Cowper's Cut 204: From leaks to launch, Electoral Recovery Plan and integration White Paper underwhelm

First the leaks ...
Delays to the completion of the elective recovery plan (which winsomely, Health But Social Care Secretary Sajid 'The Saj' Javid cannot stop calling the 'electoral recovery plan') hit the headlines on Monday, with a story briefed by PM Boris Johnson to his real boss the Telegraph that those mean, nasty Treasury Munchkins weren't letting him have the Euros for the plan.

Boo, Treasury Munchkins! Boo!

As I remarked in Cut 202, recent ERP delays were caused by policy disagreements over actions on delayed discharges. The Treasury Munchkins never want to give up the money to make things achievable, and NHS England doesn't want unattainable targets.

The notion that there was a fresh row over funding is, I'm told, not correct.

This is politics. It's very much an attempt by a flailing, failing PM to drag potential Tory leadership candidate Rishi 'The Brand' Sunak down into the mire of unpopularity.

And of course, the Treasury was briefing back, to The Times that the "incredibly well-funded NHS" would have to deliver on targets.

There are several obvious reasons why this electoral recovery plan was not in danger of becoming important in real world:

1. Covid19 is still significantly restricting hospital capacity because of infection control requirements.

2. Hospitals lacked the resources of workforce and physical space to ramp up activity before Covid hit.

3. Annual allowance and pensions taper tax have massively cut staff’s willingness to do extra shifts evening and weekends. The Treasury Munchkins are still not moving on this.

4. The DHBSC 'returner staff' initiative led by Andrew Foster was stopped. This was one of the most foolish decisions in health policy during the pandemic.

5. Management capacity and capability and data use remains very variable, even in a world of the Foundry-based NHS Datastore.

6. The current Government’s general political instability and incompetence are not helping inspire people to buy in to it.

On what probably self-identified as 'Reset Monday', there was also a leak to Chris Smyth of The Times that the PM hoped to persuade Dame Emily Lawson to become the new No 10 permanent secretary.

Perhaps Ms Lawson has taken leave of her senses, but I suspected when I saw this that The Dame might decline this potentially poisoned chalice.

My instincts on this proved correct: on Wednesday evening, Steven Swinford of The Times (!) revealed that the PM's health advisor Samantha Jones has been appointed as interim permanent secretary and COO of the Office of the Prime Minister. Congratulations and good luck to Sam with that challenging new role. (Obviously, she'll now need a secretary; and that person is likely to soon be so busy, they'll need one too; which will bring us to the interim permanent secretary's secretary's secretary. Which is clearly peak job title.)

The Times also had a story about the Treasury blocking the ERP. It is even sillier than usual, including as it does a quote from one source that “the NHS are the ones who didn’t want to announce any targets”.

Ahem. An elective recovery plan that doesn't have any targets would be very much what we in the trade call 'Not A Plan'.

The Times followed this piece of analytical genius up with one even better, which quote a senior source in Government who describes "an incrediby well-funded NHS". Double-ahem.

It's worth re-reading the magisterial Kings Fund piece on the vaccination programme by Nick Timmins and Beccy Baird, which states on page 27 that "Simon Stevens, Amanda Pritchard (then Chief Operating Officer for NHS England), Emily Lawson and indeed Matt Hancock, who was also pushing for the fastest possible progress, were determined not to have impossible targets. They had watched what happened to Test and Trace when impossible targets were accepted, with the programme’s credibility undermined when they were inevitably missed".

... then the launch
At a few minutes after 12.30 on Tuesday, The Saj stood up in the Commons to announce the release of the elective recovery document.

Now I see why, as outlined above, my dear chums the Treasury Munchkins have been leaking to the nationals like a plumber’s wet dream these past few days.

They’ve had their arses felt by this electoral recovery plan, in the biggest way.

It is indeed Not A Plan. It has "ambitions, guidance, and best practice”. So creating 30% more elective capacity over pre-pandemic levels by 2024-5 is an “aim”. Other aims include to "make progressive improvements on long waits, with a goal to eliminate waits of over one year by March 2025, and waits of over two years by July 2022".

The words 'ambition', 'aim' and 'goal' all allow for a lot of wriggle-room, obviously.

There are re-statements of the cancer plan targets, of course.

Likewise, there are commitments that by March 2025 (which lies beyond the next General Election),  there will be no 52-week waits.

The document hopes that by July 2022, no patient will wait longer than two years for elective care; that by April 2023, no patient will wait over 18 months; and that by March 2024, the waiting list will be falling and no patient will wait longer than 65 weeks. Waiting lists are to be prioritised by age, deprivation and ethnicity.

The plan also dilutes the existing (but un-hit) diagnostic target. Presently, 99 per cent of patients needing a diagnostic test should get it within six weeks. The plans say that by March 2025, the NHS will deliver this for 95 per cent of patients.

It's not long until we get to Caveat Time: "these ambitions are important for improving outcomes for patients, but they of course depend on returning to and maintaining low levels of COVID-19, enabling the NHS to restore normalised operating conditions and reduce high levels of staff absence”.

Ahem. There are 14,000 Covid patients in hospital currently, and just under 500 in critical care beds, on ventilators. The Omicron wave is very much not yet over.

HSJ's coverage suggests that the elimination of 52-week waiters by March 2024 (before the next General Election) was a bone of contention between the Government and NHS England. Agreement that the relevant March 2024 target should be that the waiting list would be falling represents a good win for NHS England's CE, Amanda Pritchard.

To state the obvious: ongoing demand from Covid19 and associated infection controls makes it hard to quantify how big the waiting list is yet to become. Likewise, our lack of clarity about how much once-anticipated demand has simply disappeared because of deaths. So an activity-based target makes sense.

Nothing on workforce
Workforce issues are not seriously addressed, in any way. That seems unsustainable, to put it mildly.

There is no workforce plan (The Saj mentioned having asked NHSE for one in the Commons); nor any sign of a budget for Health Education England for the next financial year, which is less than nine weeks away.

The most important passage on workforce states that "any solutions for tackling the COVID-19 elective backlog cannot rely on making the same staff – whether in primary, secondary or community care – work ever harder. To succeed, we have to grow and support our workforce, so they can deliver excellent care”.

The NHS Pope is clearly no mean counter-puncher in negotiations. Good for her.

Nor was there anything on backlog maintenance (bill: £9.2 billion), nor on the pensions taper tax and annual allowance.

One final thought: if this really is the version after the Treasury Munchkins put their adorable little feet down and insisted on more targets, then it'd be comedy gold to see the previous version.

Or maybe that 'row' was all gubbins, briefed to the media. The downside to Government by ‘comms-ing it’ is that you’ve had your leaked news stories long before the launch. Either way, sell your shares in Sunak.

As Rob Findlay's latest analysis for HSJ confirms, the waiting list issue is very far from settled. The Tory right is going to come for it again and again, as made clear by Kate Andrews' piece for The Spectator, based on leaked official data.

What a good thing it is that there's no sense of extreme urgency, with the waiting list tipping over 6.1 million ... oh. That's 310,813 people on the list who have been waiting over a year: a nudge up from 306,996 in November. Two-year waiters have likewise risen, to a new record high of 20,065 - up 8% on the 18,585 patients in November.

Javid vs Streeting
The Commons sparring between the main parties' health leads was lively. Labour's Wes Streeting went on the absence of any workforce plan and lack of a budget for Health Education England (the national training body).

Mr Javid was affronted, and attacked the 'tone' of Mr Streeting's reply. Yep, it’s clear that the line is that criticising the dire current state of the NHS is "playing party politics".

The communications genius on display from the Government is dazzling. Apparently, talking about this longstanding and lousy state of affairs is undermining clinical staff: this will be news to most NYS clinicians I've ever met, who know exactly how bad things are.

Mr Javid seemed to think that Mr Streeting should not criticise NHS mismanagement, and instead "work together in the national interest", which is (if nothing else) an interesting take on the role of an Opposition in a first-past-the-post Parliamentary democracy.

It was a proper bit of needle between Javid and Streeting. The former also claimed - wrongly, as Hansard shows - that Mr Streeting said "there is no Covid backlog", in what seemed like a pre-cooked line. The best such line was actually Mr Streeting's critique that "the only big new idea seems to be a website that tells people that they are waiting for a long time, as if they did not already know".

The Spectator's Steerpike has a nice little spot about The Saj's current goes at self-rebranding, ahead of ... oh, perhaps a Conservative leadership contest?

Return of OSAL
Our Saviour And Liberator Andrew Lansley popped up on BBC Newsnight on Tuesday evening (19 minutes in), gamely venturing the entertainingly reality-avoidant concept that long NHS waiting lists "wouldn't have been like that, but for the effects of the Covid pandemic".

OSAL seems to have forgotten that the 6 million-strong waiting list today was already 4.4 million long in December 2019.

Ooops!

PMQs
As Prime Minister's Questions began, the Mirror's ace Pippa Crerar dropped a new photo from a Downing Street party, featuring the PM and a prominent, open magnum of Prosecco.

The PM's "there was no party" line is looking pretty vintage (unlike the Prosecco).

As the Commons exchanges began, the PM announced the intent to move towards a early ending of the remaining Covid19 restrictions, including the mandate to self-isolate once diagnosed as infected. The proposed basis for this was the reduction in infections and hospitalisations.

Mmmmmm. And where where the scientists to back this move?

Cathedrally silent. For good reasons. This is deeply scientifically unjustified.

“We have to clear our Covid backlogs”, the PM went on to tell the Commons, just after trailing ending restrictions a month early, at a time when there are over 13,000 in hospital for Covid and over 400 in mechanical ventilator beds.

It got more stupid still, as the i newspaper revealed plans to abolish the ONS national weekly Covid19 infection sampling survey. This ONS survey is regarded as the “gold standard” because (although it lags daily case numbers), it has tracked the same households since June 2020: as such, it is not subject to variations in numbers of people self-testing.

What a silly Gilly!
Health Minister Gillian Keegan delighted us last year, with her comments at the Conservative Party Conference that the NHS recruitment of overseas nurses (which was her Government's policy) was "stupid" and "wrong".

This week, the minister took a lateral flow test and then went into an in-person and evidently un-masked meeting with charity campaigners. Part-way through this meeting, her assistant (with whom she evidently left the still-developing test) came in to tell Ms Keegan it was positive. So the campaigners and her staff are all now at very high risk of infection.

The minister took to Twitter for a mea culpa before the media broke the story, but just how stupid can one person be?

The Alan comeback
It caused me almost physical pain to have nothing for you in 'The Alan comeback' stakes last week, so thank The People's Partridge that our hero released this statement on the PM's mooted ending of Covid restrictions on Twitter.

Alan asserts "Britain got the big calls right - massive early investment in vaccines, one of the biggest testing systems in the world, the amazing response from the NHS, discovering the main treatments to save lives and a balanced response to new variants".

Some of this is fair (the point on vaccines procurement, and dexamethasone), but much of it is absolute bollocks.

Test And Trace was 'a costly failure' at its main aims; the responses to the Alpha variant wave was late and failed to learn from the delay in bringing in the first lockdown; and many front-line NHS staff don't agree that the response was 'amazing', given the position of ongoing stresses and shortages from which it started.

Integration White Paper
What a relief it has been to get the integration White Paper before the current Health Bill is even through the Lords. So what does 'Joining Up Care For People, Places And Populations' have to say for itself?

Stop the search. The Integration White Paper is officially The Greatest Policy Document Ever.

It delivers something for which politicians will be desperate as ever-more attention focuses on the NHS backlog: a single point of blame.

The introduction, jointly byined to The Saj and Levelling Up Secretary and Chatty Chap Michael Gove, offers the potently emetic opening line "The storms we have weathered over the past two years have been a great test, but also a great teacher".

Really? Really?

I mean, this is up there with 'Time may be a lousy beautician, but also a great healer'.  

Cowper's Thirty-Seventh Law Of Health Policy ststes that the relationship between the height of  a document's rhetoric and the achievability and credible theory of change of its plans is usually inverse.

Hence, when I read the lines "It sets out a new approach with citizens and outcomes at its heart instead of endless form- filling, unnavigable processes and a bureaucracy which sees too many people get lost in the system, not receiving the care they need. It is the start, not the end, of a new wave of reform which will both put power and opportunity in the hands of citizens and communities and build a state that is sustainable and just", I reach for my gun.

What other fresh joys do The Saj and The Chatty Chap offer us? "Through introducing a single person accountable for delivery of a shared plan at a local level, our proposals will ensure a more joined-up approach between health and social care".

No. They really won't. They'll give you a single individual to bully or sack when things are going wrong in the run-up to the next General Election.

Inevitably, it's not all bad. the section on data use is sensible. The proposals for an outcomes framework are likewise, but of course, these things are hard to do.

There is, obviously, zero coherence betweenn the White Paper's contents and The Saj's Times-leaked proposals for 'academy hospitals' and 'nationalising GPs'. Likewise, the noise about pooling budgets doesn't really mean anything. The Pothole Care Fund was, let us remember, effectively NHS money pooled for social care.

Having a go at the coherence of integration policy in health and care can be a bit like shooting fish in a barrel, so I'll stop here. Health Foundation head of policy Hugh Alderwick made numerous fair observations in this Twitter thread; Nuffield Trust boss Nigel Edwards likewise. (Robert Ede of Policy Exchange, a think-tank which contributed to the paper, also made pertient observations about this policy's evolution.)

Likewise, the NHS Confederation's new review of The State Of Integrated Care Systems is worth reading.

Oh, and public health? The allocations to local authorities were published this week, and as Adam Briggs of the Health Foundation notes, the total allocation of £3.417 billion (a 2.18% cash terms increase on 21/22, and so well below inflation) leaves the non-prescribed functions the same as previously, and continues to include COVID responsibilities. The ADPH picked up on this pretty disgraceful decision.

Bollocks Of The Week: Peak Pollock
Professor Allyson Pollock takes our 'Bollocks Of The Week' title, with her wonderful assertion that Sam Jones' work at Operose/Centene was "playing a pivotal role in privatising primary care services and take over of GP surgeries".

As Axel Heitmueller pertinently asked, "how can you privatise the privatised?"

I've got time for Professor Pollock's work which went against the orthodoxy of the day and pointed out that PFI was dreadful value for public money; but on NHS privatisation, I'm afraid her work is foolish and legitimises fools. This is Peak Pollock.

Getting The Bill
Further Lords debate this week threw up little of huge note, bar the Government's proposed U-turn on permitting local councillors to sit on the new integrated care boards, which HSJ noticed.

The real action (if there is to be any) lies ahead, at Report stage, in early March.

Cronyvirus and coronamillions update
The Good Law Project this week alleged that the Government misled Parliament as to the size of the VIP fast lane. The GLP claims that it "has seen documents showing the Government misled Parliament, the National Audit Office and the High Court about the size of the illegal VIP lane it adopted which advantaged associates of Government Ministers.

"In October 2020 Good Law Project revealed the existence of the VIP lane. In November 2020 the Government informed the National Audit Office that there were 47 VIPs. In November 2021, after losing an FOI battle with Good Law Project, it published a list of 50 VIPs. However, internal Government documents leaked to Good Law Project now reveal that the true number of companies fast-tracked down the ‘VIP’ lane was far higher", the organisation claims.

GLP states that "at least 18 other companies, who between them were directly awarded a further £984 million in PPE contracts, were also given the ‘VIP’ treatment. The full list of additional names can be found here. These 68 VIPs were awarded a total £4.9 billion in PPE contracts. All without competition. The new VIPs include:

• Hong Kong based oil and gas firm Jason Offshore Equipment was handed a £25 million contract in June 2020. 18 months later, the DHSC still hasn’t published the contract, directly contradicting Boris Johnson’s claims in Parliament that all PPE contracts were now “on the record”.
• PPE contracts worth £173 million were awarded to China Meheco Co. Ltd and Winner Medical, both of whom have been linked to Uighur human rights abuses in Xinjiang. Government has previously misled the public about other aspects of the deal.
• A £96 million contract awarded to Beijing Union Glory Investment Co. Ltd – a firm that operated out of a hotel room in Beijing".

It's going to be a very long public inquiry.

Recommended and required reading
Future Health Research Centre boss and former Alan SpAd Richard Sloggett makes good points about the Government's current 'taking back control' political dynamic regarding NHS policy: grip may be trumping all

The IFS and Health Foundation published a new joint briefing on the Government's planned changes to the proposed social care costs cap, which they conclude "puts more people at risk of catastrophic care costs, particularly those in the North East, Yorkshire & the Humber and the Midlands".

Useful NHS Confederation published long read by Ian Kirkpatrick and Becky Malby on whether the NHS is over-managed (erm, nope: massively not)

Shaun Lintern has a disturbing (and clearly legally sensitive) story in the Sunday Times about a doctor accused of sexual assault on under-age children who was apparently allowed to continue practising following a police inquiry, before re-offending

Interesting Nuffield Trust piece on the reasons why staff are leaving health and social care jobs