Feb 9, 2025 7 min read

Cowper’s Cut 361: Schrödinger’s 10 Year NHS Plan

It’s been quite the week for news about Health But Social Care Secretary Wes Streeting’s advisors.

New Cavendish Streeting

Health Service Journal reported that the noble Baroness Cavendish of Little Venice is being bought onto the DHBSC board of non-executive directors, presumably to give a street-level, working-class perspective to discussions. Just kidding. You’d be hard-pushed to find a more establishment figure.

Baroness Cavendish was appointed as director of policy for Prime Minister David Cameron in 2015 (frankly, a thing that one might want to drop from a CV), and before that was a board member of the Care Quality Commission for two years. She also wrote a couple of reviews of health and care support workers and of social care. She currently writes for the Financial Times, where her recent columns have very much been of the ‘gizza job, Wes’ variety.

It is not as if Baroness Cavendish has had too few opportunities to share her opinions and thoughts about the public realm and the NHS in particular.

A clearer critique might be that she is neither a genuine outsider, able to bring the refreshing ‘yes, but why do we do that?’ perspective; nor a genuine NHS or health and care insider, with valuable operations experience and insights.

She feels like a comfortable re-tread of known quantities.

Putting the Kibosh on the NHS Ten-Year Plan

Speaking of comfortable re-treads of known qualities, we also got the HSJ exclusive that Tom Kibasi (a chair of three mental health trusts, former management consultant and Institute for Public Policy Research leader 2016-19) is being brought in to draft the NHS 10-Year Plan due in May.

Mr Kibasi’s hire as a direct ministerial appointment puts him on the same exalted par as Alan Milburn. He was the lead drafting author of last year’s blame-apportioning Darzi Review. His appointment at this fairly late stage does not indicate strong confidence with the current progress, and seems likely to exacerbate known tensions about the 10 Year Plan’s development, particularly with the steering duo of Sally Warren and Paul Corrigan.

Mr Kibasi is not known for his reluctance to repeatedly emphasise his views.

Schrödinger’s 10-Year NHS Plan

Long-time readers know of my fondness for the quantum mechanics thought-experiment of Schrödinger’s Cat.

I learned this week that Mr Streeting has been asking external experts to prepare for him a vision of a three-year English NHS transformation plan. I use the word ‘vision’ with deliberation: I could equally have opted for ‘hallucination’. If you’re seeking genuine transformation, then the fact is that here in The Real World, this will not happen to a million-staff-employing, £192-budget-spending, £13-billion-maintenance-backlog-bearing in three years *.

So this is Project ‘Win Me The General Election 2029 On The Available Money By Making A Miracle Happen’: WMTGE2029OTAMBMAMH. (Bless you.)

Put together with the Kibasi appointment, Project WMTGE2029OTAMBMAMH tells us all we need to know about Mr Streeting’s confidence in the 10-Year Plan: he hasn’t got any.

Now in terms of shaping a delivery strategy, you’d clearly want to have a medium-term plan as well as the 10-year version. The issue is that if you believed in the NHS10YP, you would finish that first, and the medium-term plan would then organically fall out of its contents and priorities.

Mr Streeting’s revealed preference is this: he clearly doesn’t believe in the NHS10YP.

So we are stuck with Schrödinger’s Ten-Year NHS Plan: it exists in a quantum state of uncertainty, being simultaneously alive and dead. In effect, we are stuck with the ‘Fantasy Football’ version of NHS reform.

Schrödinger The NHS Cat

I have long been suggesting that, since the NHS now has birthdays (and de facto must have achieved corporeal form and sentience), then it should get a cat.

It has evidently done so. Mr Streeting has taken me at a quantum version of my word, which may prove unwise.

We can only presume that Schrödinger The NHS Cat is powered by AI, perhaps sponsored by top AI fans the Tony Blair Institute.

- terms and conditions apply: the one thing that Team Streeting could do which would deliver a three-year NHS ‘transformation’ would be to majorly cheat and game the figures and metrics. That could probably be done: the big problem would then arise if Labour were to win the subsequent general election.

Gwynne gone

Health minister Andrew Gwynne was rightly sacked by Prime Minister Keir Starmer this week, on the revelation of Mr Gwynne’s various offensive, racist and anti-Semitic WhatsApp messages, published by the Mail On Sunday.

Wishing constituents who don’t vote Labour dead is not exactly a good look, and the offensive racist comments are ugly. Worst of all, perhaps, is the sheer stupidity of believing that WhatsApp messages are private (especially group messages), and that people involved will not have incentives to leak them. And WhatsApp’s ‘disappearing messages’ function has been around for some time now.

In qualified praise of Wes Streeting

Taking part in a Macmillan Cancer Support event this week, Mr Streeting announced that there were “some really daft things being done in the name of equality, diversity and inclusion which undermine the cause.

“For example, there was one member of NHS staff who was merrily tweeting a job ad online and saying part of her practice was anti-whiteness.

“And I just thought: ‘What the hell does that say to the bloke up in Wigan who’s more likely to die earlier than his more affluent white counterpart down in London?’ We’ve got real issues of inequality that affect working-class people.”

“The ideological hobby horses need to go”. Yep. That’s right.

The money’s fine, honest

In the finance report to this week’s NHS England bored meeting, director of N̶e̶c̶r̶o̶m̶a̶n̶c̶y̶ finance Julian Kelly told an adoring public that “compared to plan, the aggregate system position shows expenditure to be above plan by £1,032 million (0.9% variance versus allocation), with a net year to date overspend of £618 million”.

Mmmmmmm. This is very much less than has been widely suggested is the genuine overspend position in aggregate.

I wonder whether a jolly big capital underspend might be somewhere nearby?

And the hits just keep on coming: “delivering against plans will require systems to deliver significant efficiencies and higher income of £9.3 billion (equivalent to 6.2% of their total allocation); and an aggregate reduction in WTE staffing of 1.2% compared to 2023/24. At month 9 systems have delivered £5.7 billion of savings which is £0.4bn lower than plan … Overall workforce levels have reduced by 0.6% since the end of the prior financial year.

“We are expecting that ICBs and providers will continue to improve their expenditure run rate in the final months of the year. To the extent that systems are not able to deliver their plans, we expect that underspends in NHS England as a result of the tighter financial controls we have now had to impose will be sufficient to deliver balance across the NHS as a whole.

“Providers have spent £2,922 million on capital schemes to month 8 (excluding IFRS 16 expenditure relating to lease assets), representing 39% of their full year budget (compared to 39% at the same stage last year). The DHSC provider and commissioning capital budget for 2024/25 (including IFRS16) is set at £8,712 million against which we are currently forecasting an underspend of £108 million.”

Ahem.