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Cowper’s Cut 175: Summer special – will ICSs work?

Cowper’s Cut 175: Summer special – will ICSs work?
Waterloo sunset's fine


It’s been quite the week, again.

And again, we learned a lot.

Firstly, that new NHS England boss Amanda Pritchard is a fan of ‘The Year Of The Sex Olympics’ tribute show ‘Love Island’ (she follows the official ITV show’s account on Twitter).

Secondly, that given its staff survey follow-up slogan we all deserve to be above average, Barts Health has comms folk who are either statistically illiterate or huge Garrison Keillor ‘Lake Wobegon’ fans.

And thirdly, HSJ’s big reveal that four ICSs are going to be placed in special measures before they even legally exist. As consultant Catherine Max observed, ‘it’s one way of teaching them that prevention is better than cure’.

I’m going to have a little think about ICSs as part of the summer sojourn of ‘Cut’ below, but first, a quick catch-up on a few key issues.

Rising numbers and this autumn’s fourth wave
Analysis by HSJ shows that hospital bed occupancy with Covid19 has kept rising. This appeared alongside a raft of speculative articles on the subject of a fourth autumn wave, with the return of the new football season, followed by that of schools and holidaymakers; compounded by reduced outdoor socialising as British weather ‘worsens’.

This Times piece, and this in the FT cover off most of the main points.

Dr Duncan Robertson gives a sober update on the emerging data on Covid19 infections, as well as making a salient point about JCVI’s need to show its working on recommendation of vaccines for those under 18. The FT compares various research studies here, but nothing is yet conclusive.

Another significant autumn wave is a reasonable possibility, but until we know more about vaccines’ efficacy as reducing transmission, forwards projection is simply speculation. All we can do is look at current data - oh, and keep on getting people vaccinated.

The creaking system
It’s really, really not great just now, is it?

The military helping with ambulance services. 124,000 patients waiting over three months for tests. Both A&E and primary care still struggling with the weight of demand, and the latter particularly affected as ever by Julian Tudor Hart’s Inverse Care Law, as shown anew by this excellent dashboard from the University of Cambridge’s Department Of Public Health And Primary Care.

Speaking of primary care, this interesting BMJ Open paper tries to quantify staff turnover in a sample of the sector. It is a striking read.

And the rising demand on mental health services keeps becoming ever more apparent.

Meanwhile, the seven-day trends in Covid19 infection numbers keep rising, as do most indicators (bar, fortunately, deaths). It’s worth reading this by actuary John Roberts; this by paediatric registrar Alasdair Munro on children’s admissions with Covid19; and this sitrep update from intensive care doctor Rupert Pearse.

Social care, social care, don't mention social care
“It appears that the Treasury has not been tasked with finding the best way to finance social care reform. Instead it has been asked to justify an increase in a narrow tax on jobs and earnings not paid by pensioners. When asked, even the smartest people in the Treasury struggle to explain why higher national insurance should fund better social care“.

Ugh. The FT’s Chris Giles understands what's going on, and it's the Treasury Munchkins doing their 'Munchkin in excelsis' thing.

Gotta heart our dear old mates, the Treasury Munchkins. As on social care, so on health funding – they hate it all and wish it would go away.

Sally Gainsbury of the Nuffield Trust is a longstanding clarifier of NHS, DHBSC and Treasury funding shenanigans, and her latest analysis is a key read.

“So, will ICSs work?”
A couple of very experienced hands, who’ve seen the NHS merry-go-round do all its twirls and curtsies for some decades, asked me this exact question recently.

It’s a good one, and it hasn't been much discussed out loud. So, here goes.

When the Sticky Toffee Pudding – sorry, Sustainability and Transformation Plan concept was revealed, I recall writing that they should be renamed either ‘platform’ or partnership’, rather than ‘plan’. My pointy was that if they were to be anything real as means for improvement, then they needed the concept of being networks, partnerships and relationships built in to their actual organisational DNA, and so their name.

Now STPs are being asked to become Integrated Care Systems. To take on the local role of population health management; after a global pandemic, which has exhausted the staff and made already-huge pre-Covid waiting lists worse; and in the broader context of an NHS which had a decade of the lowest funding growth in its history, driving workforce shortages and capital and maintenance backlogs. The OECD’s 2019 ‘State Of Health’ UK report remains a highly salient read.

Population health management is not a stupid principle on which to plan a health system. But it won't work without adequate resources and management systems.

We come straight back to my point above: are ICSs intended to be anything real as means for improvement?

It remains to be seen what the revealed preferences of both the Government on health (to become more apparent in the Spending Review settlement, and in the willingness to amend the Health Bill in committee) and the new NHS England leadership will be.

Once we see that, we can make a judgment on ICS’s chances of enduring, let alone achieving things. If they are to be mans of enforcing further relative cuts to NHS resourcing, then they will have no defenders and few great staff. One or two ICSs will do interesting things well (as always happens with any iteration of NHS structural redisorganisation); but most will simply fold into the ‘other’ of management for far too many staff to make any positive difference.

What participatory and localism-driven approaches in health could achieve (and did during the peaks of the pandemic) is hinted at in this thoughtful paper from think-tank New Local.

We can, however, take an instructive look back to clinical commissioning groups. Meant to be, alongside dear old Lord Lansley’s choice and competition, the drivers of NHS reform, in the main, CCGs ended up as budget-PCTs, but with far less capacity and budget (and minus public health). All they did in practice was act as local outposts to the achievement of the national policies that summed up to The Nicholson Challenge of the English NHS doing without another £20 billion that the Wanless Review modelling had anticipated that it would have.

Where CCGs varied from NHS England’s plans, particularly about increasing rationing of access, they were quickly kicked back into line. Handmaids of the failed economic experiment that was CamBorne-era austerity, CCGs helped the system’s leaders prepare the NHS for what it has become.

ICSs could easily go the same way, and the smarter system leaders know this.

The vaccine sting
Despite the Telegraph seeming so confident that booster shots will be starting in September (and the FT being briefed that pharmacies will lead with vaccination of third doses), the distribution of booster shots does not yet seem to be nailed-on by the JCVI, according to a briefing they gave The Guardian.

A yet-to-be-peer-reviewed study from Oxford has indicated that the delta variant may well be complicating the task of reaching herd immunity through vaccination, although the protection against serious illness from both doses of both Pfizer/BioNTech and AstraZeneca evidently remains strong.

Speaking of vaccines, former PM Gordon Brown attacked Europe’s and the USA’s ‘neocolonial’ approach to Covid19 vaccine supplies in this piece for The Guardian. And this stinging BMJ editorial by Abbasi and colleagues proposes that profiteering from vaccine inequity could be a crime against humanity.

Easy as ABC: anthropology, bullying and culture
A pair of HSJ stories this week gave further evidence for my hypothesis that the NHS needs a chief anthropologist more than it needs any chief inspector.

Nottingham University Hospitals NHS FT has been given a written CQC warning notice because of problems with its culture, as well as governance and risk management issues.

And UHNM has returned to the new spotlight with a group of 50 doctors writing to the CE to ask for protection against bullying.

The capital and maintenance backlog
This issue of reinforced autoclaved aerated concrete (RAAC) in roof planks and beams has yet again escaped into public view, with this BBC Look East find of a report commissioned into the prospect of corporate manslaughter charges.

The BBC story reports the “existence of an emergency plan in the event of a "significant hospital structural failure" in eastern England. Operation Rapture would see automatic authorisation to divert ambulances to other hospitals and invoke what was called the Mass Casualty Plan.

“The leaked documents described how, in 2020, hospital trusts participated in Exercise Hodges that simulated a scenario where part of a hospital collapsed due to RAAC plank failure. Among the questions raised was whether such a failure at one hospital would mean the three others in the region built using the material would have to suspend activity and transfer patients”.

Eeek! Not without good reason is the backlog the topic of iridescent Professor John Appleby’s chart of the week for the Nuffield Trust.

David Camewrong
David Cameron is going to take a lot of beating as the least impressive former UK Prime Minister of the 21st century. (That said, Boris Johnson will give him a strong run for his millions; speaking of whom, the FT offers us this respectable-looking story suggesting that any 2021 Cabinet reshuffle will take place after the COP26 Summit in November.)

I wrote last week about the bonfire of Mr Cameron’s reputation: on Monday, his oleaginous lobbying for Greensill Capital was outlined in even gorier detail by Henry Zeffman for The Times.

The target of the Cameroon smarm was NHS England chair Lord Prior of Brampton. The ex-PM emailed the ex-MP for North Norfolk and ex-junior Health Minister on July 23, 2019 asking him to meet Lex Greensill, saying “I’m so glad that you are battling for NHS improvement. It is reassuring to know that there is such an experienced and safe pair of hands at the helm”. Dry heave.

Cronyvirus and Coronamillions update
‘Cut’ also touched last week on the market failure of allowing the present Wild West of commercial PCR testing. It emerged this week thanks to BBC News that the Competition and Markets Authority warned the Government about this certain outcome of an unregulated free-for-all back in April.

The Telegraph reported that private testing firms are failing to pass on up to 150,000 results of their analyses to Test And Trace each week, undermining the contact tracing programme and pursuit of potential variants of concern.

Might the University of Birmingham have the answer? Their new Exponential Amplification Reaction (EXPAR) method is just as sensitive, but faster, than both PCR and LAMP tests currently used in hospital settings. The Birmingham COVID-19 test, called RTF-EXPAR, gives a sample-to-signal time of under 10 minutes, even for low viral levels where current lateral flow tests are less effective.

“The team is now seeking commercial partners for rapid licensing, to make the RTF-EXPAR test as available as widely as possible”, their announcement adds. Moving from sub-par to EXPAR would work for me.

Saturday’s Guardian had an exclusive about RT Diagnostics, a PCR testing firm owned by a former Labour justice minister and a Labour councillor, which has been accused of failing to deliver kits and test results and not refunding customers, forcing them to rely on the NHS service.

This morning, the FT has been briefed that Health Secretary Sajid ‘Power-Poser’ Javid will “unveil a crackdown” on rogue PCR testing firms. The People’s Saj has threatened 82 companies faced removal from the gov.uk site (almost 18 per cent of those listed) with being removed for breaching their advertised prices.

Mr Javid has not, you will note, actually done anything here. He has not even committed to do anything. He has merely said that he might do something. There’s nothing like effective governance of a private sector industry shamelessly ripping off the public, and this is nothing like effective governance of a private sector industry shamelessly ripping off the public.

The Good Law Project (yep, them again) exposed a new VIP lane for ministers’ mates: this time, for testing contracts.

Getting the Bill (Health and Social Care)
As we move towards the first Bill committee meetings, the first set of proposed amendments (mainly from Anne Marie Morris and Karin Smyth) has been compiled.

It will be interesting to see whether the leader of the Bill Committee for the Government, junior health minister Edward ‘Eddie The Stove’ Argar, meets these with the verve and élan that marked out Simon Burns as an emerging political megastar during his time in that role for the Lansley legislation.

Speaking of which, Our Saviour And Liberator made heroic efforts to rewrite health policy history and his place in it in a recent interview with the Institute For Government. It’s quite a read. I covered it, and had some reflections on how much dear old Lord Lansley has learned, here.

Other important things
Would appear here.

Recommended and required reading
NHS Property Services has published this pertinent document about the Government’s revised National Planning Policy Framework, which will affect the treatment of planning applications coming forward within their property portfolio.

The Nuffield Trust’s Nigel Edwards and Stephanie Kumpunen are lead authors of this interesting study in Health Policyof changes in primary care across Europe during the pandemic.

Excellent Institute for Fiscal Studies briefing on the health impacts of SureStart.

NHS England’s interim guidance on the functions and governance of Integrated Care Boards is here. Curb your enthusiasm, innit?

Decent LSE politics blog on how the sugary drinks tax worked.

An elegant and thoughtful read on the Covid19 origin story by Economist health policy editor Natasha Loder.

Alan’s baseball cap was stolen by some mean girls on the tube. Let’s hope it won't derail his ministerial comeback, eh?