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Cowper's Cut 182: Shooting the Messenger on supply and demand issues

Cowper's Cut 182: Shooting the Messenger on supply and demand issues

At a time when the NHS is under immense demand pressure, self-care is very important. With this in mind, I’ve been treating myself to not watching The Meh Show on BBC1 on Sunday mornings for a while now.

However, the Prime Minister’s interview on this week’s edition was worth watching, in a self-harming kind of way.

It was a fiesta of lies, of course: that is priced in with Boris Johnson.

But it had some moments of mild interest. While few observers probably expect Mr Johnson to be well-versed in economics, his answers to questions about the current petrol shortages revealed that the PM does not know the difference between the supply and demand elements of the problem.

This is going to be a problem for the NHS and social care as we approach the Spending Review. Tim Shipman of the Sunday Times describes an explicit deal between the PM and Chancellor Rishi ‘The Brand’ Sunak on spending restraint now to deliver potential tax cuts in the run-up to the next General Election.

I don't need to tell Cut readers about what’s happening to demand in these sectors. The increases in demand means there need to be serious plans for increasing supply.

And at present, there are no such plans. We got the NHS Operational And Planning Guidance for the second half of this financial year, but that’s a firefighting manual. (One which, concerningly, confirms that there will not be central funding for the successful, funding-row-busting Discharge To Assess scheme beyond 2021/22.)

So the Government’s got serious about planning, yes?


Don’t shoot the Messenger
What the Government did instead is launch the heroically inappropriate distraction of a ‘major review of NHS and social care leadership’. (The social care bit in particular may really come back to haunt them.)

The obligatory briefing to the Telegraph revealed that “General Sir Gordon Messenger, a former Vice Chief of Defence Staff, will be charged with driving up the quality of management and ensuring “every penny” of taxpayers’ money is “well spent”.

Longstanding NHS observers will remember that in the wake of the Griffiths Review of NHS management for PM Margaret Thatcher, several ex-military types were brought into positions of NHS leadership. They will also remember that this cohort was not noticeably more successful or durable.

So what’s the Messenger Review about, then? Basic politics: it’s anticipatory blame-shifting. The Telegraph story goes on to reveal that “a senior government source added that the review had been launched to ensure that the health service did not squander the major cash injection announced by Mr Johnson last month to overhaul social care and clear NHS backlogs. The Government is determined that every pound of investment is well spent so that everyone gets the care that they deserve”.

A political prophylaptic
Here’s what’s actually behind this move.

This Government doesn’t know much, but it knows enough to realise that the NHS and social care are about to walk into a very difficult winter indeed. Even if the weather isn’t too bad.

This review of management is the classic deflection tactic of getting your excuses in first about the coming crises. It is a political prophylaptic.

We’re going to see a lot hard questions about deteriorating NHS performance. To these, Ministers’ and MPs’ replies will begin with ‘well, of course the Messenger Review is looking at all aspects of how the NHS and social care are using this extra money (yes, the money that doesn't start until next April), so we shouldn't anticipate its conclusions, but I want to reassure you that nothing will be off the table’.

Externally-led reviews (the bigger, the better) are the politician’s deflector shield of choice when it’s hugely apparent that things are about to get seriously bad. Event X happens: “our wide-ranging review will be dealing with the causes of Event X”.

And this won’t be just a ‘big’ review. Nor will it be merely ‘major’. This, ladies and gentlemen, will be a landmark review. We deserve no less.

The chances of a broadly quite stupid national media noticing what’s happening here are not high. The paucity of challenges to the blatant lying over 40/48 new hospitals, as again here by the PM, has been a good index of the quality of our media.

Tell it to the Marines
So, other than for political flag-wrapping purposes, why is a former Marine being brought in to lead this review?

The record of the military in the key areas of understanding NHS management - healthcare demand and supply; the determinants of health; clinical variation; NHS workforce culture; outcome measurement; management and data resourcing; capital expenditure - well, let’s be charitable, and say it is yet to be proven.

We should bear in mind the open secret of long standing that military procurement is abysmal, as every reader of Private Eye knows. The FT highlighted the latest mega-blunder this weekend: none of the Ajax tanks has yet come into service, ten years after the £5.5 billion project started.

How much will this amount to in practical terms? Well, let’s remember that in the dim and distant political past of three weeks ago, also on Meh, Health But Social Care Secretary Sajid Javid promised us a review of ‘nonsense’ NHS targets.

I think what we need next is someone to start reviewing all the NHS reviews. Maybe we can get Bagpuss to lead it. This could get properly meta-.

The last major review of NHS management was former M&S boss Stuart Rose’s 2015 effort, which I wrote about here. It was a quite startling piece of shit, shot through with clichés and riddled with authorial self-unawareness.

I recommend Suzie Bailey’s observations on the announcement of this new review, and wholly endorse Roger Kline’s BMJ article on NHS management.

The anti-GP campaign and Dr Sajid ‘The Saj’ Javid
There is an active anti-GP campaign under way in much of the media, almost certainly being pushed by those in and around the government. This is of course just about the most stupid, counter-productive thing a government could do, so it’s pretty firmly on-brand.

And it has consequences in terms of making staff actually quit, as this depressing but necessary Guardian article reveals. Unfortunately, I’ve evidently missed the point at which power-poser Sajid ‘The Saj’ Javid qualified as a GP, but it’s fucking fascinating to learn that he’s become able to determine the necessity or otherwise of face-to-face GP consultations.

Or maybe he’s not really a GP: just psychic. Or maybe he’s just a fool. One of these, for sure.

This BMJ blog is also a decent corrective to the lunatic anti-GP narrative.

Poll tacks on the new tax
There is interesting new polling from Ipsos MORI on public attitudes to the new Health But Social Care Levy. (The Institute for Government’s new ‘explainer’ is a good read on this new tax.) It asks whether the money raised is enough (and gets a strong ‘no’); and then drills down into detail about the perceived fairness of using NI to raise NHS and social care funding.

A critical finding is that there is near-unanimity that this will not be enough extra funding, either for the NHS or social care. 76% of respondents felt it is likely that the NHS will need even more funding than this policy provides; and 74% that social care will need even more funding than what has been announced.

Belief that the NHS will improve as a result of this policy was low: 37% seeing it as likely as against 48% unlikely.

The findings on whether staff shortages in social care services will be reduced as a result of this policy are also important: 35% likely to 47% unlikely. Belief that the quality of social care services will improve as a result of this policy was similar: 35% likely to 48%  unlikely.

Eye-catchingly, only 33% of respondents thought it likely that staff shortages in the NHS will be reduced as a result of this policy: 51% believed this is unlikely.

Opinion polls are snapshots of a moment, but at the moment, it does not seem that the Johnson Government has emulated the 2002 New Labour success in making a tax rise for health and care popular.

The Conservative And Unionist Party’s conference is getting under way in Manchester. It was interesting to see the BBC News team show some backbone and run this piece on who funds them.

Among the past week’s pre-conference pitch-rolling by the Conservatives was this announcement of 40 new community diagnostic centres. This was, as Andrew Ward pointed out, in fact a re-announcement of the 2020 NHS England pledge. I suppose this kind of recycling might be a bit of green levelling-up?

We got Rishi 'The Brand' Sunak: The Movie this week. Which is really quite extraordinary.

Signs of life in the Opposition?
Labour’s conference in Brighton was neither fish nor fowl, but its leader Sir Keir Starmer achieved rule changes he needed to prevent the Corbyn children (of all ages) from re-hijacking the party.

The Health Policy Insight ‘Don't Mention The Fictional Privatisation’ Award went to shadow health lead Jonathan Ashworth for delivering a reasonable (albeit expensive-sounding) speech, in which the terrible but un-real spectre of imaginary NHS privatisation completely failed to rear its head. That’s progress, of a kind - which is better than Momentum. It's not much, of course, but it’s a sign that Labour may become worth taking seriously again.

Sir Keir Starmer’s own speech was good, if a bit long. The heckling of Corbyn children as he delivered it probably helped reinforce the public's sense that the main task of this conference was nail-knocking into the coffin of Corbynism.

In health terms, the biggest story was his new mental health commitments to make treatments available in less than a month. Sensibly, Sir Keir did not provide a deadline by which this would become a reality under a Labour Government.

The actual content of Sir Keir Starmer’s speech got a very good review from Isabel Hardman in the i. The next bit of Labour health policymaking will be something to watch: there is an interesting tension between their declared NHS performance recovery and prevention/public health aims. It will take some resolving.

Covid19 update
The data shows us that new infections are rising sharply, and vaccinations are slowing to a crawl. The creator of the Zoe app also finds that we are not including re-infections in the national numbers.

An extremely ugly story has been uncovered by Ceri Thomas for Tortoise regarding Pfizer’s conduct over the rival AstraZeneca Covid19 vaccine. Billy Kenber, writing in The Times, highlights other disturbing areas of the vaccination market.

Meanwhile, actuary John Roberts reviewed the latest ONS Covid19 infection survey data release, and looked into the association between mask-wearing and current rates of Covid19 infections. His conclusion is that “those who don't wear masks are around 50% more likely to test positive (after adjusting for other demographic factors, e.g. age)”.

It was interesting to see The Guardian pick up on the UK Statistics Authority’s report criticising Matt ‘Alan’ Hancock’s abuse of statistics during Covid. This pertinent story didn't make any other news outlet that I saw.

The creaking system
This long read from New Statesman medical editor and GP Phil Whittaker is not full of optimism about the state of things as we head into winter.

Even less sure-footed were Health Education England boss Navina Evans’ remarks about the need to learn from frugal innovation in developing nations, reported by HSJ. In the week when the Health Foundation’s REAL Centre released research showing that we will need to recruit a million more health and care staff over the next decade to deliver both stabilisation and recovery, this felt a lot like an unforced error.

The Guardian’s Denis Campbell had a good story about the breaches of the Government’s pledge on out-of-area mental health placing of patients.

I wrote here some months back about the increasing use of private healthcare driven by NHS backlog: the topic made it to BBC Panorama this week.

Cronyvirus and Coronamillions update
The Good Law Project has an update on their story about Tory lobbyist Samir Jassal successfully getting a project passed by Matt Hancock.

Getting the Bill (Health and Social Care)
Nothing to report this week.

Other important things
Would appear here.

Recommended and required reading
Former New Labour advisor Geoff Mulgan shares useful ideas about how Governments should manage big risks.

A thorough FT update about the generally slow progress internationally on antimicrobial resistance and new antibiotics.

Thoughtful piece in the BMJ by David Oliver on secondary and primary care clinicians.

Excellent Health Foundation podcast interview with former NHS CE Sir Alan Langlands.