11 min read

Cowper's Cut 262: On the defensive

Cowper's Cut 262: On the defensive

In life and in politics, when you're explaining, you're all too often on the back foot.

PM Rishi 'The Brand' Sunak proved this maxim, with one of the main emphases in his uncomfortable interview with BBC Breakfast this Tuesday being the Budget's abolition of the lifetime allowance on pension contributions.

I'm guessing that once the implications of the policy have sunk in with people, Downing Street's private opinion polling may have found that this policy (whose upshot is vast inheritance tax breaks for multi-millionaires) will be regarded as problematic.

It remains baffling (as I wrote in last week's 'Cut') why the Treasury did not simply take the existing 'tax unregistered scheme' model developed for senior judges and create a senior NHS staff version.

As the Office for Budget Responsibility analysis showed, these changes will cost the Treasury £1.1 billion a year by 2027/8, and perhaps boost overall employment by 15,000 workers.

In contrast to my hypothesis above, initial Budget polling from Ipsos shows that 43% of those surveyed supported the ending of the cap on pensions lifetime allowance. That was, of course, pretty much instant reaction.

Nor do these Ipsos findings offer unalloyed relief for the Government: 12% of those surveyed "feel more reassured for Britain’s public services (down 7 ppts compared with November), 35% more concerned (also down 11 ppts), and 35% neither (+12)".

The survey also found that "Labour are more trusted to manage the economy over the Conservatives by a margin of 32% to 26% (similar to last November), while Rishi Sunak has lost his lead over Keir Starmer as the most trusted leader with the two level-pegging on 29% vs 27% respectively (after the Autumn Statement Sunak led by 36% to 28%).

"Similarly, only 29% are very or fairly confident that the Conservatives have a good long-term economic plan for Britain (down from 34% in November), while 61% do not have much confidence.  Labour performs slightly better, with 35% confident in their long-term economic plans, 51% not (little changed from November)."

It's also relevant to observe that the latest Ipsos 'Issues Index' shows that 'NHS/hospitals/healthcare' has dropped into third place, among self-reported (undirected) public concerns.

Junior doctors escalate

And a three-day strike by junior doctors is to be followed by ... a four-day strike, beginning on Tuesday 11 April.

Yes, it is almost as if the junior doctors' committee leaders had worked out in advance what their escalation was going to be.

And it is as if there is an implicit pattern of progression.

Health Secretary Steve 'The Banker' Barclay claimed that "I met the BMA’s junior doctors committee yesterday in the hope of beginning constructive talks. They placed a pre-condition on these talks of a 35% pay rise. That is unreasonable. My door remains open to constructive conversations, as I have had with other health unions."

Alas! The Banker was fact-checked on this assertion in pretty much real time by the junior doctors' leaders who'd actually been there in the room with him. Both the official Junior Doctors' Twitter account

and GP trainee and JDC committee co-chair Robert Laurenson's pointed out that Mr Barclay's account of events was less than wholly truthful, backing up their version of events with a photo of the DHSC’s negotiating ‘rules’.

The JDC WhatsApp message confirming the strike was promptly leaked to HSJ, (oh, the post-2016 WhatsApp JDC leak irony, as I'm sure Shaun Lintern will agree). It stated that "Barclay came with no alternative offer but asked our negotiation team to “reflect on” our demand. Whilst in the room, he produced a new set of preconditions, including ‘media silence’ but immediately briefed the Mail and the Telegraph post-meeting".

Ready to rumble

The junior doctors have been smart here. They had obviously prepared for a Barclay intransigence scenario (the attitude evident in the DHBSC's pre-negotiation statement was, as I pointed in last week's 'Cut', scarcely conciliatory).

Nor did they concede the battle of the media spinning to the Government.

The junior doctors' leadership in 2023 have taken their media training and message discipline seriously, as this clip from Andrew Marr's LBC programme demonstrates. This is a necessary, if not sufficient improvement.

It looks very much as if someone in or around the BMA noticed that their 2015-16 contract dispute had been badly damaged by their inept attempts at decentralised leadership; freestyle communications and media stunts; and lack of message discipline.

That dispute showed the utter folly of letting such an approach roll: the belief that ‘we’re doctors; we’re great at everything, including political communications’ was predictably and promptly tested to destruction.

Why, yes, thank you for asking: I did indeed mention these things at that time.


Mr Barclay chose to antagonise the junior doctors, perhaps believing that the proposed (but not yet adopted) settlement for the Agenda For Change NHS Staff Council groups including nurses and physios gave him the momentum and the upper hand.

Momentum – in both the Corbynite and metaphorical senses – appears to be more with the junior doctors. Mr Barclay has been caught out promptly and publicly on making inaccurate statements.

A four-day stoppage will worsen the problems in cutting the NHS backlog, and this is one of PM Rishi Sunak’s ‘five pledges’. NHS England is regularly publishing data on the capacity that is being lost to industrial action.

Mr Barclay’s peremptory approach to the junior doctors' leaders effectively handed them the ability to reply, ‘nice commitment to cut waiting lists you’ve got there: be a shame if anything bad happened to it …’.

That is evidently unwise.

Radicalised, or just younger?

There has been media speculation about the current JDC leadership being ‘hard left’ (or more accurately, Broad Left). It is in fact not unusual to see fairly left-wing people elected to BMA Council positions.

The context in 2023 is also radically different. The impact of Brexit driving the governing Conservative And Unionist Party into years of nationalist-populist leadership has affected public attitudes to them: it has also hit the UK economy. The Covid19 pandemic also boosted public affection and support towards the NHS, and again hit the UK economy. The current inflation crisis has likewise hit the UK economy.

Many people are feeling the cumulative impact of all of these things. The likelihood of greater public sympathy for industrial action isn't hard to understand.

As data presented by John Burn-Murdoch in the Financial Times shows, younger people in UK society are increasingly supportive of left-wing causes. They are not becoming more  politically right-wing as they get older, nor once (or if) they own homes.

As I've previously noted, the 2022 findings of the long-running Ipsos Veracity Index shows that doctors and nurses are among the most trusted people in British society. Politicians rank very low for trust (as do journalists): this year's data sees politicians’ trust ratings fall back to the levels triggered by the Parliamentary expenses scandal.

So in brief: doctors usually have trust on their side in the court of public opinion; politicians usually don't.

Getting a 35% (or even 26%) pay ‘restoration’ claim is unlikely, and the junior doctors’ leaders clearly know this: their statement describes it as a "starting position".

But they have put themselves into a stronger position, and Mr Barclay has avoidably weakened his.

The Government's improbable plans

I don't want to use the H L Mencken quote to death, but the Government appears to be having a push on policy ideas which could charitably be described as untested and implausible.

They briefed the Times that cloud-based GP reception telephone systems will be the salvation of primary care. OK, not in quite those words, but nearly.

“Surgeries will be told that they must upgrade their telephone lines to cloud-based systems which allow patients to queue, or request a call back at less busy times.” Mmmmmm. The track record of telling GPs what to do?

So, there'll be a theory of change as to how this happens, right?

Ahem. “To encourage family doctors to make the change, the GP contract for the coming financial years has already been rewritten to focus financial incentives on speeding up and offering more appointments. The £246 million payment fund, at present focused on measures such as health inequalities, will be “entirely” repurposed on targets to improve patients’ experience of contacting surgeries and being seen promptly.”

One must have a heart of stone not to laugh. This will not increase primary care capacity significantly; nor reduce demand; which has been rising for some years.

It gets better: Sunday Times health editor Shaun Lintern has been told that "the NHS will be told to send more patients private", as our bonsai Prime Minister Rishi 'The Brand' Sunak "plans new patient choice legislation this summer".

Is there significant spare capacity in the private sector that can make a difference? We don't actually know empirically with reliable data whether there is, but anecdotally I am told by clinicians who practice both in the NHS and privately that there is not significant spare capacity in the latter sector.

Ah ... cloud-based phone systems; virtual wards; fictional 'new' hospitals; illusory private capacity: they just can't stop winning!

The New, If Fictional, Hospitals Programme update

It's great to see the New, If Fictional, Hospitals Programme going from virtual strength to virtual strength.

HSJ's Zoe Tidman reports that trusts have received less than 25% of the funding requested for crucial 'enabling' preparation works for the NIFHP. Enabling works include demolition works, new car parks, electrical infrastructure, and setting up 'decant' spaces to be used during the new, albeit fictional, building work.

The consequent delays to 'enabling works' means, Tidman writes - presumably with the straightest face possible, that trusts fear "this could slow down the pace of their projects". Clearly, that would be awful.

BSA NatCen survey: social care crisis

The latest data from the long-running British Social Attitudes survey by NatCen (sponsored by the Nuffield Trust and the Kings Fund) on social care is out, and it makers for grim reading.

It finds that "just 14% of the 3,362 people questioned said they were very or quite satisfied with social care. Of these, only 2% were very satisfied. On the other hand, dissatisfaction rose significantly to 57% of respondents (up from 50% in the previous year) and reached its highest level recorded.

"These findings show that dissatisfaction has been growing since 2018 and more people have been dissatisfied than satisfied with social care since 2014."

Ooops. One wonders how bad the forthcoming data from the health questions is going to prove to be.

Andrew Foster RIP

This week, we learned of the death of one of the most impressive NHS leaders I've yet known.

Andrew Foster was one of the grown-ups, and he will be much missed.

The NHS will likewise miss Andrew greatly, but should hopefully try to maintain his traditions.

The Alan comeuppance

Thanks to Led By Donkeys, we got an update on Alan's day rate for working for non-existent foreign lobbying firms: a mere £10,000 sterling.


God bless The People's Partridge. What would we do without him?

EveryGrifter: the tea partnership

Speaking of shameless grifters without a hint of credibility, our old chum 'Dr' Julia Grace Patterson was bringing the merriment again this week.

What could be more lucrative than tea and nonsense scaremongering about the future for the NHS indeed?

EveryGrifter's accounts are a riot. As our dear amigos say, "keep an eye out for our full 2022 Annual Report in early 2023".

Aloytius Parsadoust  might lose his money? Say it ain't so!

You want more on low-credibility, health-adjacent grifters?

We've got you covered.

Babylon Health virtual GP app faces cash crunch
Start-up championed by Matt Hancock could have as little as three months worth of cash in the bank

Aloytius Parsadoust's credibility-light 'Babylon Holdings' is, as the Boris Johnson Fanzine spotted, in significant financial trouble.

Team Babsters "has raised around two months' worth of working capital after securing a $30 million (£24.5 million) bridging loan from London-based lender AlbaCore Capital, accounts filed with Companies House reveal.

"The New York-listed company had around four months of cash in the bank at the end of 2022, based on operating costs of around $19m a month. The figures suggest Babylon could have as little as three months worth of cash in the bank ... AlbaCore previously invested $200m (£163.6m) into the healthcare company in 2021".

So Aloytius might not be a rich man? Couldn't happen to a nicer fashion icon.

Cronyvirus and coronamillions update

I'm surprised to find myself impressed by two thorough and reasonable health pieces in the Boris Johnson Fanzine  within the same week (see R&RR below for the other one), but this summary by Harry de Quetteville on the PPE scandal is well worth your time.

Ignore the crap headline: Tom Whipple's Times article about the World Health Organisation is fair and thoughtful.

I'm frequently critical of the Boris Johnson Fanzine, but its global health security editor Paul Nuki deserves credit for this piece.

New Tony Blair Institute report by Heitmueller, Blakeley and Carkett calls for Governments to set aside 10% of health spending for preventive and public measures (such as cycle lanes and anti-obesity strategies).

HSJ's astute Henry Anderson spotted that NHS England chair Richard Meddings hgas involvement with failed bank Credit Suisse. It reminded me that Sir Derek Wanless chaired the audit and risk committee of failed bank Northern Rock ...

The Guardian has discovered that the quality of residential social care for old people is often appalling. Who knew?

My new columns for Pharmaceutical Journal and Pulse.

It's not health policy/politics, but Tim Harford's latest FT column on making forecasts vague is extremely good.

23 years ago this week, Alan Milburn (greatly helped, one suspects, by Simon Stevens) made one of the most substantial speeches on NHS reform.