Cowper’s Cut 358: Towards NHSCapital
It’s only January, but Health But Social Care Secretary Wes Streeting may already have made 2025’s most futile statement about English health policy and politics.
Andrew Sparrow
Mr Streeting told the Commons, “let me address the issue of corridor care, which became normalised in NHS hospitals under the previous government.
“I want to be clear, I will never accept or tolerate patients being treated in corridors. It is unsafe, undignified, a cruel consequence of 14 years of failure on the NHS and I am determined to consign it to the history books.
“I cannot and will not promise that there won’t be patients treated in corridors next year. It will take time to undo the damage that has been done to our NHS, but that is the ambition this government has … this government will not accept corridor care as normal care.
“We will not tolerate corridor care as being acceptable care. We will do everything we can, as fast as we can, to consign corridor care to the history books.”
Mr Streeting, may we introduce The Real World?
Shaun Lintern, Health Editor | Caroline Wheeler, Political Editor
Oh dear.
Painting-by-numbers-style political rhetoric of this kind is unequal to a one-to-one meeting with The Real World at the best of times, and this is quite clearly not the best of times.
This government has no choice but to accept and tolerate corridor care as normal and acceptable care, because they have put in place no capacity and no plan for anything else. (I suppose that local politicians could try to ban people from being ill, as is being tried in Planchez, in rural France.)
The advertisement for corridor care nurses by the Whittington is the clearest signal that this is business as usual.
That point was hammered home by ‘On The Frontline Of The UK’s Corridor Care Crisis’, a new report compiled by the Royal College of Nursing, using their members’ testimonies on just how bad and dangerous corridor-delivered hospital care can be.
The report is 460 pages long.
One example reads, “after appearing in a TV programme, the corridor was closed for several weeks.
“Unfortunately from October 2024 the corridor was opened with 4 extra spaces being seen as normal, with another 4 in the ambulance receiving area made up of 2 which are used as rapid off-loads for treatment of sepsis patients then 2 extra places one against the wall and one against the nurses station desk, 1 space in majors by the oxygen storage cupboard all became part of the escalation policy and Hospital Full policy.
“This is normal and to have 40 plus medical DTAs in the department.”
Shaun Lintern, Health Editor
Shaun Lintern’s latest Sunday Times piece adds to the sense of a crumbling system, with its look through NHS Resolution data at the compensation costs of restitution for people languishing on long waiting lists.
Shaun’s piece puts the figure at £8 billion since 2010.
Matt Discombe
New Office for National Statistics analysis shared with Health Service Journal found that patients spending 12 hours and over in A&E were twice as likely to die within 30 days as those treated, transferred or discharged within two hours.
Shaun Lintern, Health Editor
Oh and in this week’s ‘metaphors writing themselves’ slot, the actual roof fell in at the Countess Of Chester’s A&E.
The Powis Irrelevance
Mr Streeting’s Commons rhetoric was of a piece with all of NHS England’s various statements and media briefings about winter pressures, which all have iterations of NHSE’s medical director Professor Steve Powis saying “nobody wants people to be treated in these circumstances” (this ‘nobody wants …’ phrase being a longstanding media trick of his).
To which the only sensible answer would be “NO SHIT, STEVE; OF COURSE NOBODY WANTS THAT! WHETHER PEOPLE WANT CORRIDOR CARE IS NOT IN ANY WAY THE POINT.
“THE POINT, STEVE, IS THAT IT IS HAPPENING, SO DO YOU BY ANY CHANCE HAVE A CREDIBLE PLAN TO ADDRESS AND STOP IT?”
It’s surprising that The Powis Irrelevance has gone unchallenged by so many national journalists. Let’s hope to see this weak and weary media bait-and-switch line get a robust challenge, the next time Professor Powis wheels it out again.
Streeting’s policy game improved markedly when he was responding to his opposite number Ed Argar’s question about extra winter funding: “The shadow Secretary of State asked about additional funding for winter. When I was shadow Health and Social Care Secretary, I was very clear about my cynicism regarding the pattern of behaviour we saw from our predecessors. Year after year, they would arrive in the middle of winter—often after the winter peak—with a gimmicky package of last-minute funding that delivered too little, too late without making any real difference on the frontline, all to give the impression that they were doing something to mitigate the crisis in the NHS, in which they played a serious part.
“I said that we would not do that, and we are not doing it. As soon as we came into office, looked at the books and saw the black hole, the Chancellor released additional funding for the NHS in-year to ensure that it had the resources it needed not to cut back.
“Thanks to the decisions taken by the Chancellor, the NHS has received more than £2 billion more in-year than it would have received if the Conservatives had remained in power, so we do not need any lectures on funding. Indeed, they continue to oppose the £26 billion we provided for the NHS.”
To give Labour some credit, the least effective thing they could have done would be to repeat the Conservatives’ winter playbook of recent years in an announcement of some minimally-structured ‘new’ winter money at some point between November and January. This trick allowed health secretaries and ministers being criticised for the winter crises to claim there was new investment, because too few in the media realised that money announced at that point will make no significant short-term difference. Short-term winter funding announcements are the health policy last refuge of the scoundrel.
New (If Fictional) Hospitals Programme a sham? Well I never
Denis Campbell
Being (as I am) the man who coined the phrase ‘The New (If Fictional) Hospitals Programme’, a wry smile played around the corners of my well-chiselled features when I read the article briefed to The Guardian’s consistent Denis Campbell about delays to delivery of the 40 new (if fictional) hospitals.
I laughter until I stopped: I’m sure you did, too.
£12 billion here, £12 billion there: pretty soon, you’re starting to talk serious money
The Grauniad article suggests that estimated costs to deliver the fictional forty have risen to £30 billion. Mmmmmmmm. This is quite a surprising number.
Zoe Tidman
Just three months ago, HSJ reported that the N(IF)HP had bid for £18 billion as being sufficient to complete the full programme of the fictional forty. So at £12 billion in just three months, that’s some fairly steep cost inflation, suggesting either that the N(IF)HP was almost criminally negligent in its estimation or that the latest number is highly inflated.
Zoe Tidman
This comes on top of the recent report from HSJ about payments to N(IF)HP consultants KPMG and Mott Macdonald being in excess of £100 million each since 2021, with significant increases since 2023.
And what do we have to show for this?
If I were the National Audit Office and the House of Commons’ Public Accounts and Health Select Committees (which thank the Lord I’m not, sir), I’d be looking to hold a joint inquiry into the New (If Fictional) Hospitals Programme’s conduct, delivery and leadership - both internal, national and political.
I am trying to swear less in 2025, and so I will merely observe that the New (If Fictional) Hospitals Programme has been neither use nor ornament.
Presenting NHSCapital
Among our problems is that the fictional forty are badly needed.
So too is fixing the ERIC-revealed capital and maintenance backlog, which totalled £14 billion at the last count for 2023-24. So it’ll now probably be £16-17 billion.
On top of this, there is the major issue of the bringing back into NHS ownership of PFI contracts. There is some good data on NHS hospital PFI hand-back here, and while most contracts expire in the late 2030s and early 2040s, it’s starting soon for the first wave PFIs (which often had pretty poor contracts from an NHS point of view).
The NHS Confederation’s recent report is a good read; as is Matthew Custance’s, particularly on the arcane but vital detail of “bizarre and nonsensical lease accounting standard, IFRS16. This document envisages a strange new accounting world where both the landlord and the tenant can own the same asset at the same time, and has run roughshod over capital allocation approaches in the public sector.
“The upshot though is simple: any English NHS entity constructing an asset through PFI, new or old, will require capital budget cover (NHS CDEL). Meanwhile, Central Government Departments and devolved Governments continue to use the old way of accounting for PFI, but they still need to apply IFRS16 for property leases.
“So, while use of traditional PFI can help governments to manage reported borrowing at a National Accounts and even Department level (where IFRS16 is not adopted), IFRS16 stymies this for English NHS budgets - and so PFI, old or new, will not help to stretch limited NHS capital expenditure budgets, unless the Department takes a different approach.”
Henry Anderson
And Henry Anderson’s recent HSJ ‘Following The Money’ column on a return of PFI also deserves your time.
Obviously, our dear old friends the Treasury Munchkins are not very likely to sign off on a huge amount of new capital expenditure for and by the English NHS. NHS England does not currently enjoy the Treasury’s confidence, to put it mildly. Government borrowing has also got a lot more expensive lately.
I think all of the above means that we need a new solution. The problems around capital and maintenance seem to me to be particularly ill-suited to management and delivery by a couple of hundred individual organisations. I’m not a person who philosophically suggests centralisation to a devolved body lightly, but on balance, the potential gains from a properly-led new organisation which has a tight remit around property asset funding and ownership could outweigh the very real potential to make very, very big mistakes.
So, we need NHSCapital. We need a Big Beast with financial experience and credibility to run it, and one such happens to be in the wild in the shape of Sir Robert Naylor. Technically, I believe Robert is enjoying his retirement very much indeed, but I also reckon that the ability to build something truly unique might appeal to him.
NHSCapital will, crucially, not under any circumstances report in to NHS England, in any way. It needs some special form of ownership, which better legal and constitutional minds than mine would have to shape.
It will have to be given distinct and probably unique fundraising powers. Some of its money definitely has to come from the Treasury, but I would also want to see it raise funds and build genuine and long-term partnerships with private sector infrastructure and investment firms (particularly pension funds).
I’d also be absolutely up for letting the public buy shares in it, and indeed donate money to it, possibly with attractive inheritance tax breaks.
OK. There you go, I‘ve Had An Idea. (It probably won’t be a regular occurrence.)
Over to one of the smartest readerships around. Why wouldn’t it work; could anything like it work; has anything similar been done elsewhere; do you have better ideas? I look forward to hearing from you.
Recommended and required reading
One of the brightest people who used to work at NHS England, Pollyanna Jones, was commissioned by the Wellcome Trust with colleagues to write a paper on a ‘UK National Data Library: Distributed Architecture For Research’.
HSJ’s James Illman reports on waiting list experts’ concerns that plans to pay providers to validate their RTT elective waiting lists are wide open to gaming (see the Christopher Hood links in last week’s R&RR for past examples of this).
Funny HSJ story on Conservative tail-end health secretaries (Barclay S and Atkins V) spending half a million pounds dismantling and then rebuilding their offices in DHBSC.
Thoughtful FT opinion piece on what we should really mean by talking about an ageing population.
Free social care exists in England, but only if you’re in Hammersmith and Fulham: interesting Guardian piece asks if this is the way to fix social care.
PM Sir Keir Starmer did a speech on AI, with some health content.
My latest column for the Pharmaceutical Journal.