Cowper's Cut 211: I Can't Get No Satisfaction
"The Government is in denial about what is happening in the health service and is failing to tell the country the truth. The health service can and will recover, but right now NHS and care staff need understanding, realism and honesty."
Matthew Taylor, chief executive, NHS Confederation
Depressingly but unsurprisingly, the Ockenden Review into maternity services at Shrewsbury and Telford Hospitals makes it clear that a toxic, non-learning insular culture there caused repeated harm and hundreds of avoidable deaths, over decades.
Non-learning cultures that are not self-critical and cover things up then perpetauate their problems, and it is blatantly clear that neither local not national commissioners nor regulators are slightly effective at detecting these problems. Lawyer-up, deny and deflect, baby.
We have been here before, of course: not just at East Kent and Morecambe Bay, but also in other fields at Southern Health and Mid-Staffs. Or Bristol Royal Infirmary.
Maternity; learning disabilities; frail elderly people; children.
Again and again.
For fuck's sake.
Really. For fuck's sake.
Patient safety campaigner James Titcombe, who lost his son Joshua at Morecambe Bay, noted that Health Jobs UK published "a job advert in the NHS two days after the Ockenden report was published. ‘…promoting a philosophy of normality…’ ‘…proud of our commitment to normal birth’."
The Commons debate on the report was actually worth following. But it's pretty hard to believe that anything much will change. Health But Social Care Secretary Sajid 'The Saj' Javid has been talking about his intention to "go after" the individuals who ran SATH, which ignores the cultural, tribal and human factors issues just about as fully as possible.
BSA survey shows record drop in public satisfaction
The latest health questions from the long-running NatCen British Social Attitudes survey revealed an unprecedented fall in public satisfaction with NHS performance and experiences of care.
I wrote about the deeply unsurprising nature of the BSA findings here for The Guardian. Gideon Skinner, head of political research at Ipsos MORI, pointed me to some recent polling of theirs about public attitudes to the quality of the post-Covid19 NHS, and how much they attribute fallen performance to the pandemic. It's worth your time.
And what do the workers think?
This week, we also got the latest results of the NHS Staff Survey: the annual canary in the coal mine.
32.7% of staff were satisfied with their level of pay: this has declined by 4% since 2020 (36.7%), and is lower than in 2018 (36.3%) and 2019 (38.0%). 31.1% said they often think about leaving this organisation. Having improved for two years running this has increased by over 4 % to a four-year high
(2018: 29.8%, 2019: 28.3%, 2020: 26.5%).
42.1% were satisfied with the extent to which their organisation values their work, down almost 6% from 2019/2020 (48.0%), and the lowest for five years (2017: 43.0%, 2018: 46.1%).
27.2% of staff said there are enough staff at their organisation for them to do their job properly. This declined over 11% points since last year (2020: 38.4%) and by over 16% amongst staff at Ambulance trusts (2020: 36.7%, 2021: 20.3%).
46.8% of staff have felt unwell as a result of work-related stress in the last 12 months. This figure has also increased for four consecutive years and now more than 8% higher than in 2017 (2017: 38.4%, 2018: 39.9%, 2019: 40.3%, 2020: 44.0%).
The findings on burnout are particularly worrying.
Likewise the findings on 'advocacy': 59.4% would recommend their organisation as a place to work. This has declined by more than 7% this year, having improved steadily between 2017 (59.7%) and 2020 (66.8%).
67.8% said that if a friend or relative needed treatment, they would be happy with the standard of care provided by the organisation: a decrease of more than 6% from 2020 (74.2%).
As I noted last week, large inflation and the small proposed pay award are likely to drive NHS industrial action.
Fantasy planning and magical realism
HSJ's Henry Anderson has had a couple of belting news stories this week about the ongoing storm of 'magical realism' in NHS England's planning.
Firstly, some genius in NHSE thought it would be a good idea to promote private patient income in its guidance. With a workforce shortage of 110,000 and an elcetive care backlog of 6.1 million patients, this is a novel approach to prioritisation: possibly even innovative.
And of course, the thought process behind actually writing this down in an easy-to-leak format is a thing of beauty and a joy forever.
This same document, Revenue Finance and Contracting Guidance for 2022/23, offered the brilliant idea that ICSs are going to have a 2022-23 requirement to financially break even. Yes, even the ones that took a massive financial deficit into the pandemic. This will obviously be a strightforward task, given that NHSE published the 2022-23 tariff the day before the new financial year starts. The Mandate also came out on the last day possible. Planning, eh?
Long-standing readers may recall the Duncan Selbie letter from the end of the Crisp era promising that Sir Nigel would be "taking a close and personal interest" in how strategic health authorities - the ICSs of the mid-2000s - achieved break-even in the final eight weeks of the financial year 2005-6. They will also recall that this stated goal didn't happen, as I pointed out at the time.
HSJ also covered the national response to a widespread perception of chaos in mdical training, which led NHSE to issue a communication making clear that training must be properly organised and prioritised. No, it shouldn't need saying.
But it does, particularly given that as the Nuffield Trust's Billy Palmer pointed out, the latest NHS Digital workforce report shows how many more UK and EU nationals left NHS nursing than joined in 2021. He adds that "looking at joiner & leaver figures separately show scale of recruitment needed just to stand still (i.e. match the numbers leaving)".
Mandate time
The new NHS Mandate and tariff both dropped on the late afternoon of the last day of the old financial year. While I'm not well-qualified to delve into the intricacies of the latter, the former is a characteristically witty read.
It is notably 'progress'-and-'towards'-heavy: "we will also continue to track progress towards improving outcomes via other existing mechanisms"; "NHS England should be transparent in reporting against all of these objectives on the extent to which progress on reducing relevant disparities has been made"; "headline metrics that the Government previously agreed with NHS England remain appropriate subject to a small number of amendments to be agreed between NHS England and the Government in due course and will be used to measure progress towards delivering the priority commitments".
'Addressing' has been added to the Official 2022-23 DHBSC Inaction Eupemism Framework: "addressing additional demand in primary and community care (which includes delivering the five-year GP contract framework including 26,000 staff in additional roles and delivering 50 million additional appointments in general practice per year by 2023-24) alongside tackling the COVID-19 elective care backlog". 'Addressing' is evidently not 'meeting': it'll be bracing watching these deadlines fly past.
We also get 'working towards and 'continuing efforts': "working towards the recovery of cancer services and delivering improved performance against cancer waiting time standards ... continuing efforts to restore and improve NHS public health services (including cancer and non-cancer screening services) that were paused or had reduced uptake due to the pandemic ... working towards recovery of mental health services performance standards, including the Improving Access to Psychological Therapies (IAPT) recovery rate and children and young people's eating disorder services waiting times".
'Subject to' also gets a starring role: "delivering more planned hospital activity to tackle the elective backlog and improve performance for the longest waiting patients, as set out in the NHS Delivery Plan for tackling the COVID-19 backlog of elective care, subject to maintaining low levels of COVID-19".
We are, of course, spectacularly not maintaining low levels of Covid19: not even with the April Fool of the end of free lateral flow tests. Speaking of which, procurement expert Rob Knott noted that three new huge DHBSC procurement contracts for LFT supply worth a total of £917.9 million have just been let in the past ten days. This seems counter-intuitive.
The negative impact on healthcare is, fortunately, still being accurately recorded as infections keep rising sharply, as seen from the remaining reliable ONS survey.
The 2022-23 Mandate is a diabetes-inducing mountain of fudge. Beautifully, it also includes the widely-discredited pledge "we will build 40 new hospitals": this was always bullshit, and the current rate of inflation and poor programme management makes it double-bullshit with an extra order of bullshit sauce.
(Oh and the New Hospitals Programme this week issued this glorious job ad: £100,000 a year to run the biggest NHS estates programme since PFI! How much less serious can you get? That is objectively the crossover point between comedy and tragedy.)
And one can only congratulate the individual who came up with "NHS performance will improve over time, once impacts of the pandemic are factored in": something that looks almost exactly like a pledge, but is nothing of the kind.
The NHS Mandate has become (to borrow Professor Mary Dixon Woods' fine analogy) the cargo cult of health policy.
Getting the Bill
The Health And Social Care Bill returned to the Commons with Wednesday's debate. The Government yet again rejected the Hunt amendment about publishing workforce projections and plans to plough on with what I dubbed the "more Matt Hancock" increased powers for the Secretary Of State to interfere in NHS operational matters.
Jeremy Hunt's intervention in support of the workforce proposals was good, and Karin Smyth's speech was excellent.
The next stage will be 'consideration of amendments', for which no date is yet set. But as stated previously, the Government will be trying to ensure it doesn't need to be rolled over. So they'll be trying to roll over the above amendments.
Privates on parade
This piece briefed to Sunday Telegraph political editor Edward Malnick highlighted noise about the Government's amendment to the Bill preventing private providers from sitting on ICS boards.
It's based on the views of name-free people: one private provider source and a right-wing backbencher, so we shouldn't take it very seriously, but it's another canary in the coalmine.
The private sector representative's take is that "by expressly excluding the involvement of private sector providers in local NHS systems but retaining a major role for NHS providers in allocating NHS resources, there is a huge risk that cosy local monopolies will emerge which are unable to take the difficult decisions necessary to secure 'bang for buck' for NHS funding, including the extra £8 billion going in from April funded by the National Insurance increase".
Well, it's a point of view. Albeit one that fails to acknowledge that the private provider sector hasn't actually got masses of spare capacity, let alone the most vestigal experience in allocating population-level resources.
Bollocks of the week
An unusual victory this week, from the generally sensible Matthew Syed: he of Black Box Thinking. Alas, the colour of box whence this piece for the Sunday Times sprang was more brown than black.
Syed argues that “the problem within the NHS is not institutional but theological. In short, we have deified this organisation for so long that it is no longer amenable to rational reform. Think of the language: nurses are “angels”, doctors are “heroes”, the NHS is “world beating”. Our politicians compete to eulogise the NHS as if by emphasising its brilliance it will thereby become so.”
Um, no. This is a dire piece of argument. Firstly, the suggestion that all public opinion, media coverage and political commentary about the NHS is laudatory survives precisely no contact with reality.
Mr Syed may be smart, but he seems to fail to spot the real problem: we are extremely poor at noticing bad culture and bad practice in the NHS in real time (or thereabouts).
Not only does the NHS obviously need a chief anthropologist more than any chief inspector (a group who have largely proven ornamental), it needs management capacity, capability and systems that not only know about why access problems happen and how to fix them, but which can also do the quality and cultural diagnostics.
The idea that the real problem is about people over-praising the NHS and ignoring its flaws is horseshit. A vein of horseshit, moreover, that it takes a truly spectacular lack of judgment to publish in the very week of the BSA survy findings.
Oh, and the last thing that was widely called “world-beating” in the NHS sphere was Test And Trace. That was by the PM. And TAT was demonstrably not so.
The NHS is perfectly amenable to rational reform: it’s just that none has been seriously tried for a considerable length of time. (The Lansley reforms were the wrong ideas, sold dreadfully, and didn’t even really happen.)
The Alan comeback
Alan told a grateful nation this week that "it's time to look forward" on Partygate. To more of them, presumably? This is a heroically bad interview.
The title's a bit 'I'm sorry?', but this read on The People's Partridge from right-of-centre blog site Unherd is quiter bracing.
Recommended and required reading
It's a decade since the Health And Social Care Bill became the 2012 Act: Richard Taunt, then the DHBSC Bill Manager and now a leader of Kaleidescope Health And Care, reflects on what did and didn't happen
The Guardian has a good piece on a survey of GPs about difficulties with access to CAMHS
Nice long read piece by Ian Kirkpatrick and Becky Malby for NHS Confed about what's next for NHS management
The Institute For Government's excellent 'Week In Public Services' is back, and as ever, worth a read
Smart Isabel Hardman Spectator piece on what the BSA survey results do and don't mean
Julian Patterson's takedown of tech utopianism in HSJ is a delight