Nov 17, 2024 14 min read

Cowper’s Cut 349: Half-a-league-table, half-a-league table, half-a-league table onward!

“Half-a-league-table, half-a-league-table,

Secretary Of State For Health But Social Care Wes Streeting announced this week in his speech to the NHS Providers conference that the English NHS is going to do performance league tables.

Again.

It could almost make a person wonder why that was stopped last time.

It’s almost as if they’ve never heard of Goodhart’s Law.

O the wild charge they made!

SOS Streeting’s press release emphasised that there will also be a crackdown on agency spending: “under joint plans to be put forward for consultation, NHS trusts could be banned from using agencies to hire temporary entry level workers in band 2 and 3, such as healthcare assistants and domestic support workers. 

“The consultation will also include a proposal to stop NHS staff resigning and then immediately offering their services back to the health service through a recruitment agency”. NHS staff: where indentured servitude meets restraint of trade. The legal advice and risk assessment on this one will be a comedy classic.

Theirs not to make reply

SOS Streeting also press released that he will also block pay rises for or sack underperforming chief executives, pledging “no more rewards for failure”.

This is a particularly brilliant idea, given that the past track record of sacking chief executives has been to instantly and permanently improve the leadership and performance of the organisation in question, while also making the job of being an NHS chief executive much more attractive.

Hang on: why are you laughing?

Theirs not to reason why

It’s clear that nobody advising Mr Streeting has read ‘The Chief Executive’s Tale’, Nick Timmins’ excellent 2016 book for the Kings Fund. It might have offered them a much-needed clue or two about the sorts of things that do and don’t effectively motivate those people.

Theirs but to do and die

It is equally clear that Mr Streeting and those around him have not clue about how attractive being an NHS chief executive currently is. Which is to say, not very.

Health Service Journal analysis from January revealed that one in three trusts in the English NHS now shares a chair or chief executive. Because of course these jobs are just a part-time three-days-a-week kind of thing. Of course they are.

One must have a heart of stone not to laugh at this approach.

Mr Streeting (and those advising him) seem grimly determined to cremate any residual sense of benefit of the doubt and provisional goodwill based on not being the Conservatives that might have existed towards them among NHS managers.

This macho bullshit, straight out of the Alan Milburn playbook, is devoid of reflection on its contribution to the glaring problems and bullying in NHS management culture, rightly exposed in the 2022 Messenger Review.

Mr Milburn’s guiding hand is also grimly obvious in the return of league tables: the artist formerly known as star ratings.

Milburn secured three stars for PM’s trust

Published: 18/12/2003 Volume II3, No. 5886 Page 3 4

Health Service JournalAlastair McLellan

The irony that (as a DH civil servant leaked to HSJ in 2003) Mr Milburn cheated the star ratings to improve then-PM Blair’s and his local hospital is exquisite.

I have often remarked on Mr Streeting’s tendency to be an Alan Milburn tribute act. But there are tribute acts and tribute acts. In their earliest days, The Beatles and the Rolling Stones were proto-tribute acts: to early US rockers and rhythm and blues artists respectively. That’s how they learned to play and write their own songs: it worked out pretty well for them.

But the lesiure centres and ‘number two circuit’ theatres of our nation regularly host a plethora of tribute acts who never deviate from note-for-note cover versions of their heroes’ tunes. There’s a significant and fairly undemanding audience for that sort of thing. And that’s fine.

The problem is that the current state of the English NHS is not undemanding. And it doesn’t really allow for the kind of health policy pissing-about that is on display here from Team Streeting.

Milburnesque macho bullshit

The Milburnesque macho bullshit approach has one core problem: it doesn’t work.

It didn’t actually works terribly well the first time around, and that was in a very different, pre-social-media society.

Yes, the 2000s performance bullying (plus the massive extra 6% real-terms cash year-on-year funding) achieved a certain Barberesque ‘from awful to adequate’ compliance, but quite often what the performance bullying actually achieved was the hiding of problems or lying about things.

It should be pretty obvious to most people why this is a dreadfully bad idea. Surely the lessons of Mid-Staffs have not been forgotten so totally, so soon?

The culture of performance bullying in the name of deliverology was a huge contributor to the centralised, kiss-up-kick-down culture that prevailed unhealthily and unhelpfully in the worst parts of the English NHS.

I am one of the last people who’d ever say that because measuring healthcare organisational performance is hard and the findings will be complex and probably unpopular, we therefore shouldn’t try.

We absolutely should be doing this.

We should, however, put our emphasis on things that are likely to work. The Milburn-Streeting strategy, of putting the community of NHS chief executives on notice that you’re going to be a terribly, terribly tough Secretary Of State For Health But Social Care, is remarkably unlikely to work. I mean, Steve Barclay tried that, and look where it got him.

Mr Streeting says it won’t work

In his speech, SOS Streeting himself actually acknowledges that the macho bullshit being briefed and press-released won’t work: “a culture that puts sparing political blushes or protecting the reputation of the NHS above protecting the interests of patients is one that stifles inconvenient truths being spoken to power, that silences whistleblowers and that ultimately puts patient safety at risk”.

Well, quite.

But the Milburnisms got SOS Streeting an approving editorial in the Boris Johnson Fanzine. Which is nice.

The centre cannot hold

Another passage from Mr Streeting’s speech is remarkable, but not in a good way: “Over the last few years, I’ve regularly heard the criticism of the top-down nature of the NHS. It can be a difficult criticism for those at the top to hear, but for the last 4 months I’ve found myself at the top of the system - at the peak of the mountain of accountability - and I not only recognise the criticism, I agree with it.

“The NHS in 2024 is more hierarchical than almost any other organisation I can think of. Even our armed forces, as the Messenger Review argued, is less locked into centralised command and control.”

This sits remarkably badly with his proposals for league tables, wage freezes and sacking for chief executives. It is almost as if nobody has thought this through in any way whatsoever.

One of the main problems facing the English NHS is not that there aren’t league tables (the CQC sort of does them, albeit it has no credibility; and NHSE’s financial performance rankings also sort of does them); nor is it that NHS chief executives can’t be sacked.

No: one of the main problems is that the English NHS in general, and NHS England in particular as the notional system leader, shows no curiosity whatsoever about the real root causes of success and failure in organisations and systems.

Mere anarchy is loosed upon the world

Another section of Mr Streeting’s speech is interesting: it is a promise of devolution and decentralisation. “The framework I’m setting out today is based on triple devolution: with power shifting out of the centre to integrated care boards (ICBs), to providers and, crucially, to patients. I want to lead an NHS where power is moved from the centre to the local and from the local to the citizen. Morrison meets Bevan.

“It starts with clarity. The centre should be deciding strategy, policy and clear objectives for the system to deliver on behalf of patients. We should allocate resources against those objectives and provide the overall accountability framework for improving performance. We should ensure the same standards of care in every part of the country and we should unlock the unrealised potential of the NHS as a single payer model by making the NHS the best partner in the world for the development of new treatments and medical technology and to make the most of our collective purchasing power to deliver value for money.

“And the centre should be smaller.

“As power flows from the centre over time, resources should flow with it. Otherwise it will keep swamping local services with diktats and demands that distract them from the job of meeting patients’ needs and improving the communities they serve. We need more doers and fewer checkers and the centre needs to learn the words ‘stop’ and ‘or’ after years of ‘start’ and ‘more’.

“Clear priorities mean a few, not 50 different targets. So the instructions coming out in the forthcoming NHS mandate and following planning guidance will be short. I want to see waiting times cut, urgent and emergency care when people need it and improved access to primary care. The shift from hospital to community needs to start now.”

That mostly sounds quite good, in theory. It also has zero coherence with the macho Milburnism trailed across the media to roll the pitch. Curiously, at one point it demands the impossible (“we should ensure the same standards of care in every part of the country”).

Oh, and there are no actual commitments or details in it whatsoever. One to watch.

The comeback of commissioning

SOS Streeting wasn’t done there: “I want to see local commissioning back and I want to see ICBs leading it. ICB chiefs … will lead the transformation of care - the pioneers of reform. Your organisations will play a critical role in doing what we’ve never pulled off before.

“I want ICBs to focus on their job as strategic commissioners and be responsible for one big thing: the development of a new neighbourhood health service. It will focus on building up community and primary care services with the explicit aim of keeping patients healthy and out of hospital, with care closer to home and in the home … Fragmentation needs to give way to integration and that is the job of ICBs.”

Commissioning is back, in other words.

However, commissioning seems to be back without much clarity about why it completely failed the last time - because a) it’s intrinsically hard; b) massive asymmetry of resources between commissioners and acute providers; c) lack of meaningful sanctions for bad performance and rewards for good performance.

It’s difficult to be confident that integrated care boards are going to be much better at all of this than primary care trusts or clinical commissioning groups were

NHS England’s Woman In Black

Not only did the lucky delegates in Liverpool get a speech from Mr Streeting, but also one from The Woman In Black herself, NHS England chief executive Amanda Pritchard.

It is quite remarkable for the chief executive of an organisation in charge of a system that is heading towards a vast overspend to fail to talk about that fact, but Ms Pritchard managed it. I wonder if there was a bet involved?

In last week’s column, I failed to remember where I’d written “you can tell when NHS finances are getting really bad: people start telling the truth.” It was here, in 2017.

But NHS England will be in charge of the new league tables, and the judge, jury and executioner of those who fall below its standards, with the forthcoming NHS Management and Leadership Framework. What a relief that NHSE’s credibility is so high, as I explored in last week’s column.

The Woman In Black even managed to squeeze a little light AI Hypebeasting into her speech: perhaps she is seeking a career afterlife at the Tony Blair Institute.

A key message of Ms Pritchard’s speech was “optimism alone isn’t enough. We can have a better future. But we have to continue working for it.

“The 10 Year Health Plan will set out ambitions for the next decade. But the real message I want to leave you with today is this: all the reforms I’ve mentioned, plus others, like implementing modern EPRs, the NHS App, and cloud telephony, digital triage, multi-disciplinary teams, Pharmacy First in primary care.

“They’ve all taken hard work to get to where we are. And that hard work can’t stop. The 10 Year Health Plan gives us reason to hope for a better future. But it doesn’t give us license to pause for breath.

“In fact, it means our relentless focus on delivery is needed now more than ever. To keep the show on the road. But to continue to lay the foundations on which a better future can be built.

“So that will take action from all of us. And I count NHS England in that.”

A “relentless focus on delivery” and “action” from NHSE: why does that sound so much like an empty threat?

In ‘The Picture Of Dorian Gray’, Oscar Wilde wrote “there is only one thing in the world worse than being talked about, and that is not being talked about”.

Social care would probably agree, and so what a thrill it was to see the current Government begin to negotiate with itself publicly in the media about social care, in the shape of Transport Secretary Louise Haigh’s remarks to Laura Kuenssberg on BBC News.

BBC political reporter Becky Morton writes that “the Prime Minister, Health Secretary and Chancellor are due to meet in the next 10 days to discuss the issue. Multiple sources have told the BBC the Department of Health is keen to proceed with an overhaul of the social care system but that the Treasury is reluctant to commit to significant costs without clear political backing from Number 10.”

This could just be kite-flying, but it looks as if it might possibly be something more. It would be a very big and very expensive thing to start to do.