“Much of the instability in the world is a product of its legacy of individualism and haphazard policymaking.”
Kwasi Kwarteng, 'Ghosts Of Empire'
Westminster gossips suggest that getting a weak pound from Chancellor Kwasi Kwarteng is not an unfamiliar sensation to PM Liz Truss.
I couldn't possibly comment, although this has already been quite the week for discovering the burial place of those in charge of the Treasury.
But it's clear that the economic impact of The Kwarteng Pyromania (about the obvious impact of which civil servants warned the Chancellor and PM) - i.e. the bond and currency markets' responses imposing yet higher inflation and borrowing costs, on top of the present cost-of-living crisis - is going to hit us all hard financially.
The health and care system will not be exempt.
The Kwarteng Pyromania continues to resonate
Reputation arsonist and chaos Chancellor Mr Kwarteng has announced that the new Office for Budget Responsibility forecast and his Medium-Term Fiscal Plan (his delivery instructions for 'The Growth Plan') will be delivered on 23 November.
Somewhere in the Treasury sits a very happy civil servant and Doctor Who fan, who's managed to get some spectacular science-fiction onto the Grid on the show's 59th birthday. Nice work, Whovian Munchkin!
It's bad luck for the charred remains of the Chancellor's reputation that the Sunday Times reveals that, on the evening following Mr Kwarteng's not-Budget, he was guest of honour at a champagne party held by a Tory donor in the company of major city financiers, who told the Chancellor to his face to "double down" on his economic 'plan', while behind his back referring to Mr Kwarteng as a "useful idiot".
The Chancellor is reported to have given party guests "insights about forthcoming government spending cuts during the event, which took place at the Chelsea home of Andrew Law, a financier and Conservative Party donor, on the evening of Friday, September 23".
Still, I'm sure that we need further public spending cuts, as Levelling Up Secretary Simon Clarke MP told The Times. The sheer opulence of our public realm has been worryingly obvious for many years now, and it just won't do.
Mr Clarke's credo is that “it is important that we look at a state which is extremely large, and look at how we can make sure that it is in full alignment with a lower tax economy.
“I do think it’s very hard to cut taxes if you don’t have the commensurate profile of spending and the supply side reform. If we’re adopting this plan, which I think is exciting and fundamentally addresses the competitiveness issue, the rest of the piece needs to move in tandem.
“We are privileged to deal with very large budgets. My experience . . . is that there is always something you can do to trim the fat”.
The IMF and others weigh in
Statements from the notoriously socialist International Monetary Fund about your economy are rarely good news for governments, and this one for PM Truss's administration is no exception.
The IMF said "given elevated inflation pressures in many countries, including the UK, we do not recommend large and untargeted fiscal packages at this juncture, as it is important that fiscal policy does not work at cross purposes to monetary policy.
"Furthermore, the nature of the UK measures will likely increase inequality. The November 23 budget will present an early opportunity for the UK government to consider ways to provide support that is more targeted and re-evaluate the tax measures, especially those that benefit high income earners”.
Former Bank Of England deputy chair Sir Charlie Bean told Sky News that "if you want to get the share of government spending to GDP down, you have to be prepared, say, to move away from our own health service, which is free at the point of delivery to one funded by social insurance like they do in Germany."
Things got substantially less good again when the White House had their say - like the IMF, recommending that the proposed tax cuts be dialled back.
Inverse Robin Hood - the consequences
So the Truss administration's Inverse Robin Hood Strategy means that public spending cuts are coming.
What will be the consequences for health and care?
Assuming that the baked-in interest rate rises see house prices decline despite the stamp duty threshold raise, then the total assets of some poorer older homeowners in poorer areas needing social care could drop below the £85,000 threshold that is still in place to next April. This may hit the hardest-pressed council's budgets hard.
The stress of economic tightening (domestic energy bills are not capped at £2,500 a year, as the PM keeps lying) will have obvious negative impacts on mental health: a field where services are already stretched to and beyond breaking point in many areas.
Governments can cut capital spending fast, particularly from projects where there are no budgets, contracts or broken ground. So we can wave a fond farewell to the fictional 40 'new hospitals' and 'more than 50' new surgical hubs.
The Great Resignation continues, as new Nuffield Trust research for BBC News proves.
The full Nuffield Trust et al work can be found here.
Will new pressures on household finances see The Great Resignation start to unwind? Probably not, I'd say. The NHS pension is to die for; returning to work in a service in perma-crisis is not attractive; those retiring will be mostly in late-mortgage or post-mortgage territory; and the low likelihood of decent pay rises in 2023-24 keeps a strong incentive for people to leave based on their salary this financial year.
Oh, and anyone hoping for new GP services had better pray that they have easily-fracked oil and gas reserves nearby.
Fresh evidence of the NHS backlog's impact
The Financial Times' Sarah O'Connor points to new ONS data showing that one-fifth of the over-50s who have dropped out of the workforce are on an NHS waiting list. Her colleague John Burn-Murdoch pointed to this trend back in July.
The survey data is here.
Not fixing the roof when the sun was shining
A Lib Dem FOI shared with The Guardian revealed that the problem of wildly outdated and unsafe reinforced autoclaved aerated concrete (RAAC) roof planks in many NHS hospitals will not be fixed until 2035. It also clarified that the cost of their removal and replacement is unknown.
In a truly dreadful broadcast round on BBC local radio stations, the Prime Minister told Radio Norfolk (her constituency's local station) that she will lobby Dr Therese 'Tiz' Coffey about the RAAC roofing in her actual local hospital, as a local MP.
Ms Truss won't, however, make promises on Dr Tiz's behalf.
The Labour Party conference saw some significant pledges on the NHS.
Shadow Chancellor Rachel Reeves promised in her speech that reversing The Kwarteng Pyromania's cut to the 45p top rate of tax will fund a variety of increases in NHS workforce training.
She told delegates, “The 45p top rate of income tax is coming back. Here’s what we will do with that money.
“The next Labour government will double the number of district nurses qualifying every year. We will train more than 5,000 new health visitors. We will create an additional 10,000 nursing and midwife placements every year.
“More than that: we will implement the biggest expansion of medical school places in British history doubling the number of medical students (to 15,000) so our NHS has doctors it needs".
Shadow Health Secretary Wes Streeting briefed The Sun that he plans to fund the restoration of continuity of primary care.
Labour leader Sir Keir Starmer is not a natural orator, but delivered by far his most convincing speech as Labour leader. Its thematic clarity that Corbynism is gone and, crucially, not forgotten was welcome.
Just as welcome was the repeated emphasis that under a Labour government inheriting a Conservative-authored economic and public sector crisis, "this time, the rescue will be harder than ever".
He warned delegates that the restoration of the public sector will be a hard and long grind, involving reform, prevention and using technology to free up professionals' time to care.
Starmer's promise of a new Office for Value for Money sounds like a reinvention of the Audit Commission and merger with the National Audit Office. It'll be interesting to see this, and the public service reform promises above, get fleshed out into something deliverable.
The Wes Streeting speech is here:
Rosena Allin-Khan, the shadow minister for mental health, said that the next Labour government would guarantee access to mental health treatment within a month. She did not say how.
Socialists for Lansley
It was nice to see that, despite its long-overdue return to the centre ground of politics where General Elections are won, Labour remains an inclusive party: one with room for the complete imbeciles who managed to get a 'Socialists For Lansley' motion through compositing for a vote on the last day of their conference.
Their motion demanded the repeal of the 2022 Health and Care Act. In other words, back to Lansley: long live competitive tendering. It also denounces Integrated Care Boards (having not noticed that their statutory responsibilities are word-for-word the same as CCGs, but on a bigger geographical footprint, and no longer with a GP led golf-club governance model.)
The motion's proposers also want everything to be publicly owned - so good luck to high street retail pharmacies large and small; let alone most GP practices.
As the health and care system's longstanding crisis becomes ever more evident, the usual NHS 'anti-privatisation' campaigners are likely to pretend that it's something to do with that.
It's to do with the deliberate crashing of social care with the austerity programme; a workforce crisis going back many years; the collapse of competent operational management in many acute hospitals; and the lowest decade of funding growth per capita (2010-19) in the NHS's history.
Anyway ... deep breath. Back to the real world of politics (where party conference motions do not matter).
Confidence and momentum aren't everything in politics, but they're more than half of everything.
For the first time in twelve years, Labour looks like a confident organisation with confident leadership. And having lost Momentum, they have gained momentum.
The Conservative And Unionist Party's self-reinvention as Tufton Street UKIP helps, of course.
But Labour has avoided the most obvious nonsense like promising NHS redisorganisation - and crucially, they are being honest with voters that pulling the public sector up out of the gutter and back on to its feet will be costly, hard, messy and slow work.
The public do notice
The latest polling on international public attitudes to their health systems from Ipsos shows that 83% of those surveyed in the UK say the NHS is over stretched- one of the highest figures anywhere globally.
The trend number of such responses internationally is around 60% reporting over-stretched systems. Around half of those surveyed across 34 countries describe the quality of their country’s healthcare service as good.
The Sunday Times' Shaun Lintern suggests that NHS England has identified 10 areas where it fears the health and care system (999, A&E, social care and hospitals) could collapse this winter.
He suggests that this list includes such major city regions as Birmingham and Leicester.
And new UK polling by Ipsos for the Health Foundation shows that "the public wants to see the NHS maintained and improved, not radically reformed. Despite the significant challenges facing the NHS, the majority (77%) support the NHS model and think we should do everything to maintain it ...
"Even as the cost of living crisis unfolds, our polling has shown that people are prepared to see taxes rise to achieve progress on their priorities of cutting waits for elective care and addressing staff shortages.
"As we head towards a difficult winter, failing to take bold actions on the major issues facing the NHS risks leaving the government significantly out of step with the public". Quite so.
Excess deaths rising
The UK public mood is unsurprising: actuary Stuart McDonald points out that the latest ONS data shows excess deaths for the year are 6% up on the 2015-19 average.
McDonald's most recent blog cites a hypothesis that the underlying causes of increased excess death rates are elevated cardiovascular risk following COVID infection; current delays for urgent treatment in the NHS; and missed and delayed diagnoses earlier in the pandemic.
Dr Kent has just quit as chief executive of a very-unhappy-sounding ICS, and the move is dressed up as a 'secondment'.
This makes no sense at all. Theresa May's blind-spot on and disinterest in the NHS was a mile wide. She only moved on meaningfully increasing funding when Jeremy Hunt and Simon Stevens finally co-ordinated a well-worked political pincer movement on her. Mrs May's erstwhile health SpAd (nice chap or not) was not then and is not now an influential mover and shaker.
Whether this is a reward for failure (or an incentive to keep quiet) for Dr Kent, or the discovery that, while an able communicator, Chris is not particularly strategic, it looks and smells dreadful.
It does, however, allow NHS England to get around its hiring ban.
I wrote in last week's column about the relationship between NHS England's leadership and the service's operational leadership, touching on the unharmonious relationship with ministers and DHBSC.
When HSJ 's Dave West was appraised that NHSE was to delay the funding for Dr Therese 'Tiz' Coffey's 2-week GP appointment guarantee to April 2023, whoever briefed Dave decisively let the cat out of the bag about the poor relationship between ministers/DHBSC and NHSE leadership.
The HSJ report notes that Dr Tiz's underwhelming NHS plans "had little input from NHSE". Mmmmmm.
I'd heard a single-sourced report that NHSE boss Amanda Pritchard and COO David Sloman were kept waiting outside Dr Tiz's office last week, with officials telling them they wouldn't be admitted until they provided data on various issues. This reportedly went on from 8 am to 9 pm. (I couldn't get this confirmed by a second source, so I didn't bring it to you.)
It seemed pretty plausible, given what I hear elsewhere: even more so now.
We should remember that it is not unusual for NHS England's leadership to come under fire: remember the charmingly comic attempts by PM Theresa May's chief advisors Nick Timothy and Fiona Hill in 2016 and 2017 to undermine Simon Stevens.
The difference, of course, is that Simon's political acumen and judo skills were (and undoubtedly remain) considerable.
The CQC needs special measures
It's had far less attention than it deserves, but HSJ's coverage of the Care Quality Commission's triggering two external legal reviews into how it deals with whistleblowers' concerns and into wider information of concern (such as on race issues) is important.
Last week, HSJ highlighted a letter signed by senior officers of Unison, the Royal College of Nursing, Unite, Prospect and the Public and Commercial Services Union calling on Dr Tiz to urge the CQC to pause its organisational change and start “meaningful discussions” with the unions.
Annabelle Collins' story says that "according to the letter, staff at the regulator have been left “in fear of speaking out” against structural changes to the organisation, which they believe “pose a significant risk” to the CQC’s ability to regulate health services.
"The letter also claims the culture of the regulator has “changed under [chief executive] Ian Trenholm’s leadership,” and that issues which had arisen during Mr Trenholm’s direct control of a £26m project while he was chief executive of NHS Blood and Transplant “are occurring again in the CQC”. The PwC review of the NHSB&T project criticised “a lack of consistent programme leadership” which led to a series of shortcomings with the project.
"Meanwhile, major concerns have emerged in recent weeks about long-running cultural problems at NHSBT, where Mr Trenholm was CEO until he joined the CQC in 2018. Reports found a “toxic environment” and accounts of bullying and “systemic racism” at NHSBT, which Mr Trenholm’s successor has claimed were present when she arrived, and had been reported particularly at NHSBT’s Colindale site".
It looks as if it's time to put the CQC into special measures, and send Mr Trenholm to do a a spot of judgment-free gardening.
Guess who's back, back again?
It's a sign of the times that "two trailer park girls go round the outside, round the outside, round the outside" is the pandemic's autumn 2022 edition 'Ring-A-Ring-Of-Roses'.
We all fall down.
Cronyvirus and Coronamillions update
Henry Anderson of HSJ notes that the UK Health Security Agency will (like the EU) be issuing qualified annual accounts, owing to the madcap economics and procurement practices around Test And Trace and the DHBSC's procurement tactics.
Anyone seen Alan's pub landlord?
Recommended and required reading
Powerful blog from Jo Maybin on the reality of living with Long Covid.
Interesting Lancet Public Health paper concludes that "Greater Manchester had better life expectancy than expected after devolution. The benefits of devolution were apparent in the areas with the highest income deprivation and lowest life expectancy, suggesting a narrowing of inequalities".
Interesting Shaun Lintern piece on a London system pilot project hoping to reduce long ambulance handover delays.
Bloomberg report on various allegations and concerns about data firm Palantir (usual COI declaration: I sit on Palantir's health advisory board).
The Financial Times reports that Dr Tiz has ignored UK Health Security Agency advice on procuring extra doses of Monkeypox vaccines. Didn't we used to have a Chief Medical Officer?
The Nuffield Trust's report on 'Future funding and current productivity in Northern Ireland’s health and social care system' commissioned by the Northern Ireland Fiscal Council, is here.
Fortune report https://fortune.com/2022/09/27/uk-four-seasons-health-care-elder-care-private-equity/ (note the source: Kaiser News)