Editorial Wednesday 5 August 2015: Catching up - 'when the going gets weird, the weird turn pro'

It's been an interesting few weeks in health policy. A lot of things that have happened have been even less reasonable than usual.

In fact, it has gotten downright weird. In the words of the late Dr Hunter S Thompson, "when the going gets weird, the weird turn pro".

The latest weirdness might have started when the Care Quality Commission announced that everyone's Secretary Of State For Health Jeremy 'Bellflinger' Hunt had asked Professor Sir Mike Richards to start to assess trusts for their use of resources.

Yes: the CQC, an organisation whose very name offers a helpful clue that their goal is to assess care quality, is now going onto Monitor's turf.

No, me neither.

The safe staffing guidance hokey-cokey
Or it might have started over the hokey-cokey furore about NICE's work investigating safe staffing levels.

First, NHS England were paying NICE to do it; then NICE stopped work because NHS England were going to do it themselves (reasoning perhaps that setting a minimum safe level would be a) rather expensive and b) prone to poorly-managed organisations simply complying and feeling that meant they were doing safe care: as big a misconception as you might find).

This is despite the DH and regulators telling HSJ that providers would have to consider the safe staffing guidance. Confused enough?

So then NICE announced that they were going to publish what they'd done anyway.

And then, NICE announced that they'd changed their mind about doing that because (officially) of the creation of NHS Improvement and (unofficially) because they'd been leant on by DH and NHS England.

Don't you love a transparent, systems-thinking, networked and open culture?

This comes over as part of the 'challenge Simon Stevens' narrative which has begun to emerge. Speaking at the HSJ Leadership summit in Birmingham (at which I presented the HSJ case for patient safety), UCLH CE Sir Robert Naylor told delegates "I've known Simon Stevens since he was in short trousers; he's a big brain. But what he isn't is in charge of the NHS, and I've told Simon to his face 'you need to get on with sorting out commissioning'."

The Wose Weview: wubbish
It was certainly present in the much-delayed Wose Weview of NHS management. I bitterly regret having regularly petitioned the DH to 'welease the Wose Weview' on Twitter.

Some weviews should not be weleased: this is one such.

It is a quite startling piece of shit. Any 68-page document which describes itself as being "as succinct as possible" is terminally lacking in self-awareness, never mind a competent editor or author. It spends much of its first five pages telling the reader how succinct it's going to be ...

Wrong in so many ways: it describes the NHS as a "federal organisation". Nothing could be further from the current legal and organisational reality. Likewise, "This ought to be a time for great transformation without structural reorganisation". I got the impression that it was actively trying to make me stop reading it.

On page eight, the document says "the Five-Year Forward View has a clear vision of what the future should look like"; on page 10, "There is a lack of One NHS Vision". Satire?

Brewer's Dictionary Of Management Cliche, Fable And Phrase has been raided hard: "because we are intimidated by complexity and scale, there is equally a danger of doing nothing. The way to handle complex matters is to  make them simplify them wherever possible. We must work with what we have.". No shit?

The Wose Weview wanges from the wrong to the pweposterous. For the wrong, look to its two pre-condition recommendations. The first is seriously wrong (the call for a single national communications function; the second - an NHS Constitution - already exists.

For the pweposterous, it suggests that thee centre "Set minimum term, centrally held, contracts for some very senior managers subject to assessment and appraisal". Um, ever heard of local accountability and governance?

It proposes that "training across the NHS should be more mobile, flexible and agile". Imagine recommending the opposite. And it suggests that "there is ... a need for all to be able to show leadership skills". Mmmm. Gardeners? Kitchen porters?

Obviously, by the sheer law of averages, not everything in it is rubbish or wrong: a rare correct bit can be found on page 44, where it notes "Now there is no one system leader; so all are vying for territory".

Without discernible irony, the Wose Weview complains about excess bureaucracy in NHS management, and calls for the Information Centre to get NHS England and the DH to produce a Burden Impact Assessment.

Simon Stevens pointed out to the health select committee at the end of a marathon four-hour evidence session on 'the NHS: further issues' (albeit 'the NHS: kitchen sink' might have been a more fitting title) that the complexity of NHS managers' jobs is slightly greater than that of "selling knickers". In the same session, Stevens pointed out the unsustainability of the wage freeze policy (a cut, if inflation keeps its course), telling MPs that "in the fullness of time, the NHS will need to pay the going rate for staff relative to the private sector: this is an economic, not a political point".

Sound and vision?
Then there was Jeremy Hunt's 25-year vision speech to the Kings Fund's annual leadership summit, calling for the NHS to be 'more human' (in a borrow from PM Cameron's erstwhile guru Steve Hilton's book title).

A 25-year vision it wasn't, in any stretch of the imagination: this is a bag of disparate ideas that Hunt likes, many of which have some merits.

The speech was also a war cry in favour of a seven-day NHS. Except that the majority of it wasn't. This had been sold to the nationals as Hunt taking on the BMA over their contract renegotiating intransigence.
Oh dear. The main thing that's remarkable about the BMA, given their acute and probably terminal lack of political nous over the past decade, is that Jeremy Hunt still pays it even an iota of attention. Their 'Stop Playing Games' campaign before the general election was a masterclass in wasted effort lobbying.

Hunt proposed an NHS reformation, perhaps unaware that the association with the dissolution of the monasteries; the hospitals of their era. He also described health secretaries as aiming at first to devolve power, and then in difficult times "unleashing their inner Stalin", indicating that he hasn't read Simon Stevens' thoughts on Stalin imagery.

In a fight between a politician and the BMA, it's rather tempting to get some popcorn in and enjoy the fun. The issue here is not only both sides' comically primary-school efforts at talking tough ('you get real', 'no, YOU get real') as it was the fact that the evidence base for moving to seven-day working is not unambiguously clear, as Meacock and colleagues have pointed out in Health Economics.

Monitor and TDA merging into a Commission for Health Improvement
There was also the news announced in Mr Hunt's speech that Monitor and the NHS Trust Development Authority are to be folded into the new NHS Improvement.

This year's tariff fiasco and the endless stream of intervention notices probably set the seal on Monitor's increasing impertinence.

The poor personal relationship between David Bennett and Jeremy Hunt didn't help, either. Bennett felt he was doing his best to shield FTs from the centre's pressure to cut spending. Most of the time, FTs didn't see this.

But there's also the sheer conceptual impertinence of having a McKinsey approach to an NHS whose problem is high demand and low funding growth. Ideally, if it had been left to its own devices, Monitor could just have started an investigation of the whole of the NHS. And in no way look at whether it screwed up setting the tariff. Or accepted fantasy plans from providers on staffing and thus training reductions, when demand was not slowing. Leaving us without sufficient trained nurses.

Monitor and TDA do a valedictory Selbie
In a last hurrah, Monitor and the TDA have sent a letter telling the NHS to stop spending money and the handful of surplus trusts to make bigger surpluses. The hope here is that the NHS doesn't bust the Departmental Expenditure Limit, putting it on the naughty step with HM Treasury. They are to do this by stopping recruiting to vacancies and by not using agency staff wherever possible.

This is the 2015 parallel of the infamous December 2005 Duncan Selbie letter sent in the immediate run-up to the 2006 financial crisis, which warned recipient CEs that "Sir Nigel (Crisp, then-NHS CE) will be taking a close and personal interest in all trusts' progress towards financial target in Q4".

Ironically, this hit CE's inboxes just before an email from chief nursing officer Jane Cummings and patient safety Mike Durkin. Its subject? Safe staffing levels.

The old Adam
NHS leaders are facing the old Adam of dilemmas: the money, or the quality and safety.

These are ugly, potentially dangerous  times. So this will end where we came in, with two more quotes from Dr Hunter S Thompson.

Firstly, "freedom is something that dies unless it's used".

Secondly, "the world is still a weird place, despite my attempts to make clear and perfect sense of it".

Good luck. Watch your backs. And those of your patients.