Editorial Thursday 8 October 2015: Toilets, party conferences, the memory of candour and not being TITs about busting the DEL
This latest dispatch from the health policy trenches begins with news of Jeremy Hunt in the toilet.
Literally.
It is a Virgin toilet, as we would expect for a Very Important Secretary Of State. However, this is a Virgin toilet in a Virgin Train to the Conservative Party Conference in Manchester.
The unlucky among you will know the kind of toilet: it has a curved automatic door, and an amusing notice above the toilet, reading ‘please do not flush nappies, sanitary towels, old mobile phones, unpaid bills, your ex's jumper, hopes, dreams or goldfish down the toilet’.
The notice is tragically silent on the effluent solubility of the new junior doctors’ contract, but you can't have everything. (8/30ths of everything, maybe.)
The Evening Standard diary column reports that Mr Hunt got the wrong kind of flush. Specifically, he pulled the train’s emergency stop cord instead of the flush, halting the train in its tracks and leaving the Health Secretary emerging flushing (as in red-faced).
The temptation to see this as a timely metaphor is huge.
It calls to mind a quote attributed to former health secretary Frank Dobson: that, on reaching office, “we pulled all the levers of government, but found they weren’t attached to anything”.
Fight for your right to party conference
Party conferences are curious rituals. Norman Lamb made a good contribution at the Lib Dems’ Bournemouth affair. Though not yet policy, he (re-)floated the idea of a NHS-and-care-specific tax to increase funding, and also suggested that English councils should be able to raise local taxes to fund the NHS. He also called for a £5 billion cash injection for social care, to prevent the system from crashing.
Labour’s Brighton shindig, its first under its grief-stages-one-to-three leader Jeremy Corbyn saw a competent, well-briefed speech from new shadow health secretary Heidi Alexander.
Labour have a mountain to climb in most areas of policy, but it was a refreshing shock to see no mention of evil, non-existent plans to privatise the NHS (when the real effects of legislative travel are denationalisation and disestablishment).
What is actually happening to the NHS is more interesting, and less planned: it is the political equivalent of a barn door as a target: one which Mascara Kid Andy Burnham never came close to hitting with a banjo. We await proof of Heidi Alexander’s musical marksmanship.
Imperial Conservatives
The victorious Conservative Party is in its imperial phase, and was in buoyant form in Manchester. Jeremy Hunt’s party conference speech unveiled his quite good new joke (“I’m sorry I’m not the most interesting Jeremy in British politics”), but went on to underwhelm in a few regards.
Ahistorically, Mr Hunt told delegates that Nye Bevan “set up the NHS in 1948 - four years after a Conservative Health Minister suggested it”.
Mmmmm.
Yes, Jeremy, and a mere 37 years after the Fabians first proposed the idea in 1911.
HPI readers know that the only Conservative politician who can mention Nye Bevan (who famously believed that Tories are “lower than vermin”) is of course the legendary Sir Simon Burns, whose timeless bellows of "NYE BEVAN!” kept the 2010-12 health bill committee and debates fitfully awake.
Hunt claimed that among the ”achievements in the last 5 years (were) record numbers of doctors and nurses”, when all of those doctors and most nurses were trained before 2010.
Mr Intelligent Transparency, homeopathic NHS funding and the memory of candour
Mr Hunt also argued that ”peer-review, transparency and openness about performance is a better way to drive up standards than endless new targets”. A hard point to criticise, you might think. And you’d be right.
So Mr Hunt, the self-styled champion of “intelligent transparency”, would be livid at the Observer story revealing the NHS’s worst-kept secret: that Monitor and the TDA had been leant on to delay the publication of data showing that the NHS’ whopping overspend is on course to be, well, a whopping overspend.
Wouldn’t he? Livid, undoubtedly.
And the TDA’s compounding, ongoing failure to reveal the list of Trusts With No Future would surely gall the second-most interesting Jeremy in British politics into a call for candour?
Mr Hunt would surely be enraged, and strike out at such stupid opacity in his speech?
Erm, no.
At no point in his speech did Mr Hunt excoriate the figures in ‘Whitehall’ (for which read the Department of Health) responsible for such blatantly politically-timed failures of openness about financial and system performance.
Mr Hunt is understoodthe memory of candour.
Similar oddness was on show from Mr Hunt elsewhere at the party conference. At a Reform fringe event, he told attendees that could literally bust our national finances", revealing a worrying lack of knowledge of the difference between the NHS (which can't, on the basis of any realistic overspend scenario) and the banking and financial sector (which did).
He told another event that the funding freeze for general practice was "penance for the 2004 GP contract".
Penance?
Fantastic! Mr Hunt is a Charterhouse boy (an sale of indulgences.
Elsewhere, the Mirror had a told the Institute Of Directors' annual conference at the Royal Albert Hall that "understandably, we're having a national discussion about how to get immigration right. My responsibility is to point out that at time when the need for nurses is growing, when publicly funded UK nurse training places will take several years to expand, and when agency staff costs are driving hospital overspends right now, we need to better 'join up the dots' on immigration policy and the NHS.
"However most nurses I speak to struggle to understand why our immigration rules define ballet dancers as a shortage occupation - but not nursing. And most hospitals tell me that the idea that we would seriously consider deporting some of our most experienced and committed nurses solely because they’re not earning £35,000 clearly needs a rethink".
(The press release of this gave intriguing hints on new ideas about funding social care). The evidence is of course that this excellent piece from Nick Timmins wondering what the future for the purchaser-provider split would be in an NHS moving to accountable care organisation-type health economies. Not much, Nick correctly concludes.]
Even less serious is the economic analysis behind the Carter Review’s suggested £5 billion in potential procurement savings: one insider, hearing that Lord Carter Of Coles was being told to suggest that up to £10 billion could be saved, told him “no, Pat, don’t say £10bn; nobody will believe you. Say five. Some people might go for that”.
Performance anxiety
The money is fucked. HSJ colleagues have run some numbers from board papers, and the £2 billion still looks a lot like £2 billion.
NHS England is asking for the Pothole Care Fund to be frozen.
Others say that even if all central levers are pulled to stop central spending, at best only £1 billion could be stopped. And there are other noises about the financial position in CCGland deteriorating at his latest HSJ column.
Meanwhile, the NHS is being asked to trudge towards seven-day working when social care stands no chance of being able to cope with the current need for discharge packages for frail older people.
The .
And that's with Part Two of the Care Act deferred.
And before 2020 introduces the Living Wage.
Not to mention the private equity-owned Four Seasons: a far bigger player in the care market than Southern Cross. Too big to fail?
Oh, and Laing and Buisson noted in August that Melanesian cargo cult, going through outdated and scarcely-understood rituals (sack the CE and board; send in management consultants) of regulatory intervention in the hope of getting the goods.
Rituals must happen, it seems. So when the NHS breaches last year's overspend, which it will, there will be a demand for heads to roll. The Treasury will want DH permanent secretary Una O'Brien, who is nearing the end of her second spell in post anyway.
Could Simon The Sun King's scalp come into the hazard? Unlikely. David Cameron and George Osborne still crave a bit of the old Blair magic dust, and Simon is a sharp operator and influencer.
Mr Osborne wants Mr Cameron's job (at the right time), and will be happy to influence the PM to leave Mr Hunt at DH, to take the initial political collateral damage of an NHS overspend. But maybe not for long. 2016 may be reshuffle time.
So we end where we came in, aptly enough. With Jeremy Hunt in the toilet.
Metaphorically speaking, of course.