Editorial Friday 2 October: What Sir David Nicholson said in his NHS Providers Annual Lecture (and what he may have meant)

The former NHS Comrade-In-Chief Sir David Nicholson gave the second NHS Providers Annual Lecture a few weeks ago.

It was a thoughtful, amusing and insightful presentation, expanding on some themes from his July seminar on what the Government should do about NHS finances, and introducing others anew.

In the interests of mischief, here are some key lines from his lecture, and what they might mean translated.

”I was absolutely beside myself about the lack of conversation in the general election campaign about the big issues that are facing the NHS over the next period, and in particular, the financial position that you find yourselves in and the consequences for not considering and discussing it after the election.”

Trans: As oppositions go, Labour haven’t been one on the NHS: not in any meaningful way. The financial state of the service and the available plans are the equivalent of a barn door, of precisely the kind Andy Burnham couldn’t hit with a banjo.

”In reality, the deficit is not what causes the problem. The problem comes when you try and tackle it, and that will inevitably be the story across the next few years in the NHS.”.

Trans: Yes, we screwed the pooch in the 2006 financial recovery. Getting back into balance by cutting the training and public health budgets was really not smart. It was quick, and relatively easy, but not smart.

”I will not be saying that the Department of Health should be abolished, or that the purchaser/provider split should be put in the dustbin of history, where it belongs”.

Trans: Do you see what I’m doing here, saying a couple of things I heartily believe in as a non-joking joke? See also Nick Timmins’ shrewd blog. Nick always was sharp.

”The NHS is held in enormous esteem around the world in terms of healthcare systems; not just by policy-makers, but by people who run and provide services on the ground. It is seen by millions of healthcare professionals around the world as a beacon of what it is possible to deliver with a relatively small amount of money in a country like ours. There is no shortage of people who want to listen to what is happening in the NHS, and give you advice about what their experiences are”

Trans: I know how tough times are and how low morale is, but we have got to retain our pride in what we do.

”Surgeons from Colombia, South Africa, Sweden, America, France, Italy, and parts of Africa … could not believe what was happening in our healthcare system, because they could not imagine a healthcare system that could deliver four hours in an emergency room from turning up to having treatment for nine out of 10 people.

“The Swedes told us that they had moved it from four hours to eight hours. The South Africans said they had started to do it and then abandoned it, because it was simply impossible. They thought it was absolutely extraordinary that our healthcare system, given the environment we were operating in, could deliver that. That ‘nine out of 10’ figure was regarded as a catastrophic failure. For those of us who have worked on this for years, it was a failure, but it is a remarkable thing to do after little or no growth in the system. When you stand outside the system and look inside, you see a system under enormous pressure, but performing fantastically well for the people of this country”.

Trans: Targets work. Never forget that. Targets work.

”We all want to operate in an environment where we are trusted, and the only way that we will deliver some of the major financial challenges that we have is if we develop and improve trust in the system. Trust is really important for our system. It is important between patients and clinicians; between clinicians and the managers of organisations; between the people who work in organisations and their boards; between the population and the board; between organisations that deliver care and those that commission care; between those people who deliver and commission care locally and the national bodies; and it is particularly important between the NHS and politicians”.

Trans: On the off-chance you haven’t noticed, we are really fucked. Because nobody really, meaningfully trusts anyone now. Nor have done for some time. Trust in delivery is one thing, but we’ve seen good leaders in the NHS carelessly thrown to the wolves for next to nothing. There’s not even a David Nicholson to stay on the right side of, more’s the pity.

”We will not deal with the problems facing the NHS unless we work on how we can deliver a greater trusting environment to operate in. Part of this issue around trust is the predictability of the system we operate in. If people believe if organisations are operating in unpredictable ways – that, every day, something different happens in a way that people simply do not understand – you undermine trust and undermine the way things operate. Consistency of purpose is critically important to developing trust”.

Trans: Nothing says trusting environment like regulators tripping over one another to put you into special measures, does it? Oh, maybe a phone call from the Secretary Of State to find out why you’re breaching on four hours and 18 weeks. Or DH emergency liquidity assistance for some providers but not for others.

Still, at least commissioning’s going to keep the whole show on the road with consistency over everything from fines to managed breaches. Aren’t you reassured?

”Can you imagine, if when Patricia Hewitt delivered Our Health, Our Care, Our Say – which set out the future of community services; how investment in primary care and supporting people with long-term conditions were to be dealt with – we had followed it from 2006 until now, how different the healthcare system would have been?”

Trans: Dream, dream, dream dream. And let no bugger mention my enthusiasm for ’High-Quality Care For All’

”The financial problems we had from 2005 until 2006 was minuscule compared with the challenges that you are dealing with now. We learned then that you make a judgment about what you want to do; you cost it; you challenge it; you test it; and then you implement it. You do not just announce something and expect something to happen. Can you imagine how different of a financial position we would be in today if that had been applied consistently?”.

Trans: Hello, Simon! I’m not saying that there was about as much science behind the £8 billion cash and £22 billion efficiencies as there is behind homeopathy. Bit like Pat Carter’s £5 billion. NRN economics, isn’t it? Nice Round Number.

”This idea of consistency of purpose is really important to build trust in any healthcare system, and particularly in ours. If NHS England is for anything, it is to create the umbrella to enable that consistency of purpose to be delivered throughout the healthcare system”

Trans: Very important thing, consistency of purpose. Also spelled G-R-I-P. Got one, Simon? Or are you too busy making up a new care model of the day?

”Politicians bear a significant responsibility for the nature of the financial position that we find ourselves in”.

Trans: What we choose to spend on the NHS is always a political decision.

”One of the lessons that we learned in 2005/2006 was that we could not find one example of a commissioner who turned round their financial position during that period without being given substantially larger amounts of money. We made the judgment that, however we constructed the system after then, we would ensure that the financial pressure was not evenly distributed between commissioning and provision, but was organised so that providers would take the bulk of that responsibility. That is how we did the tariff, and all of the rest”

Trans: We knew providers would be the most stable, able and least-redisorganised bit. The second you have to do anything that’s actually hard, you notice very quickly that commissioning is essentially ornamental bollocks.

”We always had to make a judgment about what was possible, and one of the dangers that we have here is people asking you to do things that they know – and you know – you cannot do”.

Trans: £22 billiion in efficiency and productivity gains is bollocks, Simon, and you know it. Nobody believes you’ll get near. We managed £18 billion with some fat to cut, wage freezes and dropping the tariff and not paying for A&E increases.

”We are not doing right for patients or for our communities if we deliver a system whereby politicians expect the NHS to do things that we know we can do and, in their hearts, they know we cannot do, or where the centre asks hospitals, trusts, and commissioners to do things that they know they cannot do, and those people provide plans that they know they cannot deliver”.

Trans: Targets are good, unless they’re un-hittable. Good luck with hanging on to the Golden Boy reputation, Simon.

”We need to find a mechanism for mobilising people. At the centre, you can do all sorts of calculations which, in a sense, satisfy you because they are intellectually sound. We can identify theoretical things that can be done, but actually, it is the practice that really matters. Getting that absolutely right is critical, and in order to make that happen, you need to mobilise people. People have to believe in their hearts that they can do it”

Trans: Clever seminars are all well and good, Simon, but you need hearts as well as minds.

”To deliver a safe and sustainable NHS going forward, with quality at its heart, built on the values of principles of the NHS that we all support, transparency is very important: for our patients, the population, and our staff”. It will be difficult in the short term, undoubtedly, when you start being open in the sort of way. All sorts of unintended consequences happen, but it is vitally important “.

Trans: One of the brilliant things about being out of the firing line is you can say this sort of thing.

”As we sit here, there is a document in the Treasury which sets out the Department’s view about what is going to happen in financial terms to the NHS going forward. I cannot imagine that there are many of you in this room who have actually seen it. That, historically, has been the case, but in order to build trust in the system, that needs to be opened up so that people understand”.

Trans: Opening up working documents to wider understanding is pretty much what the Treasury exists to prevent.

”We should not get into a place of trying to deliver things that we know we cannot deliver”.

Trans: No idea what you promised George and Dave, Simon, but I hope you have some compromising photos safely stored.

”If you want the NHS to do something, you have to first of all provide the money to do it, and if the money is not there or it is theoretical, you need to be able to say, ‘What are we not going to do in order to deliver it?’ … We should not be in a position where we are identifying objectives without being absolutely clear as a service what it means to deliver them, both in terms of the money that you need and the people that enable that to happen”.

Trans: Provider reconfigurations, seven-day services, new cancer targets, 24-7 GP access and no significant extra money? Bound to work. What could go wrong?

”France spend £400 per head on their population more than we do. The Germans spend £800 more per head than we do. If, next year, we got a budget for the NHS which was the same size as the Swedish healthcare budget, we would have a £50 billion increase in healthcare expenditure. The position that we are in is completely nonsensical.

“I saw the stuff that John Appleby did on this. To be fair, Simon and the team have worked hard to get £8 billion from the Government in very difficult circumstances, but that will only take us to the position we were in 2005 by 2020”.

Trans: A competent Labour opposition might have mentioned some of this stuff.

”We also, as an NHS, need to do more ‘shaking the tree’. There is still money in bits of the NHS that needs to be shaken out. There are a variety of national bodies now that have money, and there are a variety of ways in which money is secreted around the system. We need to shake every tree to get all of that money out, and make sure it is all spent on delivering services to patients. It is all of our responsibilities to make that happen”.

Trans: Did I mention grip?

”We need some kind of overdraft facility, to enable some of the Trusts to make some of the changes that need to happen. When we had surpluses, on two or three occasions, the Treasury would ring us in February and say, ‘Can you increase the surplus you are going to make in the last couple of months or so? We desperately need the money for something else.’ Based on the agreement, they would give it us back in April, and we did that. We created £300 million to £400 million worth of extra surpluses to enable the Treasury and other parts of the system to work. It is not unreasonable to have the equal and opposite opportunity, coming down the other way. That is what government and politicians need to do to help solve the problem, and I do believe that in time, all of those things will actually happen. People will complain, and there will be lectures about ‘You cannot spend more money than you have got’, but that will happen one way or another. It is much better if it happens up front when people can plan and organise for it, rather than for it to happen way down the road, when we are all in real trouble”.

Trans: We need it frontloaded, but we won’t get it. So there will be chaos.

”It was a central part of the Health and Social Care Act that autonomous providers and commissioners would think about the interests of their local communities and would, in some way, all work together and solve all of the problems of the NHS. It does not quite work like that; it might have, but it does not. When you have significant national intervention, it is very difficult for people locally to work out how to do things. Even in the best-run organisations, the tendency to look up to the people who have power over people’s careers in the NHS inevitably outweighs the forces bringing people together.

“We need to invent in the NHS some local forcing mechanisms to enable it to happen … you need a forcing mechanism at a local level to make this happen. Without that forcing mechanism, we will not be able to make the kinds of difficult decisions that we need to make about the balance between commissioning, provisioning, and where people are”.

Trans: George and David are going to be looking for a forcing mechanism to help restore grip on the NHS? My day rate is very reasonable.

”We also need to make sure that we can restructure the debt that people have got. Some of these accumulated deficits are not going to be solved, even in a three- to five-year period”.

Trans: ‘Somewhere over the Parliamentary political horizon …’

”Creating an environment where people constantly look at the cost of things and think about the way in which they can deliver it is lower cost is important“.

Trans: Thank goodness we haven’t cut the tariff, eh?

”This great generation of people, who are going to do fantastic things for our service – who are going to change the nature of how we deliver services, and make the NHS sustainable in a much more hostile environment than I ever encountered – need support and nurturing. We need to make sure that those of you who have been around for a while make yourselves available to these people, to enable and support them on the journey that they are on. We need the national bodies to make sure that they nurture and support these people. We need the politicians to make sure that the first response is not, ‘Get them out the door’. If we are going to expect fantastic things from them, we are going to have to support them and help them in a way we have not done for quite a long time”.

Trans: It might happen, I suppose. If all the chief execs don’t get sacked by Monitor and CQC first. And if we can find some different politicians - and media.