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Cowper's Cut 185: Lessons learned and unlearned; more briefings and more cases. What could possibly go wrong?

Cowper's Cut 185: Lessons learned and unlearned; more briefings and more cases. What could possibly go wrong?

Only more briefings can save us now
Goodness me. I mentioned in both of the last ‘Cowper’s Cut’ posts our plenipotentiary power-posing Health But Social Care Secretary Sajid 'The Saj' Javid’s charming and motivational briefing to The Times that NHS managers would be sacked for missing targets.

Team The Saj counter-briefed to HSJ’s editor Alastair McLellan, as shown in this editorial, that “the message fed back to NHS’ national leadership, and to HSJ, by the health secretary’s team was that The Times had got carried away when interpreting the briefing it was given”.

‘Carried away when interpreting the briefing’
Mmmmmmm. Well.

It’s possible that Team The Saj thinks an HSJ editorial won't make its way across the desktops of those Times journalists whom he/they briefed.

Equally, perhaps he/they think that journalists won't remember, or won't mind, being publicly shown up in this way.

That would be a splendidly naïve assumption. But these are splendidly strange times. Perhaps Mr Javid will yet brief against his briefing against his briefing. It’d be unlikely to be the weirdest thing to happen this week.

A Mailstrom of confusion
And indeed it proved not to be: Team Javid briefed the Mail that GPs would be “told to tear up social distancing rules to allow them to see more patients in person … onerous 'enhanced cleaning' regimes will also be relaxed”.

What a relief it is that current Covid19 infection rates aren’t currently continuing a sharp rise, while testing numbers fall … oh.

Stop shirking, GPs!
The day after the Daily Mail’s loudly declaring victory in its ‘Let’s See GPs Face To Face Campaign, it observes that Covid19 infections are now at their highest rate since the January third wave.

One must have a heart of stone not to laugh.

Ah, deal old the Mail. Or to give it its full, formal title, The Daily Mail Onanists’ And Their Sons’ Gazette. Truly, it is the place where irony and thought go to die.

The Mail celebrates a ‘naming and shaming’ agenda for GP practices who do what the Government’s and NHS England’s policy asked them to do – move to more digital.

It is depressing to see that the inadequate NHS England £250 million ‘support’ announcement – that is about £33,000 per GP practice – came alongside a supine Mail editorial piece by the new NHS Pope, Amanda Pritchard, playing firmly along the Mail editorial line.

The lack of a strong national defence of general practice has been duly and widely noted. It is always folly to give in to bullies: the Mail and suchlike nonsense-mongers are classically such.

People’s expectations of NHSE and its new Pope are accordingly altered.

Lords come, Lords go
Last Friday, NHS England announced that its colourful chair Lord Prior of Brampton will be stepping down at the end of the current financial year.

Who will next unexpectedly call for £50 billion bonds for NHS capital funding? Whose dining support for Palantir will sustain us now?

Well, Jim Bethell’s out of a gig, so let’s see.

A Johnson you can trust
Paul Johnson, director of the Institute for Fiscal Studies, wrote an excellent summary on local government funding for The Times. Describing the new 2.5% Health But Social Care Levy, Johnson predicts a “better than even chance that the funding that’s been allocated won’t be enough to achieve all this. Probably three times as much will be needed in the longer term.

“If the money isn’t enough then councils will probably do the only thing open to them: make the care needs assessment even more stringent. In other words, do even more to remove care from any but those with the most serious need. That’s already been the biggest effect of funding constraint: the number of older adults receiving free social care services over the last decade has plummeted.

“If that is what they end up having to do, this long awaited and sensible change to social care funding will have the unintended consequence of reducing support available to poorer pensioners in need of care”.


Then Kings Fund has a decent summary of the upcoming Comprehensive Spending Review, and its health and care implications. In a geeky but pertinent related point, the FT spotted that the independent Office for Budget Responsibility is choosing to use out-of-date data to assess the Government’s financial situation in the run-up to the CSR. This bends the playing field towards a less generous settlement now, allowing more leeway in the CSR just ahead of the next General Election.

The first draft of history: the ‘lessons learned’ report
The joint report of the Commons select committees on Health And Social Care and Science And Technology on ‘Coronavirus: lessons learned to date’ published its findings this week.

It is a bracing read. It doesn't make for comfortable reading, which is probably why the Health But Social Care Secretary said he has not read it.

The report is even-handed, giving credit where it is due, to the vaccines procurement and initial roll-out and the development of treatments such as Dexamethasone.

But it is damning on various aspects of the response, concluding that:

·       The delays in establishing an adequate test, trace and isolate system hampered efforts to understand and contain the outbreak, and it failed in its stated purpose to avoid lockdowns;

·       The initial decision to delay a comprehensive lockdown - despite practice elsewhere in the world - reflected a fatalism about the spread of Covid19 that should have been robustly challenged at the time;

·       Social care was not given sufficient priority in the early stages of the pandemic;

·       The experience of the Covid19 pandemic underlines the need for an urgent and long-term strategy to tackle health inequalities; and

·       The UK’s preparedness for a pandemic had been widely acclaimed in advance, but performed less well than many other countries in practice

It is illuminating on NHS capacity issues, noting that then-NHS England CE Sir Simon Stevens praised the flexibility of NHS staff, saying “people, under the most difficult circumstances, have all pitched in with incredible esprit de corps while recognising, frankly, that people across the health service are tired, stressed and frustrated”.

Likewise, it is damning about the performance of Test And Trace: “the failure of the Test And Trace system to rise to meet even the most predictable of demands in Autumn 2020, especially given many weeks to prepare, suggests that lessons that were learnable during the pandemic were not applied. An urgent priority for the Government must be to satisfy itself that there is now a dependable organisation for covid testing that can both anticipate and meet future demands.

“In the autumn of 2020, Test And Trace made a series of submissions for a budget to allow it the operational resources it assessed were required during the year ahead. The sums of money were vast. The budget of the operation was established at £37 billion  … for such an unprecedented request, a big justification was mounted, most notably that investing at that level would avoid the need for future lockdowns. New outbreaks would in future be rapidly detected and eliminated, so allowing most of the country to resume much of normal life”.

Yet for all TAT’s £37 billion budget, we were back in a third lockdown by early January 2021.

Not for nothing do the committees recommend that “those responsible for future Test And Trace programmes should establish a culture and processes to learn rapidly from errors and to act to prevent them being repeated”.

NHS capacity
The joint report also notes that “the NHS responded quickly and strongly to the demands of the pandemic, but compared to other health systems it ‘runs hot’—with little spare capacity built in to cope with sudden and unexpected surges of demand such as in a pandemic”.

It recommends that “the experience of the demands placed on the NHS during the Covid-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS … comprehensive analysis should be carried out to assess the safety of running the NHS with the limited latent capacity that it currently has, particularly in Intensive Care Units, critical care units and high dependency units”.

That sounds expensive. Will it happen? We shall see.

The Government’s response to the report
On the initial ‘hindsight’ and scientist-blaming narrative the Government sought to generate in response to the report, it’s worth reading this from Martin McKee about the science,  and this from Stephen Reicher about the fictional-looking behavioural science being cited.

The Government are likely to have to do better than that. That may be a problem, as this is really quite a stupid Government.

The first draft of history: the lessons not learned report
Those who successfully FOI the Government’s past pandemic preparations may or may not be condemned to repeat them.

This ‘Exercise Alice’ PHE report from the 2016 exercise on a MERS-type coronavirus concluded with four key themes: “quarantine vs self-isolation, and the clarity required about the options; PPE level and the need for instructions on use; community sampling planning; and effective proportional communications to both front-line staff and consistent public messaging”.


It doesn't seem as if those lessons were really taken on board, does it?

Covid19 update
The Independent’s Shaun Lintern got the skinny on the recent DHBSC round-table on the impact of ‘long Covid’, and in particular the disproportionate number of NHS staff affected. It seems that The Saj has noticed that this is a big and real problem. Woo-hoo.

Having the highest rate of Covid19 infections in Europe will do that sort of thing, of course. And it’s a choice, as this striking set of reflections from epidemiologist Deepti Gurdusani on the UK’s approach to Covid19 risks makes amply clear.

But, you know, let’s be fair. Ish. It’s great that The Saj has recognised this.

Now he just has to do something about it.

Doesn't he?

HSJ highlighted eight hospital trusts with an average occupancy of one in ten general and acute beds due to Covid19 admissions over the past two months. Looking quickly at the list, what these trusts seem to have in common is serving relatively poorer populations. It would be interesting to see further work on this, such as that done by the Nuffield Trust on inequalities and health services back 2020.

Clearly, it would help if there hadn't just been a high-profile and enormous screw-up in the PCR testing system, as evidenced this week when the media and social media drove an investigation into why positive lateral flow tests (LFTs) were being followed by negative PCR tests.

It turned out that the PCR testing lab was screwing things up.

Meanwhile, the UK Health Security Agency published its first set of data on flu and Covid19 surveillance.

The creaking system
Whew. Where to start? It’s getting peak winter bad, in mid-October.

The Guardian has this accurate but bad news, complied from NHS Providers’ members.

How screwed are we? Oh, we are really quite screwed indeed, as the latest waiting times data shows. There are nowover 5.7 million people on our steadily-growing waiting list, as Insource’s Dr Rob Findlay calmly observes in HSJ.

And we have got no plan whatsoever to clear this backlog.

The latest 2020-21 ERIC data on the capital and maintenance backlog shows that the sum required to deal with the backlog has risen further, to £9.2 billion. The increase since 2019-20 is 2.2%. This does not include planned maintenance.

In this regard, it was no surprise to learn from HSJ that just slightly more than half of trusts’ maternity units’ applications for “urgent” capital funding had been approved.

Likewise, analysis by HSJ’s Nick Kituno and Dave West of leaked data shows that the capital’s A&E situation is rather worse than previously thought. One in four A&E attenders is now waiting more than four hours. Kituno and West quote a director as saying, “things look even worse if you look at the number of long ambulance handover delays, 12-hour ‘trolley waits’, bed occupancy, and patients with very long stays in hospital due to discharge delays”.

As frequently stated, the pensions taper tax allowance is one of the dominant problems facing the NHS as it plans to reduce the backlog by getting senior staff to work more sessions at evenings and weekends. Dr Tony Goldstone, national pensions and pay clinical advisor for the BMA, has written a detailed guide to what such people have to do to get themselves set right for the 2020-1 tax year and annual allowance.

The un-appointment of Alan’s UN appointment
It was fascinating to learn that the PM’s wife Carrie Johnson’s friend Nimco Ali had recommended that Matt ‘Alan’Hancock be appointed to a role with the UN regarding its economic affairs in Africa.

No doubt Alan would have been the perfect person to advice on Ugandan discussions.

Tragically, it seems that due process was not followed in the appointment, and so Africa will remain Alan-free. The Alan comeback will be a little delayed, it seems.

Cronyvirus and Coronamillions update
Lawyers for Abingdon Health have attempted to accuse the Good Law Project of lying about their Covid19 contracts, in an intriguing approach. Learn more about it here.

You can also read here about the University of Oxford’s attempt to make a charge of £140,000 in costs to disclose information about Sir John Bell’s involvement in the award of the Abingdon Health contract.

Getting the Bill (Health and Social Care)
Again, party conference season and recess mean that there is nothing new to report this week. Parliament resumes sitting on 18 October. The Committee next sits at 9.25 am on 19 October. More amendments may be forthcoming before then.

Other important things
Would appear here.

Recommended and required reading
The House of Commons Library has brought its NHS stats up to date: a sobering read.

The Guardian has pertinent analysis showing that the poorest-performing care homes by rating have the most council-funded residents. The issue of cross-subsidy and quality is very far from being resolved.

A fascinating report in The Times about a private medical insurer’s senior doctor being charged by the GMC for misconduct for putting his employer Travel Insurance Facilities’ interests before customers’.