Editorial 30 November 2020: Cowper's Cut 138 - Pretty vacant (part two)

Owing to constraints of space and time, this material written for my weekly column for Health Service Journal could not be used there. So it's here.

DHSC Covid19 Winter Plan
The Department for Health But Social Care’s Covid19 Winter Plan officially revealed that Test And Trace's budget is almost going to double: "This strategy is backed by an additional £7 billion for NHS Test and Trace to increase testing and continue to improve contact tracing, taking the overall funding provided for Test and Trace this financial year to £22 billion."

"Work to improve contact tracing continues, including the roll-out of tracing partnerships with Local Authorities to ensure a greater proportion of people who have tested positive are reached, help provide the support they and their families need to self-isolate successfully and more quickly, and identify and reach any contacts they have had outside their immediate household”.

Mmmmmmm. The document was silent on the gross and ongoing failure of the national contact tracing programme led by management consultants and delivered by outsourcers. As I reveal below, it seems they’re changing their software platform.

This extra £7bn for TAT is "to support increased testing, including community testing and ongoing improvements to tracing". As social care expert Richard Humphries tweeted “the planned increase for Test & Trace is roughly the same as total spending on social care for older people (£7.8b) & working-age people (£7.3b)”.

The TAT of the land
And TAT’s performance? Still not good, the latest data shows. The contact tracing rate is still way below the 80% target. Last week, just 60.3% of 'close contacts' were reached. The number of people testing positive has decreased by 9% week on week: in context, positive cases had been rising steeply since the end of August.

There is some good news: test turnaround times improved. For in-person tests (local test sites, mobile testing units and regional test sites), 50.6% were received within 24 hours, compared to 38.0% in previous week. But this remain far short of the 100% target by end of June set by the PM.

On TAT’s planning for mass testing, I recommend this piece from Manchester Evening News’ Jennifer Williams on the rhetoric and reality of ‘Operation Moonshot’.

It was interesting to learn that a Birmingham-based organisation called , who style themselves as ‘a leading social, economic & market research agency’, are using the Salesforce customer relations management platform and a warehouse management module for the next stage of TAT’s system operations.

Challenge the NHS, with Alan Partridge!
The People's Partridge, Health But Social Care Secretary Matt ‘Alan’ Hancock, repeatedly announced this week that he has "challenged" the NHS to roll out the Covid19 vaccines (Astra Zeneca’s one imagines, being subject to some further clinical trials, following significant controversy over the data).

We all know Mr Hancock as The People's Chat Show Host, but he seems here to be proposing to treat the NHS as Anneka Rice. I’m not sure whether TV genre-bending is quite his thing.

At Monday’s Downing Street briefing, Alan told the nation "that ’if in doubt get a test’ should [from now on] not just refer to coronavirus but everything. "Why do we think it's ok to soldier on and go to work if you have flu symptoms? "If you have in future flu like symptoms you should get a test for it". Um. This comment from the Secretary Of State For "A-HA!" could make good sense, if TAT were working well.

In the real world, TAT isn't working well.

It’s a lesson too late for the learning
On Tuesday, The People’s Partridge gave evidence to the ’lessons learned’ joint Health/Science select committee meeting. We couldn't really claim that many lessons were learned; nor indeed that many questions were in danger of being answered.

It’s worth reading the latest transcript, to get the flavour of just how unproductive most of it was in terms of learning any lessons. Mr Hancock has evidently been briefed by DHSC-hired lawyers to within an inch of his political life. It’s far more likely to be a ‘lesions learned’ experience, in terms of highlighting where the damage has happened.

But one particular exchange on contact tracing bears quoting:
Dawn Butler: What proportion of contact tracing is carried out by local teams?
Matt Hancock: I will try to find the figures for you … If you want to get a public/private split, you have to look at a different set of figures because you are looking at who is employed directly by a public authority, as opposed to who is brought in by contract. I can get that split, but it is immaterial. What matters is the service that you are delivering.
Dawn Butler: I agree. It seems like the local service has been better than the national service.

Corruption and cronyvirus update
On the Covid19 Tsars (Lord Deighton, Kate Bingham, Baroness Harding)
“There are some quite serious questions about accountability and appointment, and transparency and propriety around some of those appointments, which should, by now, have been regularised.”

On Government procurements over Covid19
“There comes a moment when the crisis becomes the normal for the next defined period—the year, or whatever—when it is important for public confidence and for the integrity of the state to regularise that. That applies both to the procurement contracts … and to appointments … It is totally legitimate in the early phases of a crisis to throw everything at it … it is important now to make sure that the public have confidence in those processes and that we root out any suggestion that there is impropriety or anything around those contracts”.
Alex Thomas, Institute for Government, evidence to ‘Lessons Learned’ joint Health and Science select committee hearing, 24.11.20

This week’s corruption and cronyvirus update brings glad tidings of great joy. We start with news of a pub landlord neighbour of Matt Hancock’s with no experience in medical supplies who won a DHSC contract for testing kit after WhatsApp-messaging The People’s Partridge: this gets extra points for including a bouncy castle manufacturer in creating its production process.

Then there is the Scottish property developer who knew
“nothing at all” (in his own words) about PPE who got a DHSC £9.6 million supply contract.

The ‘lessons learned' session mentioned above also gave us the fun case of the DHSC’s procurement of Conservative propagandists Topham Guerin for digital work.

NHS procurement expert Rob Knott pointed out this week that the National Audit Office “exposed that Govt had sourced £489m worth of PPE through their freight firm, Uniserve. What it didn't pick up was the spend with Uniserve for the core freight service. Published today, a contract value of £473m. Awarded in March. Total spend to date: £962m”. Anyone for unambiguous conflicts of interest?

NHS redisorganisation update: new legislation in Spring 2021
We also learned the timetable for the NHS’ next redisorganisation. Sun King of Skipton House Sir Simon Stevens told HSJ’s Provider Summit that legislation in the Spring of 2021 should enable the NHS to move into statutorily-based Integrated Care Systems by April 2022, with the abolition of clinical commissioning groups.

Stevens won't be unaware of the symbolic timescale of this: a decade on from dear old Lord Lansley’s 2012 Health And Social Care Act, its market mechanisms mission will finally be interred with a stake through its heart. During this week’s NHSCB board meeting, when Sir Simon Stevens quoted Nye Bevan on how legislation is basically useless unless people are enthusiastic about it, NHSCB chair David Prior replied: "You might want to send that quote to Andrew Lansley and see what he makes of it".

Lord Prior is in a different class to ‘six-month leave of absence’ NHS Improvement chair Baroness Harding, of whom more shortly.

We shall see whether the statutory independence of the NHS Commissioning Board is to be rolled back as well. This Government, like Mrs May’s before it, made repeated noises about reasserting ministerial line of sight on control, and absolute NHS monarch Sir Simon is on his way towards the exit.

The new NHSCB document
gives further reading on this.

The (Non-)Comprehensive Spending Review
The extra £3bn for the NHS in the CSR was heavily leaked last week. The Chancellor also made last year’s extra £1bn for social care recurrent. The Treasury’s CSR documents promised proposals on social care reform ‘next year’ – year unspecified, of course.

Former Special Advisor to Mr Hancock, Richard Sloggett of Policy Exchange, observed that this  “looks like a downgrading of ambition … the phrase used today: "In the longer term, the government is committed to sustainable improvement of the adult social care system and will bring forward proposals next year" feels like a significant shift away from full reform”.

Siva Anandaciva of the Kings Fund’s analysis of the CSR’s implications for health and social care is a good read: likewise, Adam Briggs on flu and Covid19 ; George Donald on NHS performance data and A&E/RTT waits; the Nuffield Trust’s Billy Palmer on the data basis of the Tiers system; and biostatistician Jon Deeks on the accuracy of lateral flow tests.

On money matters, The Independent’s Shaun Lintern reported NHS boss Simon Stevens suggesting that negotiations with Treasury over increased funding for the NHS post Covid will go on into the new year. Just in time for a March budget, Shaun thinks.

Stevens is reported as saying, “what we have agreed with the government is that they are putting in the extra funding for some of these new health needs next year, over and above the Long Term Plan, and they are working with us on identifying what the extra Covid costs look like going into the next financial year 2021-22, but the truth is, there’s still quite a lot of uncertainty about what those costs will be, and so we think we agree with them that it makes more sense to answer that question earlier in the New Year”.

“There’s no point in asking, you’ll get no reply”
When it comes to not answering the questions, everybody’s favourite noble baroness, the Baroness Harding of Winscombe is without peer. (Nope, not even sorry for that one.)

Baroness Harding’s recent appearances at the ‘lessons learned’ committee (which I covered last week) and the HSJ Provider Summit are masterpieces in not answering questions.

She told the Summit that she doesn't owe the NHS an apology for the dreadful performance of TAT on contact tracing, nor for its appropriation of the NHS name.

Once again, the noble Baroness emphasised the fact that TAT is the size of Asda. And as I pointed out previously, her ‘retail fallacy’ analogy stops right there: TAT is far less good at doing what it is meant to do than Asda is. (Given her well-known professional associations with the customer data disaster at Carphone Warehouse and Sainsburys 2007-10 in its non-imperial phase, one could suggest that appointing Baroness Harding for her expert understanding of how to do retail is like appointing Dracula for his expert understanding of how to do blood transfusions: an inexplicable, yet memorable category error.)

The noble Baroness Harding could not say when her ambition for TAT to do the necessary and get to 80% of contacts would be achieved: “The challenge was to reach 80 per cent of index cases and then 80 per cent of their contacts. And yes, I do think we will hit those targets. I’m not going to give you an exact date but we’re making really good progress … please don’t take the fact that I don’t want to give you a date to mean that it’s a long way off. Actually, that is not the case.”

How reassuring.

Impossible is nothing
Her finest moment was in non-answering the question about whether she’d like to succeed Sir Simon Stevens as NHSCB chief executive, as rumoured: “I’m really focused on what I’m doing now … I’m not thinking about what I’m going to do after this and I would find it impossible to answer the question even if you were asking me where do I want to go on holiday next year. I’m afraid I’m focused on doing the job I’m doing now”.

There is evidently no impossibility in answering that question: only unwillingness. It’s always opaque why people who won't answer questions do interviews. Maybe they think people are too stupid to notice. Or perhaps they just don't think.

NHS Kiss and bureaucracy
In fantastic news for fans of digital and reviews (and this is surely each and every one of us?), we learned that another NHS Kiss review
may be delayed. The little teases!

Readers who have been around the block a few times know the mainstay of every new Health Secretary’s tenure is her or his first ‘NHS bureaucracy-busting review’. Now we have ‘Alan’s Big Bureaucracy Bust’, and unsurprisingly, it is a thing of beauty and a joy to treasure.

Its eight recommendations are:
• Data and information will be shared, asked for and used intelligently
• System and professional regulation will be proportionate and intelligent
• Day-to-day staff processes will be simple, helpful and effective
• The government will legislate to make procurement rules more flexible
• GPs will have more time to focus on clinical work and improving patient care
• Medical appraisals will be streamlined and their impact increased
• There will be greater digitisation of services
• A supportive culture is needed at a national and local level

The notion that 'the government will legislate to make procurement rules more flexible' deserves particular scrutiny, given the crony Covid19 procurement scandals. The other seven aren't necessarily malign: they are just slogans. (A slogan is instantly identifiable, as its opposite would be an evidently ridiculous statement)

This review leans on heroic assumptions that you can make regulation, both of individual clinicians and of organisations, services and presumably systems, better and less burdensome. It says nothing about how you make them better.

There seem to be a lot of 'actions' for NHS Kiss: "NHSX will launch and then implement a Data Strategy for Health and Social Care in the coming months. This will capitalise on the good practice from the response to COVID-19 by building on the permissive approach to data sharing, such as the use of Control of Patient Information (COPI) notices, while protecting the need for patient confidentiality."

"NHSX is convening a new Data Alliance Partnership, bringing together key bodies such as the Care Quality Commission, NHS Business Services Authority, Public Health England and NICE, to agree principles on data collection, sharing and use to minimise the burden of data collection and processing. It will facilitate increased access to data, by making aggregate/anonymised data accessible by default, for legitimate purposes and within existing legislation."

So NHS Kiss are going to be the James Bond of all this. Licensed to bust bureaucracy. Mmmmmmmm. NHS Kiss Kiss Bang Bang?

I've been banging on and on and on about NHS culture for years and years (NHS chief anthropologist blah blah blah), and so this sub-heading drew my eye: 'Supportive culture at a national and local level'. So what does this have to say?

"A supportive culture, at every level, is just as important as specific actions to bust bureaucracy. In fact, the success of the actions listed above will be impacted by how leadership at every level of the system embraces them."

(English translation: Here are a set of words that we have written down, which do not mean anything. Please just nod thoughtfully.)

It goes on from there, I'm sorry to say: "Each part of the system must question and call-out organisational habits or local rules which increase excess bureaucracy. Everyone needs to play their part in busting bureaucracy, from national government to local providers and frontline staff."

(English translation: excess bureaucracy of course arose because people did not question and call-out regulation and reporting. Yes, it did. Look, just nod, OK?)

And of course when you see the phrase "everybody needs to play their part", you instantly know that what's everyone's job is no-one's job.

So you sigh. And you shrug. And you consign the 2020 bureaucracy busting review to the dusty shelf of NHS management history, along all the others. There’ll be another one along next Health Secretary.

Good news? I have a little: some interesting innovations highlighted here in the FT.

And the latest Ipsos MORI Veracity Index finds that again, doctors and engineers are the most trusted professions in the Ipsos MORI Veracity Index 2020, while politicians, government ministers, journalists (hello!) and advertising executives are least trusted. A smart profession could do something with that level of trust, chaps. No, clearly I’m not talking about mine.

Encouragingly, we also learned that a new Ipsos MORI poll finds half (50%) of Britons think this second lockdown in England will be effective in significantly reducing the spread of the coronavirus, while 41% believe it will be ineffective. These numbers are largely unchanged among just English respondents (50% effective, 42% ineffective). Older Britons have slightly more faith in the measure, 54% of 55-75-year olds believe it will be effective compared to 48% of those aged 18-54.

Almost three-quarters (73%) say they are following the restrictions completely or nearly all of the time with a further 21% saying most of/ about half the time. These figures are near unchanged from October 2020.

Britons are less convinced when asked about the behaviour of others. Despite three in four (73%) saying they are abiding by government rules, just one in ten (11%) think all or nearly all other Britons are doing the same. Nearing two in three (63%) believe that most or about half of the British public are following the rules. However, one in four (25%) believe it is less than half, hardly any or none of them, which has increased from fewer than one in five (18%) in May.