - but too few NHS organisations have treated them like this.
This leads on to our next issue: staff morale is affected by pay and conditions, of course, but just as significant is the storytelling about how things will improve.
Will the Darzi BTFMAAP Review provide this? Its stated aim is to “stimulate and support an honest conversation with the public and staff about the level of improvement that is required, what is realistic and by when”.
I don’t think it’s possible to overstate the need to be able to tell staff a convincing story about how things will improve in their working lives. This means …
Improving NHS system management
Importance 9/10; solubility 7/10; current priority 3/10
The Lansley reforms cut of 45% in NHS management capacity has absolutely not had the attention that it deserves as a cause of growing NHS waiting lists and general dysfunction. The loss of capacity in waiting list management, understanding of queueing theory and other hard-won gains of the 2000s remains a big, big problem.
Post-Lansley, we have seen a series of Messiah Concepts come and go. In response to arriving in post to the Mid-Staffs Public Inquiry Report, Jeremy Hunt instigated the era of ironic patient safety. That went well.
Via Fremantle and colleagues’ now-debunked BMJ piece, Mr Hunt also brought us the completely wrong concept of the Monday-to-Friday NHS.
Despite the remarkably modest impact of the very costly New Care Models, Simon Stevens did leave a two-part legacy beyond his legendary political legerdemain.
Firstly, he forged the consensus of a need to change the health and care system to being a genuine system: moving the concept of the NHS becoming a more patient-centred and less institution-centred ecosystem into a mainstream policy and political nostrum, and also into a set of potentially (if by no means yet) effective organisational forms. As The Other Mr Blair so nearly said, integration, integration, integration.
Secondly, he won the argument that the internal market of Stevensism Mark One was not achieving significant results in the environment of the lowest decade of per capita funding growth in the history of the NHS.
The problem is that no idea has yet come in to replace the internal market. Everything was swept away during the pandemic: in a Jubilee spree, the NHS’s vast debts were cancelled.
Integration is not an idea, as such: it is a method.
And there is no serious debate whatsoever that NHS productivity has tanked in recent years. There might be some about the root causes why this happened, but there is none at all that this is a fact.
In the absence of a new or credible idea about how to improve system management, the NHS remains unaware-seeming of its loss of system management capacity and capability.
This matter, because it will not start to improve without these things. This is to no small extent due to the next big issue: that of …
Improving NHS national leadership
Importance 9/10; solubility 10/10; current priority 0/10
I would describe NHS England as a joke, but jokes are funny and have a purpose.
The penny has now widely dropped that the Care Quality Commission is neither use not ornament: so bad are matters that they have even admitted it themselves. This has been a long time coming. The CQC has been pointless and inept for many years now.
Amazingly, the use/ornament penny is yet to drop about NHS England. Having itself ingested regulators in the shapes of Monitor/Trust Development Authority/NHS Improvement, NHSE set itself up as both The Fat Controller and the uber-regulator of the NHS. It’s not been any perceptible good at either function.
David Nicholson’s original development of the NHS Commissioning Board was (contrary to his previous image) not as a grip-first-ask-questions-later organisation. It was also hugely occupied with landing the chaos of the Lansley reforms into the equally messy reality of the early 2010s, while also meeting The Nicholson Challenge (which was largely done by holding down wages).
On his arrival, Simon Stevens promptly re-tooled the NHS Commissioning Board as a wholly Simon-centric organisation (before rebranding it as NHS England). Unless you trust a lot of people a lot, you probably can’t pull the political acrobatics that Stevens managed without this degree of grip.
Mr Andy Cowper
But there was a clear down-side to this degree of Simon-centricity: as I wrote on his appointment in 2014, nothing grows in the shade of an unchallenged Big Beast. Heliocentricity may work for The Sun King, but it doesn’t grow new little Sun Princes and Princesses.
That’s how we got Amanda Pritchard as Simon’s successor.
I wouldn’t be surprised if Amanda is left in place until 2025 to take the blame for what is nailed-on to be another appalling winter. That leaves a big part of the problem still with us and still generally unadmitted for at least another six months.
That isn’t ideal. Nor will it help with the next big issue: that of …
Fixing finance
Importance 10/10; solubility 5/10; current priority 9/10
NHS England encouraged providers and ICBs to submit fictional budgets that they could not possibly hit, and then threw histrionic hissy-fits when they missed them.
That was in 2023-24.
And it obviously worked brilliantly, because they did exactly the same thing again in 2024-25. Henry Anderson’s Health Service Journal piece on the latest state of play is a good, cheerless read.
The Treasury rules the Government, and so overspending the Departmental Expenditure Limit (which means redoing a Budget) is not wildly popular over there on Horseguards Parade. They tend to frown on it.
This leads us into a ‘blind leading the blind’ situation: NHS England has incentivised and suborned financial lying, and at the end of the day, it has had minimal consequences: either for NHS England, or for those whom it puts on the ‘naughty step’. There is not hot competition for most NHS chief executive or director of finance jobs.
Neither regionally nor nationally does NHS England pay any meaningful attention to organisations who deliver on incentivised programmes such as respiratory hubs. Unfairnesses in budget-setting are simply glossed over, year after year. Underperformance rarely results in any consequences for those in charge: indeed, some contracts actually incentivise underperformance: the mental health sector can be particularly scandalous in this regard.
There is good practice: this HSJ piece about Simon Worthington shows that things can be successfully done, even in tough environments. But the idea that local leaders have either the respect or the fear for NHS England to motivate them to do financial things better holds no water whatsoever.
In the meantime, we’ll probably just see more raids on budgets for …
Capital and estates
Importance 8/10; solubility 7/10; current priority 1/10
Let us avert our eyes from the political fiesta of rubbernecking that is the flaming wreckage of the last Conservative And Unionist Party government’s New (If Fictional) Hospitals Programme. I have done that one often enough.
Here we go again: the capital and maintenance backlog is now £12 billion at the last count, so in reality almost certainly now nearly £14 billion.
Shaun Lintern, Tom Calver and Ben Spencer
Maybe some RAAC ceilings will have to actually come down and maim or kill people before we see action on this. We’ve already seen a surgeon get a broken leg from a failed lift falling four floors at the Royal London.
I am increasingly thinking that the scale of the work required has yet to properly register. There was raw sewage in the handwashing sinks in the Countess Of Chester neonatal paediatric department.
In my first post-election ‘Cut’, I wrote about the possibility of a PFI reboot, as trailed in the Grauniad by NHS Providers boss Julian Hartley. Is revisiting PFI good value for money? No, probably not. Might Treasury Brain make it happen? Yep, it sure might.
There is another issue on which nobody appears to have any sight whatsoever: the ending of the original PFI contracts. The National Audit Office did some work on this, and the House Of Commons Public Accounts Committee took evidence, but these are a few years old now. Nick Timmins’ piece for the Institute For Government is more recent, and of course excellent: this more recent short blog by commercial law firm Browne Jacobson is also fine, if very basic.
This is billions of pounds of taxpayers’ money in value at stake. And it appears to be on nobody’s radar. Well, I’m reassured.
Recommended and required reading
Sam Freedman’s blog of reflections on being a successful policy advisor are a good taster for his book ‘Failed State’.
“The last Labour government poured too much cash too quickly into the NHS, and it is definitely not the case that all the problems in the health service today can be solved with more money. But some problems really are caused by underinvestment, particularly in mental health services. A government cannot talk about the need for people to keep their side of the social contract by going to work if they can, when it is breaking its own side of that agreement by failing to offer them appropriate and timely treatment.” Again, spot-on by Isabel Hardman.
Liar and Everybody’s New Favourite Noble Baroness Mone and PPE Medpro were back in the news, with the National Crime Agency telling a press conference that they are not scared of PPE Medpro’s lawyers.
Decent Times piece about why general practice is finding it such hard going.
The Financial Times covers the NHS’s new ‘subscription’ scheme to incentivise the pharmaceutical industry to research and deliver new antibiotics.
NHS data sharing needs to improve, chair and co-founder of the Open Data Institute writes for the FT. Robert Chote makes a similar point across government, in this Observer piece. Data: it’s the new data, perhaps.
HSJ reports on Labour purging the Conservative And Unionist Party-apppointed DHBSC NEDs.