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Cowper's Cut 202: A let-off for the PM, as The Saj reveals 'a cunning plan'

Cowper's Cut 202: A let-off for the PM, as The Saj reveals 'a cunning plan'
The ex-Goldman Sachs banker to the rescue: The Saj has A Cunning Plan

The delayed publication of the Sue Gray report into Partygate due to the Met Police inquiry appears at first sight to have given PM Boris Johnson a let-off. (It seems that the report may be published today in some form.)

In truth, this is pain deferred. Karma may be tardy, but the ongoing unpopularity for Mr Johnson is perhaps proof that this ne plus ultra of narcissism and populism is finally getting the very sentence he most deserves and can least bear. Limping on, wounded, unpopular and hostage to his backwoodswomen and men: justice may be slow, but it has poetry.

The Universe may take her time, but she has a wicked sense of humour. Mr Johnson doesn't do hard things, and he will find ongoing public unpopularity particularly hard.

It couldn't happen to a nicer man.

Tables turning (wine and cheese optional)
On top of that, the tables are turning within the Conservative And Unionist Party. Until the Owen Paterson affair started his slide, Mr Johnson's apparent electoral magic held his Party hostage. Tory MPs made him leader because while they knew he was a turd, they thought he was a winner.

Now, the hostages have become more like the captors: Mr Johnson's backbenchers can push him around, and tried doing so over the 2.5% NI hike to fund the Health But Social Care Levy, due to take effect on 1 April. We're unlikely to see Stockholm Syndrome developing here.

If Mr Johnson had conceded on this, his emboldened backbenchers would have asked for ever more: they learned over the EU how effective this can be.  If he folded, he would also fall out with his Chancellor.

The PM hasn't folded: in his jointly-bylined Sunday Times article with the Chancellor, this pair who self-identify as "tax-cutting Conservatives" promise full steam ahead with the NI increase.

So a fight with his most obdurate backbenchers lies ahead. Fraser Nelson has a good column about the current state of the CAUP.

The health and social care consequences
This matters to health policy, because Government is in effect part-paralysed.

I understand that the Elective Recovery Plan is now in the longish grass for at least a couple of weeks. The outstanding internal issue for the NHS is about the extent of its focus on discharges.

(It isn't clear whether things are over the line in inking the 'asks' deal with No. 10 and the Treasury, either. Amanda should probably take an ambush's worth of Prosecco and cake?)

The Saj at the Committee
Health But Social Care Secretary Sajid 'The Saj' Javid graced the Health select committee with a content-free, question-avoiding session on Tuesday.

Chair Jeremy Hunt, citing the Health Foundation figures of a shortage of 4,000 doctors and 19,000 nurses to return to waiting time standards, asked whether the promised DHBSC workforce plan will set out the numbers of additional healthcare workers needed.

The Saj replied that it will talk about the importance of workforce. (Public health notice: waffles such as this are high in sugar and may cause weight gain.)

Hunt, evidently unsatisfied by this answer, asked if Javid agreed with Lord Stevens of Birmingham's analysis in the Lords that there is "wilful blindness" over workforce planning. In full Nelson mode, The Saj saw no wilful blindness.

Asked about social care problems contributing to delayed hospital discharges, The Saj promises a new Health But Social Care Integration White Paper.


The Saj is already blatantly showing his unwillingness to answer the questions. There is a more-than-mild arrogance creeping in, too, which shows no sign of being justified.

The Times, they are a-changing, as The Saj has a cunning plan
Delightfully, The Saj leaked his latest policy plan to The Times this week.

He is building on the undoubted genius of his last revolutionary plan leaked to The Times: to invent Foundation Trusts - sorry, Acadamy Trusts, and allow the magnificent successes of hospital chains and management takeovers to be repeated.

Now, The Saj is going to allow hospitals to nationalise GPs, which is apparently going to make them do more to keep patients out of hospitals.

Yes, really. The Saj is setting himself up as the Baldrick of health policy: he has a cunning plan.

The Saj concludes that “whilst there are some strengths to the system of primary care, it’s also clear that the historic separation of general practice from the wider healthcare system as created in 1948 comes with considerable drawbacks including an underinvestment in prevention”. He plans to launch “an independent review of the future of primary care”, to review “workforce, business models and how GPs work with the other parts of the NHS such as hospitals”.

There is one example of this apparently working successfully and durably: in Wolverhampton. Others have tried: Sandwell and West Birmingham took over four practices; but Northumbria Healthcare FT's partnership GP not-for-profit sub-body  undid its takeover of one GP practice due to workforce issues (another eight GP practices remain part).

In the wake of The People's Partridge, it seemed implausible that we would get as stupid a Health Secretary along immediately. But it's happened.

As Nuffield Trust boss Nigel Edwards points out, international evidence does not point to hospitals as being better integrators of care than primary care.

Obviously, nationalising primary care - even if doen in a 'nice' way, as suggested - will not add a total of one (1: CI=95%) extra GP to the workforce. Indeed, this kind of back-of-a-fag-packet policymaking could have a 'final straw' effect.

In the real world, the Government's aspiration to increase NHS capacity by 30% of the pre-pandemic level, together with addressing the workforce, capital and maintenance backlogs, would require some sort of serious plan.

The Saj is evidently not a denizen of that world. Nor ever a regular visitor, it appears. Insteand, we get this sort of policy Tourettes, with The Saj leaking any old top-of-his-head bollocks to poor Chris Smyth.

The Saj's interventions have the policy coherence of a fart in a spacesuit, without any of the charm.

The public inquiry is delayed
The Independent's Rob Merrick reports that various issues have combined to delay the launch of the public inquiry into the handling of the pandemic. His story reports that "now hearings will not be possible before the summer after hold-ups appointing a chair and agreeing on terms of reference", citing sources from the Institute For Government and Kings Fund.

Unvaccinated staff
Following NHS Pope Amanda Pritchard's comments at the NHS England board meeting this week about sacking unvaccinated staff presenting "an element of risk", Shaun Lintern writes in the Sunday Times that a climbdown of sorts seems probable "if they would be dangerously understaffed".

This will not reduce future friction between vaccine-averse staff who have held out and their colleagues. One to watch, I suspect.

Getting the Bill
The Lords continued their scrutiny of the Health Bill this week, with some coruscating contributions.

The twin main points of criticism are of course the absence of workforce planning as per the rejected Hunt amendment; and the SOS power-grab proposals (the 'more Matt Hancock' clauses).

On workforce issues, Lord Stevens of Birmingham took no prisoners: "It is a statement of the blindingly obvious, particularly coming out of the pandemic, to say that we need better workforce planning at a time when staff are exhausted from having dealt with Covid for several years and the NHS is confronting the need to deal with the backlog of care.

"But, frankly, it would be a statement of the blindingly obvious at any time, because the lead times for decisions on training for health professionals are such that they go beyond any individual term of Parliament or government manifesto. Universities need a strong signal as to what future demand will look like. The interconnectedness between health and social care means that we are actually thinking about a workforce of 3 million plus, and the materiality of getting it wrong over a five or 10-year period is bigger in this sector of the workforce than any other part of the economy.

"... what we have been confronted with is wilful blindness. Health Education England, which should be looking at 10 years, does not yet have its running budget for 10 weeks’ time. If we look back over the history of recent years, we can see a series of missed opportunities. The Minister may assure us that we will be presented with this 15-year further vision from Health Education England this coming summer, which will, of course, be welcome. But if we remind ourselves of the history since 2014 or 2015, as I say, we can perhaps be a tad sceptical.

"It was back in 2014 that the NHS Five Year Forward View talked about the service changes that were required, but it was not permitted to talk about future capital investment, social care or workforce training, since they were being kept separate. So, in summer 2016, the Department of Health and Social Care was going to produce this detailed quantified workforce plan instead. Twenty-sixteen came and went and instead, in December 2017—three years after the Five Year Forward View—Health Education England launched a consultation document which said: 'Your responses will be used to inform the full strategy to be published in July 2018 to coincide with the NHS’s 70th birthday'.

Twenty-eighteen came and went, and answers saw we none. Then in June 2019, we got another, in this case interim people plan, with lots of excellent content but unfortunately no actual numbers and no new pound notes. Despite the fact that it promised 'We will aim to publish a full, costed five-year Plan later this year', quantifying 'the full range of additional staff needed'.

"But again, “later this year” came and went, and no such documents saw the light of day, until in July 2020 we had a one-year people plan which, at that point, was covering just the next eight months. Fear not, though, because it said: 'Further action for 2021/22 and beyond is expected to be set out later in the year'— in 2020— 'once funding arrangements have been confirmed by the Government'.

"That did not happen.

"Instead, in July 2021, last summer, the Department of Health and Social Care again commissioned Health Education England to start from scratch. Last November, HEE published a short PowerPoint—commissioned from a firm of accountants—with the discouraging disclaimer on the first page that, 'We do not warrant or represent that the report is appropriate for your purposes' and 'no warranty is made as to the accuracy of any data'. As it happens, that does not really matter because there were no real data in the document anyway, which came to startling conclusions such as “workforce demand will be affected by demography and disease”.

"I think we are entitled to say that this litany tells us that what, to everybody else, is blindingly obvious has instead been confronted with wilful blindness".


A few days later, Baroness Thornton asked about the duplicative nature of Integrated Care Partnerships and Health and Wellbeing Boards: "who was consulted on the structure, membership and role of ICPs? The Minister has said several times that this is what the NHS wants—well, which bit of the NHS? Who was consulted? Indeed, in a previous debate, we asked how this will work with the role of health and well-being boards. That has still not been answered. It is not at all clear why both things are needed ...

"It smacks of a fix. The Minister might not be prepared to say on the Floor of the House what exactly the fix was between the various bits of NHS England and various bits and other parts of the machinery. I suspect that Lord Lansley, might know better than the rest of us what that fix was". Indeed.

Lord Lansley's pair of proposed amendments were "to restore the independence of the Care Quality Commission in undertaking its activities and in the way in which it goes about its job. The Government’s drafting of the legislation is wrong anyway. There are references to objectives and priorities. The priorities are referred to in new subsection (3), inserted by Clause 26(2), which says that they 'must include priorities relating to leadership, the integration of services and the quality and safety of services'.

"There is no way in which the Care Quality Commission is not going to incorporate such indicators of quality. We know that from the generic nature of the quality indicators that it uses generally for existing NHS bodies. The reference to setting objectives is not only novel but completely undefined. The Secretary of State can set whatever objectives they wish to; we do not know what they are and there is no indication of what they might be.

"I think this clause proceeds from the mistaken apprehension that the Care Quality Commission is a part of the management process of the NHS. It is not. If the Secretary of State wishes integrated care systems to proceed in any particular way, the Secretary of State has the means to do so available via the mandate; the Government plan to add specific powers of direction; and NHS England has duties that go in exactly the same direction.

"The Care Quality Commission is not part of the management process for integrated care systems; it is an inspectorate. If—and this is a risk we must avoid—the Secretary of State were directly intervening to set objectives for integrated care systems to be inspected subsequently by the Care Quality Commission, whereas NHS England is itself setting objectives for integrated care systems through its responsibilities and duties, those two may come into conflict".

Lord Lansley would have no truck with Buttle Of Britain Earl Howe's attempted reassurance, which "I am sorry to tell him, wholly fails to provide reassurance. First, he was wrong, in the sense that he maybe implied that my amendments would have removed the Secretary of State’s requirement to approve the indicators on which the commission chooses to base its reviews. That is left in at new Clause 46B(4)(b), so the approval of the Secretary of State for the indicators would remain. What is being taken out by my amendments is the requirement for the Secretary of State to set objectives and priorities. I am afraid that everything that my noble friend said went to support my view that there is an erroneous perception on the part of the Government that the CQC must be turned into an integral part of the management of the NHS and the integrated care system. That is simply not the case".

Lord Lansley moved onto the subject of provider collaboratives: "Where are we going to end up with this? It will be with NHS England having within it, as each integrated care board has within it, the provider interest and the commissioner interest. The Government purport to be abolishing the purchaser/provider split. Every Secretary of State prior to the former Secretary of State, Matt Hancock, seemed to believe in it, with the exception of Frank Dobson. There was a reason why we did that: because it is a fact. We might legislatively abolish the purchaser/provider split, but, in reality, it will exist. As my noble friend Lord Hunt of Wirral said earlier, if that conflict of interest is not properly recognised and managed, it will emerge with potentially damaging consequences. Transparency about how provider interests are to be properly managed inside the NHS is not something I yet see in the substance of the Bill".

Lord Hunt of Kings Heath took on the 'more Matt Hancock' Clause 39, "which I think is one of the most significant ways in which the Bill will increase the powers of the Secretary of State over the NHS. The clause gives a general power of direction over NHS England in the exercise of its functions. It is a very significant change from the legislation the noble Lord, Lord Lansley, put through in 2011-12. It also is clear that many NHS bodies are, like the Nuffield Trust, 'concerned that these new powers will result in a more politicised NHS, with ministers dragged into micromanaging how local services work'.”

Pertiently, he added, "once you have a power of direction, it changes the relationship between the Secretary of State and NHS England in any case, because if NHS England knows that the Secretary of State has a power of direction, it is bound to take note of that in terms of their relationship and the instructions and advice the Secretary of State may give it. I am not naive enough to think that my amendments would necessarily prevent undue involvement by Ministers in the operational activities of NHS England, but I do think they would go some way to providing some reassurance".

Lord Lansley echioed this, calling Clause 39 "the product of circumstances where we had a Secretary of State who was encountering an emergency and thought he could press lots of buttons and things would happen, but pressed some and they did not. I think, even in his experience, that was more outside NHS England than inside it— I may be wrong, but that was certainly my impression. The point is that the Secretary of State did not even realise what powers he had in an emergency; they are all there and he was not required to change the mandate, because it was an emergency. In a public health emergency, none of this, strictly speaking, is within the same bounds.

"Ministers have quite rightly said that this is the Bill the NHS asked for. But Clause 39 is not the clause that the NHS asked for; it is the opposite of what it is asking for".

On the Independent Review Panel proposals to increase SOS powers, Lord Hunt of Kings Heath noted, "There are a lot of marginal seats, and there is going to be a general election in two and a half years—maximum. A lot of  reconfiguration proposals usually relate to smaller places with smaller hospital or DGHs because their viability is often in doubt. So it is quite clear to me that any MP, particularly government MPs, will immediately take any threat of that sort to their local services to the Secretary of State. That will not speed up the process; it will guarantee the opposite. The signal that I would get from the health service as a result of this is: “Forget reconfiguration proposals until after the next election because you ain’t going to get any through.” That is why we think this is a disastrous move".

And on the proposed powers for FT capital direction, Lord Stevens of Birmingham said, "it is not unreasonable to have a set of measures in the Bill that would enable Ministers to ensure that the NHS sticks with the capital expenditure, voted for by Parliament, for the NHS in any given year; nor is it unreasonable on the part of the Government to seek to ensure that there is a mechanism by which that capital can be allocated fairly across the country according to need, rather than purely according to an individual institution’s ability to finance it.

"All that being said, rather than this being a fundamental matter of principle, these amendments have a lot to commend them. They are entirely pragmatic and put the right safeguards around what should be only an emergency power. As the noble Lord Crisp laid out, that was the basis on which a consensus was achieved back in 2019. It provides good incentives at trust level for sound financial management and, frankly, it provides a bit of a pressure release or a safety valve against an overly artificially constrained capital settlement in certain years or parts of the country".

It's well worth reading HSJ's Dave West's analysis.

The Bill returns to the Lords on Tuesday.

Coronamillions and cronyvirus update
Lib Dem MP Wendy Chamberlain seems ot have unearthed something pertinent in her question about PPE purchase and use. Health Minister Ed Argar's written answer has been picked up by The Guardian, with its revelation that £2.7 billion worth of PPE is either no longer needed, or cannot be used in the NHS.

Argar said the Government’s PPE programme had ordered more than 36.4 billion items since the pandemic struck in March 2020. “Of this, approximately 3.4 billion units are currently identified as potential excess stock. The estimated price for those items is £2.2 billion”.

The minister said that 6.96 billion items “are not currently provided to frontline services ... of these, 1.2 billion items are deemed to be not fit for use. The purchase price for these items was £458 million.”

Of this total, the Good Law Project reveals that £437 million worth of unused/unusable PPE stock came from three VIP lane suppliers: Pestfix, Ayanda and PPE Medpro.

A 10% rate of “potential excess stock” is quite something, after three major waves of hospitalisations for Covid19. It looks as if there could be more to come on this.

Bollocks Of The Week
In what I imagine may become another 'Cut' regular, I'm launching a 'Bollocks Of the Week' slot.

The latest stage of the Alan comeback bid (see below) was a strong contender, but alas, insufficiently health-related.

So our first winner is Ross Clark's laughably bad article for the Daily Mail.

Its headline calls the analysis 'forensic', which is about as close to reality as the Mail tends to get on NHS issues. It has every bad NHS critique cliche - lacking only 'God Is Love' and 'please adjust your dress before leaving' for a full-house.

The Alan comeback
We must have beeen very good boys and girls this week, because we got the huge treat of this article about cryptocurrencies from The People's Partridge.

This could be Peak Alan: “we have not been able to do the same with genuinely new innovation. This often struggles because of professional conservatism, ideological opposition to private enterprise, or because of a thicket of claustrophobic regulation designed for another age – and a risk-averse attitude by the regulators".

“Genuinely new innovation”. As opposed to?

Some people think Alan is merely thick, but we cognoscenti know a Dadaist genius when we see one. This is less the world’s least subtle wannabe political comeback; more performance art.

Required and recommended reading
A clear first place this week goes to Nick Timmins and Beccy Baird's excellent summary of the vaccination programme for the Kings Fund.

Labour's generally impressive shadow health lead Wes Streeting is the subject of two major profiles published this week: in The Guardian and the New Statesman. Ambitious guy: good news. Neither is analysis-worthy, other than showing a real ambition within Labour to be back on the pitch.

Another useful sitrep thread on Covid19 in acute settings from London intensive care consultant Rupert Pearse

Less-than-reassuring UKHSA news highlighted by actuary John Roberts about the duration of vaccine immunity, particularly where AZ was the primary course