10 min read

Cowper’s Cut 273: Living in financial times

Cowper’s Cut 273: Living in financial times
Our NHS is Not For Sale!


Most people have heard of the negotiating technique of 'low-balling'.

The BMA's leaders seem to be 'high-balling', as regards their ongoing (and probably growing) industrial action over pay, with remarks about a 50% increase in doctors' pay from two senior figures.

Vishal Sharma and Mike Henley (chair and deputy chair of the BMA’s consultants committee) are up at bat. The former told the Senior Review podcast, “we now need to start from scratch and say what should a doctor in the UK in 2023 be paid. We can argue that it should be 50 per cent higher, the government can argue whatever it should be. And I have to say, even 50 per cent . . . is still a drop in the ocean compared to America, Australia and other places”.

Henley added, “when you consider . . . the 17 years of training, the stress, difficulty and complexity of what you do, you’re worth every penny. So the question to you lot is, ‘What do we do?’ Do we go on Newsnight and say, we demand a 50 per cent increase . . . well I would, obviously”.

Health But Social Care Secretary Steve 'The Banker' Barclay continued his pay dispute trolling with a remarkable effort in this Tweet: "today over a million hard-working NHS staff will begin to receive more money in their pay packet — including a backlog bonus for all their efforts during the pandemic. We hugely value their work and this pay rise recognises the vital role they’re playing to cut waiting lists".


It's almost as if The Banker has forgotten his former reverence for the 'independent' pay review body's original recommendation, which industrial action forced the Government to change.

After all, who among us can forget The Banker's saying that "we have an independent pay review body - which the unions campaigned to set up - and we will continue to defer to that process to ensure decisions balance the needs of staff and the wider economy"?

Not 'Cowper's Cut' readers, that's for sure.

To The Banker's banality, this seemed like a good reply: A&E consultant Andrew Meyerson observed of a 'going home checklist' "just finished a night shift in A&E and feeling wrecked. If you have a job that has a "going home checklist" like this, you deserve better pay and conditions".

Reddit updates from the BMA junior doctors' camp imply that the upcoming three-day strike is a model for ongoing three-day actions every month, until they get a satisfactory pay offer. The JDC will need a fresh mandate from its members, but that is evidently likely to be forthcoming. The BMA's consultants are still voting, but I'd bet a pint or two on them voting quite heavily for industrial action, too.

The high likelihood of ongoing strikes make the achievement of waiting list reduction (one of PM Rishi 'The Brand' Sunak's five pledges) much harder. The recent IPPR paper, Waiting for prosperity: modelling the economic benefits of reducing NHS elective waiting lists, features research claiming that getting people off waiting lists would bring benefits equivalent to £73 billion between now and 2027.


The Sunday Times carries this news-ish story from Shaun Lintern and Harry Yorke that the PM is shortly to announce "a £1 billion cash injection to try to fix the NHS staffing crisis. Tens of thousands of extra nurses, midwives, doctors and dentists are to be trained over the next five years ...

"Under proposals still being discussed, the government is expected to announce a doubling of medical school places for doctors to 15,000 by 2028-29. The plan would also train 24,000 nurses and midwives by 2030, 2,000 more trainee GPs and thousands of dentists".

I call this news-ish because it's clearly an accurate snapshot (Shaun being Shaun) of an outline of an as-yet-un-done deal. Unsurprisingly, "the Treasury is understood to have resisted calls for the 15-year plan to be fully funded, instead agreeing to spending commitments for certain aspects ... The Treasury has committed itself only to funding all training costs for the next five years". In other news: ursine sylvan toileting habits uncovered!

Meanwhile, NHS England continues to expand its overseas medical recruitment drive, as their brilliant policy of trying to recruit their way out of a retention crisis continues.

Covid inquiry

A Lot Of News was incoming this week with the Covid19 Inquiry. The Government is seeking to take legal action against the inquiry that it set up to learn the lessons of the pandemic.

Yes, really. The Cabinet Office thinks it is a good idea to pursue judicial review against the decision of the chair Baroness Hallett, one of the most experienced judges in the UK, to request documentary evidence.

Chair Lady Hallett asks, among her preliminary questions to former PM Boris Johnson, “did you receive advice from the then cabinet secretary that Matt Hancock MP should be removed from his position?”

She also asks the ex-PM to “please confirm whether in March 2020 (or around that period), you suggested to senior civil servants and advisers that you be injected with Covid-19 on television to demonstrate to the public that it did not pose a threat?”

And the Hallett hits just keep coming: “in or around autumn 2020, did you state that you would rather ‘let the bodies pile high’ than order another lockdown, or words to that effect?”

“Please confirm whether in March 2020 (or around that period), you suggested to senior civil servants and advisers that you be injected with Covid-19 on television to demonstrate to the public that it did not pose a threat?”

“Did you say on or around 22 September 2020 that you felt that Sage had ‘manipulated’ you into imposing the first lockdown?”

Andrew Rawnsley's Observer column on all this is particularly good. Oh, and in the world's least surprising revelation this week, we learned from the Boris Johnson Fanzine that The People's Partridge and his SpAd Damon Poole had leaned on the BBC to be friendlier in its coverage. Only more Matt Hancock can save us now.

Living in financial times

Health Service Journal's Henry Anderson did the maths to point out that over a third of ICSs did not set balanced budgets for 2023-24.

15 of the 42 ICSs refused to submit NHSE-mandated budgetary financial fictions. They include more than half the integrated care systems in the north of England, with the balance in the midlands and south-east. The other 27 will get found out as the financial year unwinds.

Problems with the grandparent of the ICS concept, Greater Manchester's devo-land, were apparent in Lawrence Dunhill's HSJ piece this week. A review by consultancy Carnall Farrar had found widespread concerns around the allocation of resources, confusion about the role of commissioning, and “muddled” governance. (This probably isn't unique among ISCs.)

The Carnall Farrar review also highlighted:

  • a lack of transparency and trust between partners, with some only sharing a “partial overview” of performance and finances which drives choices likely to “bias” some organisations;
  • complex architecture of system boards, committees and forums, with “muddled” governance, unclear paths for critical decisions to be made, and unclear delegations to localities;
  • frustration at the quantum of meetings that take place at system, locality and provider level;
  • confusion/ambiguity around the roles and responsibilities of the integrated care and provider federation boards, and particularly around the role of commissioning;
  • leaders in some places felt “the ability to make progress at ‘place’ had gone backwards”; and
  • many partners felt delivering the overarching strategy for the system (to improve population health) is conflicting with achieving financial balance and meeting NHS targets.

Greater Manchester's performance across electives, emergency care and cancer has been an increasing concern over the last year, as Dunhill rightly records.

You'd like to hope that their Devo-Manc headstart would have put their system in a better place. But then, this collaboration / integration stuff is very different indeed to how system leaders and organisations were trained to behave under previous decades' 'New Public Management' rules; and making this change is clearly also very difficult.

The Financial Times (by some way the best daily national media brand) had two notably strong pieces this week, both of which merit mention. The first was Sarah O'Connor's insightful interview with London Business School economics professor Andrew Scott, who makes a hatful of pertinent points about longevity, and how societies need to change to accommodate it.

The FT also had this piece on NHS productivity, drawing on Institute for Fiscal Studies research, which observes that NHS productivity lags as recruitment fails to keep pace with demand. It found that "the NHS in England has 11 per cent more nurses, 10 per cent more consultants and 16 per cent more junior doctors than pre-pandemic — even after adjusting for higher rates of staff sickness absences. The number of nurses increased by just 3 per cent between 2010 and 2019.

"The NHS also carried out 9 per cent fewer emergency admissions, 5 per cent fewer outpatient appointments and 11 per cent fewer elective and maternity admissions in March 2023 than in the same month in 2019.

The number of incidents recorded by ambulance services was 5 per cent lower in April 2023 compared to April 2019, despite 35 per cent more 999 calls".

The article cites IFS senior research economist Ben Zaranko observing that although the numbers of GP and first cancer appointments have both increased since the comparable rates pre-pandemic, in many other categories, fewer patients were now being treated.

Zaranko said that in certain areas, “treatment volumes and the waiting lists are heading in the right direction”. He cautioned that about 8 million fewer episodes of treatment from the waiting list had been carried out during the first two years of the pandemic than would have been expected pre-Covid, and that the longer-term impact of this missed care remain uncertain.

While it was “within the realms of possibility” that the NHS would meet the government’s targets, he added that “they were challenging when they were set ... I’d say they’re probably even more challenging now”.

Clearly, a large part of this is Not Surprising. You can’t recruit your way out of a retention crisis. Your most experienced staff are your most valuable, when you have a massive backlog to fix. And as I noted last week, there is a big old retirement trend.

Going up in vape?

Former DPH Kate Ardern pointed out fascinating inconsistency in this week's welcome (albeit rare) prevenatative public health measure of the Government's announcement on combating vaping amongst children and young people.

The original Number 10 press release had quotes from CMO Professor Sir Chris Whitty, and ... two spokespeople from the vaping industry including Juul Labs. But curiously, there were none from other public health organisations.

Once an online fuss kicked up, the Juul quotes were promptly deleted.

Kate put the original quote online here, and notes that "Joe Murillo has an interesting history as  he worked for Altria (Philip Morris USA) for over 23 years before moving to Juul after Altria bought a big stake in the company. Pushing the combustible fag market".

EveryGrifter prove that laughter really is the best medicine

Our old merch-vending chums EveryGrifter were hard at it again this week making fools of themselves with wild accusations against Labour MP Stella Creasey, who donated a speech fee from insurer Aviva to a charity, and recorded it entirely properly on the Parliamentary record.

EveryGrifter think that this is privatising the NHS, apparently. (No, me neither). Few things are funnier than EveryGrifter on NHS privatisation. Laughter really is the best medicine.

Team Imbecile then doubled-down on Creasey's perfectly fair use of the word "unhinged" to describe their conduct, on the grounds of its stigmatising mental illness. Alas for EveryGrifter, it was promptly pointed out that their own official Twitter account had described something as "completely insane".


It was also noted that EveryGrifter associate Dr Maria Corretge works in the private sector. She charges self-funding patients £220 for a first 30-minute appointment and £150 for all subsequent appointments. She also accepts payments from Aviva. People in glass-houses ...

Still, at least EveryGrifter have got an in-house barista. Sorry: in-house barrister. They can sure afford one, as I noted last August. Although it's slightly unfortunate that EveryGrifter’s in-house lawyer’s website is an empty Mastodon server. But perhaps this is an elaborate quadruple-bluff.

But, you know what? I agree with EveryGrifter. The privatisation of health policy and political commentary has gone too far. I'm disgusted that people are charging money for analysis that should be owned by the Government and free at the point of use, according to need and not on the ability to pay.

'Cowper's Cut' is launching a campaign against this privatisation. But I can't do it alone: I need your help.

A donation of £10,000 will help me to buy a few cases of fairly decent claret. If you can make it £30,000, you can become a Gold Member. (Certainly a member.)

Platinum membership of the 'Cowper's Cut' Against Health Policy/Political Commentary Privatisation campaign starts at £75,000. Numbers are limited, although my in-house barista reminds me that the limit is very high.

Our shop will be online shortly, selling coffee at £25 a pack to support indigent health policy commentators. Special 'Cowper's Cut' pens will be available at £100 per pen* (*only sold in packs of three).

It's depressing to think that members of the Hard-Of-Thought Community actually give and pay EveryGrifter money.

But one last thought, on an Alan-adjacent tip: why haven’t EveryGrifter launched their own cryptocurrency? It'd be a perfect fit for their brand. #NH$

Waiting times expert Dr Rob Findlay of Insource wrote in his latest HSJ column that Labour's promised restoration of 18 week waits within five years is feasible.

A presentation of NHS trials of the Grail 'Galleri' testing technology suggested that the equipment has the potential to spot and rule out cancer in people with symptoms. However, the FT reports that more than 400 patients in the USA who took part in this test were sent erroneous letters last month suggesting they may have developed cancer.

HSJ's James Illman notes that the hoped-for (albeit unplanned) transformation of outpatients has very much not happened.

Convicted Theranos fraudster Elizabeth Holmes starts her prison sentence this week.

Good summary by Professor David Oliver of the Forty New (If Fictional) Hospitals for Byline Times. HSJ's Lawrence Dunhill pointed out that despite the official encouragement for mental health organisations to apply for the 40 N(IF)HP, none got through.

Related, The Economist had a pertinent 'Bagehot' column on the 'Reform Fairy'. Only structural reforms can save us now ..;. except that structural reforms will not fill the £10.1 billion NHS backlog maintenance hole; let alone provide actual budgets for however many of the Forty New (If Fictional) Hospitals ever get to the point of physically breaking ground.

Smart piece in the BMJ by Alison Leary on workforce planning.

Pre-print, non-peer-reviewed causal study suggests that the shingles vaccine may offer some protection against dementia.