13 min read

Cowper's Cut 278: Dido's lament - "The fish rots from the head, so it does matter the way political leaders talk about our health and care system, because they set the climate"

Cowper's Cut 278: Dido's lament - "The fish rots from the head, so it does matter the way political leaders talk about our health and care system, because they set the climate"

It's bizarre to see PM Rishi 'The Brand' Sunak shilling the success of the 'I Contain Multitudes' NHS Workforce Plan on his Twitter.

(And Twitter! Yesterdaysville! Get with the hip Threads crowd, Daddio!)

You can't help thinking that if The ICM Plan had landed in the way they had hoped, then this would be fairly unlikely prime ministerial behaviour. It doesn't seem confident, shall we say.

NAO reviewing the 'I Contain Multitudes' NHS Workforce Plan

The National Audit Office is running an independent assessment of NHS England's modelling to support their 'I Contain Multitudes' Workforce Plan. This will include assessment of:

  • the chosen methodologies for modelling the demand and supply of workforce;
  • the accuracy and robustness of the models;
  • the governance arrangements for the models;
  • the reasonableness, completeness and sensitivity of the assumptions supporting the model and the approach taken to estimate uncertainty.

This could prove very interesting.

Towards winter with trepidation

NHS England boss Amanda Pritchard's appearance at the Public Accounts Committee session on 'Access to urgent and emergency care' on Monday saw her committing news. It might even have been intentional. James Lyons might have been involved.

The Mail picked up on her comments about the NHS's current extraordinary staff sickness rate, saying "there was an extraordinary response from the NHS during Covid ... people did do the most extraordinary things on a personal and a professional level but that does have a long-term impact that’s well understood. So we are seeing some of that in the current sickness figures."

In a moment of wild self-confidence, NHSE medical director Professor Steve Powis told the PAC that the NHS was "doing all the right things" to prepare for the coming winter. Perhaps there are high-level plans for the public to applaud NHS staff to keep them warm while they wait for ambulances?

In slightly more comprehensible vein, Health Service Journal's Dave West talks to a range of contacts about their anticipation of how bad the coming winter will prove to be, in this sobering read.

There are some hopes around marginal gains, and some sentiment that it may not be quite as truly appalling as November and December 2022, but as Dave notes, "everything remains a lot worse than pre-covid. The question is whether the last few months are entirely a seasonal blip, or if we’ve turned a corner and that some of the underlying post-covid faults are now easing.

"It is not only important for emergency care: These issues also drag down productivity, hold up elective recovery, and tell us whether ‘integrated care’ is starting to deliver."

And the PAC bared its teeth in correspondence from chair Dame Meg Hillier to Ms Pritchard on "selective reporting" of cancer statistics, as HSJ's Henry Anderson spotted.

Dame Meg's call for "greater realism" may not be heeded so well: an NHSE spokeswoman told HSJ, “NHS England has NOT painted an inaccurate picture of cancer recovery – while there are really clear plans in place to address backlogs and progress has been made thanks to hardworking staff, the NHS is totally clear that there is a huge challenge ahead to recover cancer services.

“The Faster Diagnosis Standard has been met for the first time since its inception earlier this year, and the 62-day backlog decreasing year-on-year for the first time since 2016. Thanks to NHS campaigns and early diagnosis initiatives, we are also seeing record numbers of referrals and diagnosing a greater proportion of those at early stage than ever before.”

Incentivising lying

I have been banging on in these columns about why the Department For Health But Social Care's wholly-owned subsidiary NHS England's incentivising of financial lying in the NHS is A Bad Thing.

It seems that people agree. They're even saying so out loud, in The Real World. At a recent HSJ event, numerous chief executives spoke out, and did so on the record, against this trend.

UCLH FT CEO David Probert said there were “definite challenges to the professionalism of some of our fantastic finance leaders”, who were “being asked to put in place plans that [they] may not fully agree are deliverable or are highly risky.”

He added: “It’s definitely the most challenging year we’ve ever had, probably in our modern history… we’re going into this year with cost improvement [at] the highest level we’ve ever had.”

Newcastle Hospitals CE Dame Jackie Daniel said the intensity of the 2023-24 planning process had not given providers the headroom to properly consider the implications of agreeing to stretching financial targets, saying that “in agreeing a control total across the system as big as ours… I went further than I wanted to go in agreeing that [total] by several million ... not a lot in the grand scheme of things.

"But the consequences of that, and trying to agree a control total… you start to unravel stable positions [at individual trusts] and the instability spreads.”

This is pretty remarkable: more and more NHS leaders are now openly admitting to it and condemning it. As with the 'Forty New (If Fictional) Hospitals' project lead's lese-mejeste that I covered last week, this is an unambiguous sign of an ineptly-led system.

Departing Kings Fund chief executive Richard Murray's take on this incentivised financial lying, in a valedictory podcast - that it is somehow the NHS’s fault that its national and political leadership incentivised financial lying - is, um, niche.

Murray asserted that the NHS was giving government “the impression of something that just can’t be trusted: ‘You said you were going to deliver this and you’ve haven’t.’”

This is a bit more than just niche, really. It is heroically, spectacularly silly. His civil service DHBSC finance background couldn't be more glaringly obvious: 'blame the NHS for its system leadership'. Ah well: once a Munchkin, always a Munchkin. If Mr Murray is meant to understand finance and economics, then he should surely have grasped that people respond to the incentives you set them.

I've always had the impression that Mr Murray has the political insight of a dead leaf, and this comment confirmed it. Despite having hired the first-rate Siva Anandaciva, the Kings Fund has been punching below its weight for some years now. The Health Foundation and Nuffield Trust are not just streets ahead, but grand boulevards.

A Blockhead former Health Secretary in an age of Netflix

An idiotic intervention on the future of the NHS?

From former SOS Sajid 'The Saj' Javid?

The man who brought us 'a Blockbuster service in an age of Netflix'-level insights?

What a shock. To the considerable surprise of absolutely nobody, The Saj chose theis week to embarrass himself in The Times with the ridiculous and unfounded claim that the NHS is making us sicker.  Even as 'pay attention to me!' rhetoric, it's pitiful fare.

Javid asserts that the poor health outcomes of the UK are "direct consequence of how the NHS is still structured. Since it was established in 1948, the world has significantly changed — yet much of the institution remains frozen in time". This is risible stuff, which indicates how much attention The Saj paid to his brief.

The Saj concludes with the rallying cry of the policy and politics illiterate: for a Royal Commission. If that is any part of your policy solution, it's clear that you have not understood the problem.

Dido on WATO

OMG. Wednesday's BBC Radio Four World At One featured an interview with Everybody's Erstwhile Favourite Noble Baroness Dido Harding of Winscombe, formerly chair of NHS Improvement and then boss of 'NHS' Test And Trace.

It was ... much.

She told the nation that "The fish rots from the head, so it does matter the way political leaders talk about our health and care system, because they set the climate". That's quite a way to describe Steve 'The Banker' Barclay.

"I'm not talking about another reorganisation ... it's operational and management change, in the numbers of people being recruited, in the culture of the organisation and in encouraging people to stay".

"You only improve services if you invest in order to change the way things work, and every year for so many years the NHS has raided the capital budgets an order to prop up its short-term budgets and that's a huge mistake. If we keep doing that, you shouldn't be surprised if the service doesn't improve."

The managemnet problems she found when running TAT were apparently because all the NHS system incentives were financial, and not personal. Eh?

As well as this, there were hymns for prevention and a "serious conversation about social care".

It's a bit like Eric Morecambe playing Greig: all the right notes, but not necessarily in the right order ... nor does it match up tremendously well with what The Noble Baroness Harding actually did when she was chair of NHS Improvement.

Streeting goes to GPland

In a genuinely interesting encounter, Labour health lead Wes Streeting spent a day at the practice of GP and New Statesman health correspondent Dr Phil Whitaker. The Staggers write-up is an interesting insight into Streeting's thinking.

Public support for NHS staff industrial action still strong

New polling from Ipsos for The Guardian carried out between January and June 2023 reveals that "about two-thirds of the public said they supported striking nurses, ambulance workers and junior doctors, despite growing numbers of appointments and operations having to be cancelled.

"Support for junior doctors has grown from 47% in January to 56% in June, while the figure for nurses has increased from 61% to 62% and support for ambulance workers has grown from 58% to 62%. In June, just 24% of the more than 1,000 respondents said they opposed the junior doctors’ strike, and 21% for ambulance workers and nurses".

Ipsos’s director of politics, Keiran Pedley, said the polling showed that “NHS staff are consistently the most supported by the public ... levels of support have been sustained over time despite any disruption caused. Support for NHS workers likely reflects strong public concern about the current state of the NHS and an inclination to blame the government, rather than the NHS or its staff, for problems that exist.”

Here comes the bill?

How the public views the NHS at 75
Six findings on how the public views the NHS at 75 and perceptions of what the future may bring.

It's obviously been a bonanza month or two for pollsters doing NHS work. The Health Foundation commissioned Ipsos to do this study of public perceptions of the NHS as it nears its 75th 'birthday'.

Of those surveyed, 3/4 "believe the NHS’s principle of ‘free at the point of delivery’ will be eroded to at least some extent over the next 10 years. Half (51%) expect to pay for some services currently free at point of use, while 13% think most services will need to be paid for upfront and 7% anticipate charges for all services (eg, consultation fees).

Data revealed the public were pessimistic about the NHS’s ability to meet key future challenges:

  • 77% believe the NHS is not prepared to meet the increasing health demands of an ageing population
  • 61% believe the NHS is not prepared to respond to the impacts of climate change
  • 51% believe the NHS is not prepared to keep up with new technologies to improve patient care

As seen in previous Health Foundation polling, "support for the NHS unites people from across the political spectrum with nearly 3 in 4 of the public (72%) thinking that everything should be done to maintain the health service. But people intending to vote Labour (86%) are more likely to agree than Conversative voters (50%).

"And while the NHS’s founding principles command majority support across the party-political spectrum, the findings reveal that people intending to vote Labour are more than twice as likely to say the NHS makes them most proud to be British (71%) than Conservative voters (31%).

"People intending to vote Conservative are also more likely to expect user charges for some services (66% vs 51% of Labour voters). Those planning to vote Labour are more likely to expect to pay for most/all services that are now free at point of use.

"There was also a political difference in the ideas on what was causing the strain on the NHS, with Conservative voters more likely to single out NHS management (43%) and inefficiency (32%), whereas Labour voters tend to point to lack of funding (58%) and government policy (52%).

"The majority (80%) continue to think that the NHS needs an increase in funding, compared to just 17% who think that the NHS should operate within its current budget. While the public generally favours paying for this through tax rises rather than increasing borrowing or cutting spending elsewhere, people remain divided on what specific taxes they prefer. The most popular options are an additional tax earmarked specifically for the NHS (31%), an increase in National Insurance (22%), and an increase in income tax (21%)".

Barclay talks about talks about moving on pay, but doesn't

Speaking to The Times, Barclay said that in the context of consultants he was “very keen to have further discussions with them ... Around 35 per cent of consultants voted to strike so that’s a significant number, albeit a minority.

"I think there are areas where there is scope for further discussion. If you look, for example, at the way that consultant contracts operate at the moment it takes about 19 years to progress all the way through. It tends to be about time served rather than qualifications and that often has a gender impact.”

Barclay said ministers had already agreed to consultant requests for pension reform. “The government got criticism for making those changes. Many people, if you look at polling, are critical of the fact some of the most well-paid public sector workers were getting a change in pensions but we felt, for the recovery from the pandemic, for the support in terms of retention within the NHS, this was an important change.”

The Banker told The Times that his door was open for talks, but they could not happen while strike dates were scheduled.

So that is The Banker talking about moving on pay (which many of the national media supinely reported as a fact) ... without actually moving on pay. British media went to shit first: British politics followed.

In Scotland, meanwhile ...


The Social Market Foundation and Chartered Management Institute got this sensible piece about the importance of NHS management into The Times.

Obviously, the same week saw The Moron's Gazette, AKA The Boris Johnson Fanzine, manager-bashing as if it were going out of fashion. Which it will.


Bloomberg constituency-by-constituency analysis of what targets the NHS is missing.

Nice Public Finance obituary for Bob Kerslake.

The Observer discovers the Disclosure UK database.

The Guardian writes up the blistering PAC report on UKHSA
Some £3.3bn of NHS Test and Trace stock transferred to UKHS
A cannot be properly accounted for.

Extracts from David Haslam's book 'Side Effects' can be found here.

Dr Margaret McCartney's FT piece on what's gone wrong with general practice is an essential read.

The new Tony Blair Institute paper by Paul Blakeley and Axel Heitmueller is an interesting and thought-provoking read.

Useful New Statesman piece on the problems with cancer care.

Remarkably sensible Times Health Commission piece.

FT piece on the NHS extending a subscription model for new antibiotics.

Share price news for Illumina.

Metropolitan-Midland-and-Liverpool's-WCH-delaying failed outsourcer Carillion's  finance director has been banned.