Cowper’s Cut 347: Let’s Twist again with The Woman In Black
I’m not saying that the English NHS has a limited repertoire of dance moves.
OK: I am saying that.
“Please sir, I want some more”
The NHS’s default to doing the Twist - the Oliver Twist, as in “please sir, I want some more” - reared its head again, in the response to this week’s Budget’s increase over the next two financial years of £22.6 billion for the NHS revenue budget, and an additional £3.1 billion for the capital budget.
HM Treasury
The political rhetoric accompanying this new money was predictable: Health But Social Care Secretary Wes Streeting told BBC News, “we’ve got to make sure that the investment the Chancellor has committed to the NHS is linked to reform”. Given the six-month wait until May 2025 for the Ten-Year Forward View plan for NHS reform, this is an intriguingly vague line.
The idea that this extra money has come without any preconditions is wrong, as Max Warner, a research economist at the Institute for Fiscal Studies, told the Financial Times. Warner pointed to the Budget’s stated obligation on the Department For Health But Social Care (like all Whitehall departments) to deliver 2 per cent efficiency savings in the next financial year.
Warner correctly noted that such 2% efficiency savings are the Surrey Panther of public policy: more talked about than seen. He also suggested that the new capital funding may be transferred to cover revenue shortfalls and overspends: he is likely to be right about this, too.
More good things, fewer bad things
We did see a new report from the National Audit Office this week, which may help the Ten-Year Forward View’s authors with their task. ‘Lessons learned: a planning and spending framework that enables long-term value for money’ is co-badged for authorship alongside HM Treasury and the Cabinet Office.
The eight lessons that it proposes for maximising value for money (above) are all fine, in the abstract. What is wholly lacking in the current national leadership of both the DHBSC and NHS England is any form of ‘how’ these eminently desirable themes will be achieved in The Real World.
Furthermore, the last two listed, ‘realism’ and ‘transparency’, are notably lacking in the leadership of NHS England, particularly over finance.
This is a big problem. Likewise, the NAO document’s near-total absence of references to the importance of organisational culture. Its concluding remarks do at least note that “changing the incentives and behaviours embedded across central government will take leadership, functional expertise and collegiate behaviour at all levels, official and political, over a whole Parliament and beyond”, and that is fine on paper. But it isn’t a ‘how’: it isn’t anything actionable.
The Old Incuriosity Shop
A notable feature of the English NHS over several years now has been a near-total lack of curiosity about the drivers of good, bad and indifferent performance.
There have been some truly impressive performance turnarounds by organisations in improving their services’ performance and access. Equally, there have been some serious deteriorations, and/or the findings-out of longstanding-but-overlooked appalling performance.
What has been absent is any attempt to understand what has driven these changes in performance. The slow puncture of the Care Quality Commission’s credibility started at least five years ago, and probably more. Monitor showed more curiosity than many organisations about what drives organisational performance, but when it was folded into NHS Improvement, this was greatly downgraded as an organisational priority.
How much does the NHS need?
Sally Gainsbury
Nuffield Trust senior policy analyst Sally Gainsbury’s pre-Budget analysis of what the NHS needs is a valuable source of reality-based information. Looking at trusts’ actual spending, she concludes that this points to “a full-year £1.4 billion overspend by NHSE, wiping out the entire NHSE budget, regardless of how much its head office may or may not have squirrelled away as “contingency”.
“ … trust spending levels to the end of July did not include the impact of pay settlements for this year agreed with staff unions over the summer, as those payments were not made until August and September … We estimate the total additional cost above the 2% plan is likely to be in the region of £3.5 billion, including the additional cost of pension contributions and national insurance at current rates.
“Taken together, the rate of NHS trust spending growth to July and the additional cost of pay deals entail a real-terms cost pressure of 6.7% above like-for-like recurrent spending in 2023/24. After adding the Treasury-imposed higher cost of pensions, that translates as a need for a £12.9 billion cash increase above the final level of total NHSE spending in 2023/24, of which £4.8 billion is not currently covered by any account of NHSE’s – or DHSC’s – funding envelope for the year.
“Fully funding that without further cuts to DHSC’s unprotected budgets would require a real-terms headline increase to DHSC’s 2023/24 revenue budget as set out in the March red book of 3.6% (including the additional cost of the Treasury’s pension rate) to £186.4 billion.”
Ouch.
Obfuscation as usual
It always takes several weeks (and sometimes months) after a Budget to find out which bits of the ‘new’ resource and the pledges are part of the Reality-Based Community. Autumn 2024’s Budget has proved no different.
Henry Anderson
Health Service Journal’s Henry Anderson has seen NHSE confidential correspondence to ICBs documents which state that Labour’s manifesto pledge to deliver 700,000 extra dental appointments comes without new money for the current financial year.
NHS England
What a good thing that 2024-25 is already looking so excellent on the financial balance front!
Henry Anderson
Interestingly, Henry also received a Treasury briefing which promised a £1.5 billion capital boost in 2025-26 to spend on new surgical hubs and scanners. This was at first badged as coming in 2024-25, as the update at the bottom of the article reveals.
The urgency of the English NHS’s capital situation was emphasised in another HSJ story this week, which tracked the effect of ongoing delays to the last government’s New (If Fictional) Hospitals Programme. Zoe Tidman’s piece showed that “infrastructure failings have led to over 1,000 operations being cancelled in the past two years at just 14 trusts whose rebuilding plans have been placed under review by the new government”.
500 cancellations a year is not a big number in the context of an RTT backlog of 7.6 million, of course.
Henry Anderson
And his Budget follow-up piece flags the lack of clarity about “timescales for Labour’s pledge to deliver 40,000 extra appointments a week, and whether funding will be available this year for trusts to continue carrying out extra elective appointments”. Maybe we’ll get it as a Christmas present, with the Planning Guidance for 25-26?
The Woman In Black
The Woman In Black is a parable of fear; haunting; being in the wrong place at the wrong time; and ultimate reprisals.
So much for monotone-attired NHS England chief executive Amanda Pritchard: The Woman In Black is also a gothic horror novel by Susan Hill, adapted into a bestselling play and film. It’s a safe bet that nobody will be making best-selling adaptations of Ms Pritchard’s tenure in charge of NHS England. (There are plenty of frightful things, but far too few intentional jokes.)
The Woman In Black is firmly back on the agenda. This is due both to the Budget creating new delivery expectations of the English NHS, and also to ‘Honest Bob’ Jenrick’s failure to beat empty-room-fight-starting Kemi Badenoch to the booby prize of becoming the Conservative And Unionist Party’s next former leader.
Three weeks ago, I covered Honest Bob’s attempt at creating jeopardy for The Woman In Black. The salience of this attack has now faded into the deepest of irrelevance. The Woman In Black may follow that trajectory before too long.
Had Honest Bob become the next ex-Tory leader, then Alan Milburn tribute act and Health Secretary Wes Streeting might have felt obliged to defend his compliant chief executive more vigorously. He didn’t, so he doesn’t.
There are two clouds imminent on the horizon. The first is winter, and it is going to be somewhere between very bad and terrible. Flu and Covid-19 vaccination take-up rates are low. Effective mitigations from previous years, such as respiratory clinics and surge capacity in hospitals, are largely un-done.
As I have previously noted, Wes Streeting previously announced that he intends to blame this winter on the last Conservative government. But that was back in early September: several months can be an awfully long time in politics.
The second is money. Informed consensus suggests that even after Budget-boosting, the NHS in England may be looking at a year-end overspend of between three and four billion pounds. And NHSE does not have that kind of money salted away down the back of Richard Douglas’ old sofa.
The consequences of either one of these blowing up into a major national media storm would weigh more than The Woman In Black’s compliance use-value to Mr Streeting. The Health Secretary is already loudly uncertain upon whom he can reply to deliver in national leadership, anywhere (not just The Woman In Black: also Sir Chris Wormald at DHBSC, whose status as permanent secretary is starting to look quite temporary).
It is highly likely that we will see both of them becoming big, bad headline news.
Ooops!
Recommended and required reading
HSJ’s Joe Talora has this interesting story that deserves more attention: legislation is set to mandate interoperability for all NHS tech suppliers. Better extraordinarily late than never, but the sanctions look desperately weak: “public censure” doesn’t seem to have bothered racist misogynist Frank Hester of TPP much.
Interesting short piece by finance director Jason Dorsett asking whether NHS foundation trusts should be abolished (which de facto, they have been).
The Economist has an editorial and some linked pieces hyping GLP-1 receptor agonists such as Ozempic and Wegovy as neo-miracle drugs. Well, maybe.
Interesting-looking Institute For Government seminar on what kind of NHS reform is needed. See you there?
Susie Green, former chief executive of disgraced transgender charity Mermaids, is now trying to flog puberty blockers, The Times reveals.
The Times also covers the Darlington Five’s meeting with Health Secretary Wes Streeting, over a male staff member’s use of women’s staff changing facilities.
“Whisper has a major flaw: It is prone to making up chunks of text or even entire sentences, according to interviews with more than a dozen software engineers, developers and academic researchers. Those experts said some of the invented text — known in the industry as hallucinations — can include racial commentary, violent rhetoric and even imagined medical treatments.” One for the depressingly numerous members of the AI stan community: AP Press reveal that US research finds that Open AI’s transcription product Whisper invents things that nobody ever said.
AI Hypebeasting Of The Week Award goes to this comical nonsense in the Boris Johnson Fanzine about AI quantum computing being used to fix doctors’ rotas.
The FT reports that the UK generic drug industry’s manufacturers’ trade body warns that its members are not ready to comply with new post-Brexit labelling rules for medicines entering Northern Ireland, raising the risk of supply shortages.
A Guardian columnist simpers inanely in response to the NHS NatChat.