Editorial Thursday 26 October 2017: The floodgates are opening

Hello. I've been a bit busy of late, so as a thing that doesn't earn me any money, Health Policy Insight has had to pause.

Why the un-pause, now?

Oh ... there's been a tipping point coming, which I've been tracking in the new weekly 'Cowper's Cut' column for HSJ every Monday.

Last night's BBC Newsnight had a good exposition of the issues facing the service.

The floodgates are opening, and people are starting to tell the truth about what's happening. There is a lot more truth to tell about the strategies people have been pressurised to use, to make things seem less bad than they are.


When a proper grown-up like Dame Julie Moore is talking about the problems in UHB like this on Newsnight, 'les jeux son faits'.

I tried to express the issue of why people won't be quiet any more in my last HSJ column, 'The Brown Stuff And The Bulletproof'.

The one situation NHS system leaders should have avoided is this one: where no NHS leader is bulletproof any more. This is just so fucking basic.

Because power in the more or less sealed system of the NHS obeys Maxwell's second law of thermodynamics: entropy increases.

Absolute power delights absolutely?
And as someone said, parodying the classic Lord Acton quote, "all power tends to delight, absolute power delights absolutely".

Well, national system leaders should have been much more careful about what they wished for, for the following obvious reason.

Once you've got to a point where nobody in NHS leadership is bulletproof, you've got the biggest unintended consequence ever: everybody in NHS leadership is bulletproof.

The people fronting these organisations know that the brown stuff is hitting the rotating thing.

They know that more brown stuff is on its way, and that the rotating thing can rotate faster and faster.

And they have worked out that neither Jeremy Hunt, Simon Stevens nor anyone else in national system leading roles has got a clue how to deal with this world.

Because it's a completely new game, with wholly unknown rules.

So what can we do?
Next, we get to the vexed question of 'what the fuck can we do about this?'

And I have to tell you: this commentator has zero simple answers.

Health Secretary Jeremy Hunt's having lost the dressing room (workforce) at a time when there's no money for pay rises could be described as unfortunate.

But here we are.

Having a Five-Year Forward View with whose principles no-one argues but which comes with zero operational delivery plan could be described as unfortunate, too.

But we are where we are.

Here's the gig: the money is Donald, the targets are Donald.

(Donald = 'Donald Ducked': one of my hobbies is inventing new bits of Cockney rhyming slang.)

MBA = epic fail
But our biggest problem is that NHS culture is deeply Donald. MBA management (management by admonishment) never actually worked.

People who got shouted at to improve or be fired just didn't know what else to do or where else to go. That, plus Stockholm Syndrome, made many of them put up with this MBA bullshit by default.

Critically, this dates back over decades. It's not recent. But it's now clear that people previously loyal to the system have had more than enough.

The consequences of all this - for NHS leaders, and for system leaders, and for politicians - are going to be quite lively.

I would stock up on popcorn, if I were you.

Maybe also on gin.

The floodgates are opening, and there is a great deal more truth waiting to be told by the newly-bulletproof.