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Cowper’s Cut 280: “There will be no more talks on pay”. Oh yes there will!

Cowper’s Cut 280: “There will be no more talks on pay”. Oh yes there will!

Pantomime Season has come unseasonably early in 2023.

"There will be no more talks on pay!"

"Oh yes there will!"

"Oh no there won't!"

"Oh yes there will!"

Etc, etc.

So, how has PM Rishi 'The Brand' Sunak's tough stance on "no more talks about pay" been going down, out in The Real World?


As swimmingly as you'd expect. BMA consultants announced two more days of strikes on 25 and 26 August, on top of those the two days that closed out this week.

NHS backlogs? The strikes are to blame? Of course!

Sometimes, so barefaced is a bit of political lying that you almost want to applaud.

Such a time came with the first answer given at this week's PMQs by 'The Brand', in his blatant falsehood that "the reason that NHS waiting lists are higher today than they were then, after actually being stable for the first few months as we put in place new initiatives, is very simple: because the NHS has been disrupted by industrial action. We have put very clear plans in place to bring down waiting lists in urgent and emergency care, primary care, ambulances, out-patient and elective. Those plans were working and will continue to work".

This is quite remarkable: it is so completely untrue. It's not even truth-adjacent.

The RTT backlog has risen every month but one in 2023. The average monthly rise since the backlog was 4.4 million in January 2020 (pre-pandemic) has been 100,000. NHS productivity remains below pre-pandemic levels. And there is no credible backlog plan.

Secretary Of State For Worrying About Being Dropped In The Reshuffle Steve 'The Banker' Barclay marked the start of the consultants' industrial action with this bid for public approval for yet another NHS near-shutdown over the pay dispute, echoing the PM's charming claim that "this pay award is final".

Ahhh. Bless!

Labour's Wes Streeting was prompt with a pithy response:

This Dorset consultant's letter to the PM and SOS is both literally and metaphorically striking, as is this blog from consultant oncologist Lucy Gossage.

The Government did realise that, in picking an industrial dispute over pay with the consultants, it was taking on one of the most senior, articulate and well-educated (as well as internationally-in-demand) professional groups in society?

Didn't they?

Consultant numbers

The Sunday Times' Shaun Lintern filleted the data to come up with this striking table on the number of consultants leaving/joining the NHS in England since March 2010.

It's quite telling.

Ipsos Issues Index

The latest data from the long-running Ipsos Issues Index saw public concern about the NHS rise to second place.

It came second only behind inflation: "concern about the health service has risen six points since June. Mentioned by a third of Britons overall (33%), the NHS is now the second-biggest issue for the country, slightly ahead of the proportion who see the economy as a big worry (30%)".

And the politics of the Conservative And Unionist Party's big by-election losses but 475-vote holding Uxbridge. Professor John Curtice's analysis in The Times and Ipsos' Keiran Pedley's video review are the key analyses.

NAO's New (If Fictional) Hospitals Programme review

The National Audit Office does not mess about in its new report on the New (If Fictional) Hospitals Programme, stating that “By the definition the government used in 2020, it will not now deliver 40 new hospitals by 2030.”

Who could possibly have predicted that the Conservative And Unionist Party’s 2019 manifesto promise was nonsense?

Oh yes, me. I did.

This NAO report warns that cost-cutting and inaccurate modelling of future demand could mean that whatever number of 'new hospitals' end up being built are too small. It also says that staff shortages mean a planned design for a standardised hospital '2.0' have been delayed until May 2024.

The NAO conclude that the Government had failed to achieve good value for money, and calls for a review of the underlying assumptions behind the plans to make sure the 'new hospitals' will be fit for purpose.

NHS England wrangles

I wrote last week about the dysfunction of NHS England: a subject that leapt into the open with this week's leak to Health Service Journal about internal and indeed external battles over urgent and emergency care recovery.

NHSE last week told systems "to ‘self assess’ their compliance against key asks in the UEC recovery plan, and asked to nominate urgent care “recovery champions” to “create a community, close to the front line, who can help drive improvement” in emergency care", HSJ reports.

This is part of a new “universal offer” of support being drawn up by NHS England under its scheme for urgent care recovery, in which ICBs are also being placed in “tiers” of intervention. This marks the debut of NHSE’s new service improvement banner, called NHS Impact (improving patient care together): a joint project involving NHSE’s “integrated urgent and emergency care” teams, and the “elective and emergency care improvement support team” (ECIST).

Do we have any evidence that this approach is likely to be effective in a highly-stressed system? The existence of two distinct bodies (NHSE’s “integrated urgent and emergency care” and ECIST) is, um, not very integrated. Is that the sound of Professor Tim Briggs laughing we hear?

System leadership issues burst further out into the open with the publication of the NHS Providers survey on its members' views of system leadership, 'Improving Regulation For The Future'. It had a 50% response rate, which in a system under the current pressure, is quite good.

Both NHS England and the Care Quality Commission got both barrels. Only around a third of respondents agreed that regulators took operational pressures into account. The majority said that regulatory burden (52%) and ad hoc requests (59%) had increased.

Respondents also reported cultural and behavioural challenges in their interactions with NHS England as a regulator. 77% perceived the NHS oversight framework as a performance management tool, as opposed to an improvement tool (31%).

NHS Providers CE, the thoroughly able Julian Hartley, wrote in HSJ, “trust leaders tend to view NHSE’s regulatory framework as being primarily about performance management, rather than supporting them to improve, and continue to report issues with the culture and behaviours modelled by NHSE colleagues.”


An unauthorised Digital overspend? Surely not!

NHSE again hit the news in a bad way, with HSJ's Henry Anderson's close reading of its mergee NHS Digital's accounts revealing that there were almost 140 irregular and unapproved payments to external consultants. He writes that "NHS Digital spent more than £7 million on consultants and external contractors without ministerial authorisation, with the organisation’s leadership acknowledging the payments were ‘irregular’."

This is a striking failure of governance. Nor is it, Henry notes, "the first time the arm’s length body broke rules around payments for external contractors. NHSD has already been sanctioned by the Treasury for breaching payment rules for three contractors, including one who was also the part owner of a firm that received at least £3m from the agency.

"The report in the accounts, signed by NHSE chief executive Amanda Pritchard, said: “At the time it was our expectation that once the process for approvals was agreed with DHSC colleagues, the cases would be approved retrospectively.”

"The DHSC subsequently indicated that it would not be approving the contracts, meaning £7.4 million in expenditure across 137 cases was classed as “irregular”."

What was the source of Ms Pritchard's "expectation", one wonders?

Is this Team Banker reneging on a predecessor's 'gentleman's agreement', to amass ballast for a potential defenestration of the NHSE boss, taking with her the blame for what is absolutely nailed-on to be the hideous upcoming winter crisis?

If so, then were I Ms Pritchard, I'd be leaking that promptly.

OBR warns on NHS Workforce Plan increased costs

Henry's had a lively week, with this clear summary of the Office for Budget Responsibility's warning that the 'I Contain Multitudes' Workforce Plan will undoubtedly force the Government into NHS budget increases above the planned 3%. That is, unless there are major productivity gains; wages are held down; or imaginary savings are found elsewhere.

So rises above 3% it's going to be. Unless they completely fail to hit the ICM Plan's targets, that is.

Fiscal risks and sustainability – July 2023 - Office for Budget Responsibility
The latest update of our assessment of fiscal risks and sustainability was published in our Fiscal risks and sustainability report. Read the Executive summary for the key points from our analysis or the full report below. Chapter 2 explores the drivers of, and prospects for, one of the most worrying…

The OBR's work is always thorough, and its chapter on health risks is particularly salient.

At PMQs on Wednesday, the PM replied to Sir Keir Starmer's attack that the 'I Contain Multitudes' NHS Workforce Plan was “uncosted spending coming from more tax rises; more cuts”, by asserting that the ICM plan was “fully funded”.


'A Covenant For Health' report

Prevention is the new rock and roll, or something. I dunno: maybe the new free-form jazz.

Whatever: the 'A Covenant For Health' report was published this week, with laudable ambitions to address the UK's appalling state of the health of the population. The names associated are impressive: the cause is good.

As ever, the question is about what the means are to make its ambitions actually happen in The Real World. If writing worthy reports about the UK's poor national health were enough, then we'd be world-class in health. It isn't, so we're not.  

Economic consequences to watch

The Financial Times has this worrying report on care home closures because rising interest rates have made remortgaging the properties unviable. Given the high level of care home fees, this seems remarkable. And the idea that care home mortgage borrowing was done on short, rolling-over bases is slightly horrific.

It may be that the financial 'innovation' of the residential and nursing care sector will have to fall into regulatory scope, given the serious externalities that this is likely to impose.

Blair Force One

I did this last week, but the triple General Election winner ex-PM is on about the private sector on health again.

So, does the private sector do it better?

Specifically, does private equity?

This BMJ article, 'Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: a systematic review', concludes that "trends in private equity ownership rapidly increased across almost all healthcare settings studied. Such ownership is often associated with harmful impacts on costs to patients or payers and mixed to harmful impacts on quality.

"Owing to risk of bias and frequent geographic focus on the US, conclusions might not be generalizable internationally".

Cronyvirus and coronamillions update: PPE Medpro

The House of Commons Public Accounts Committee published its interim work on the PPE  Medpro contract award. The two related sub judice investigations and legal cases mean that this is inevitably incomplete.

It reminds up that "PPE Medpro was one of the private companies awarded valuable contracts having been referred through this High Priority Lane by Baroness Michelle Mone. PPE Medpro was set up on 12 May 2020. It was awarded its first contract, worth £81 million, a month later on 12 June to supply 210 million face masks. The Department awarded a second contract a couple of weeks later on 26 June, worth £122 million for sterile surgical gowns.

"In January 2022, the House of Lords Commissioners for Standards announced that Baroness Mone was subject to an inquiry relating to her alleged involvement in procuring contracts for PPE Medpro leading to potential breaches of the House of Lords Code of Conduct. That investigation is currently on hold while related matters are the subject of criminal investigation by the National Crime Agency. It was announced that Baroness Mone would be taking a leave of absence from the House of Lords on 6 December 2022."

The PAC report concludes that "the recurring themes from the Department’s approach to procurement over recent years have been inadequate financial controls, governance, documentation, and transparency, and poor management of due diligence and conflict of interests".


EveryGrifter update

Offered without comment.

Lib Dem analysis shared with The Times finds that over 1.3 million people waited four weeks for a GP appointment in May (versus 912,000 in May 2022).

Steve Black's latest HSJ Mythbuster column is a lovely summary.

Shaun Lintern reveals that Spire Healthcare has to significantly expand its victims' compensation fund for disgraced, imprisoned former 'cleavage-saving' breast surgeon Ian Paterson.

Times report on Britain's biggest pharma companies urging the Government to rejoin the EU's Horizon programme.

Observer piece on the well-known practice of pharma 'astroturfing'.