Editorial Thursday 14 August 2015: Journey To The Foot Of Our Stairs - on the Tories' offshoring health policy to Simon Stevens

If it hasn't been done already, the socio-cultural impact of classic phrases from Lancashire is undoubtedly a PhD thesis waiting to happen.

Lancastrians are a withering lot, which presumably you need to be if you're going to fight people from Yorkshire about flowers.

And this is a good thing for the benefit of gnomic idioms of the English language. We would unquestionably be a poorer nation linguistically, without the Lancastrian put-down 's/he is no better than s/he ought to be'. (What does it actually mean? Answers on a copy of the 2012 Health And Social Care Act impact assessment, please.)

Better suited still to health policy debate is a put-down to which I will return: that something is 'neither use nor ornament'. Simply put: much of our current system architecture fails to recommend itself in either the useful or ornamental category.

But perhaps the finest Lancastrian phrase is an expression of surprise: 'well, I'll go to the foot of our stairs'. It's as wonderfully inconsequential as it is un-sweary.

As the NHS continues to run out of money and into unchecked and ongoing demand pressures, 'well, I'll go to the foot of our stairs' must be the perfect expression of utter un-surprise at this wholly predictable turn of events.

HSJ's recent revelation of fresh capital-to-revenue transfers by DH, with Treasury permission, and of DH use of ringfenced depreciating funding to avoid busting its departmental expenditure limit just confirm what has long been obvious.

The last Health Policy Insight blog was a catch-up on various weirdnesses. (The safer staffing stuff got even funnier, with a further U-turn-as-clarification from Monitor.)

To my complete lack of surprise, the following week has seen sterling efforts to convince any onlooker that Salvador Dali has risen from the grave and become the Machiavelli behind the system's current flailings.

Simon Stevens: 'it's a system, not a set of standalone silos'
In our recent interview, NHS England's very own Sun King Simon Stevens could scarcely have been less ambiguous that the entire financial, legal and transactional mode of the current NHS system is not up to the task of coping with sustained underfunding relative to demand.

Stevens said, "Our future lies in networks and health systems, not individual go-it-alone institutions ... a circle has to be squared here, between ensuring proper organisational autonomy and accountability; while also ensuring that the broader NHS acts more as a system. We need to be more than the sum of our parts.

"As I say, our future lies in networks and health systems; not individual go-it-alone institutions. On too many procurement and workforce issues it has felt the opposite of that. That’s going to change."

The CQC moves to regulating systems? Hmmmm.
It is no co-incidence that the Care Quality Commission anounced that it is moving to regulating systems, rather than individual organisations.

If you only read the headline, that is. In practice, chief inspector of GPland (and ex-NHS Future Forum (Pause edition) lead Professor Steve Field reveals that they will be doing both for the foreseeable future: "the future has to be looking at place, but there is always going to be a role for looking at the provider within the place".

Reading the text of the HSJ article, we learn that CQC are actually asking ministers for permission to assess whole systems. And well might they ask: there is no legislative basis for this to happen.

The traumatised legislators
The move to a more planned, HMO-style system is probably the right way to keep the system upright-ish if NHS funding is not going to rise to match demand. Which is clearly the case for the foreseeable future. Southern Health, a Vanguard provider, is already getting under way; a fellow-Vanguard, Northumberland CCG, is looking at handing over its budget and most functions to a local provider, in a very accountable care organisaion-looking manner.

What makes this slightly difficult is that it is orthogonal to the whole legislative basis of the 2012 Health And Social Care Act.

The Conservative Party's trauma over that legislation cannot be overstated. They are literally traumatised by the prospect of bringing forward anything that looks like major NHS legislation.

This would not be a problem, because as I pointed out when the Five-Year Forward View was released, Simon Stevens has an elegant solution to all these many legislative inhibitions and confusions. He simply ignores the shit out of them; acts as if they were not there; and dares anyone to do anything about it.

Tories offshore health policy to Simon Stevens
The current Conservative Party leadership are fine with this: sagacious Simon has kept his political capital un-spent. Tory heir apparent Chancellor George Osborne even referred to the Five-Year Forward View (whose collaborative nature Stevens has hymned repeatedly) as 'The Stevens Plan' in his emergency budget.

Osborne's exact words repay attention: "We will fund fully the plan the NHS has itself produced for its future – the Stevens Plan". The unambiguous inference is that as far as Heir George is concerned, Simon Stevens is the NHS plan. Tories are all for open markets, but even so, this represents a spectacular and high-stakes offshoring of policymaking.

All of that would be fine, up to a point. The point in question was neatly realised by the revelation that the Prime Minister has been lobbying NHS England on specialised commissioning.

Mr Cameron's old Etonian-cum-Bullingdon chum Boris Johnson may currently appear to be eating dust in the wake of Chancellor George Osborne's marvellous economic medicine, but this looks to be the clearest example you could want of a "pro-having cake; pro-eating it" health policy.

Outlawing the Oliver Twist
The 2012 legislation's charming faith in market mechanisms meets its apotheosis in this HSJ report that DH wants to raise the objection threshold to the tariff even higher.

Why is a rise in objections from 51% to 66-75% required? Because, DH asserts, "a small number of large trusts were able to use the share of supply element of the objection process to object to a number of issues, not all of which fell within the objection process. The result was significant disruption to the financial planning of the whole sector".

Ahhh.

Right.

Nothing to do with the tariff being wrong and unsustainably low? As we are now seeing with the prevailing levels of provider economic distress?

Well, I'll go to the foot of our stairs.

Here are two quotes from the original Sun King to finish: "laws are the sovereigns of sovereigns".

And perhaps more pertinently, "it is legal because I wish it".