Cowper’s Cut 377: Narrative drift and fortune cookies
Almost everything
I write these columns on the presumed basis that we, as a society, want effective public policy to follow from our politics. It’s optimism of a sort, I guess.
If we indeed want effective public policy to follow from our politics, then we need to see narrative in the way the economist Professor Paul Krugman sees productivity: “productivity isn't everything, but, in the long run, it is almost everything. A country’s ability to improve its standard of living over time depends almost entirely on its ability to raise its output per worker”.
Narrative isn’t everything, but in the long run, it is almost everything.
Narrative is the ‘why’. It is meaning, and it is purpose.
A cogent and credible narrative is why the people working in and leading our public sector would feel motivated to do really difficult things, such as driving and sustaining improvement in a system that has not even slightly been set up to do improvement. (Crucially, I mean improvement: not change. You can hide in change, and a lot of people do.)
The current Government was elected in July 2024, with a huge majority. For the past ten months, there has been no narrative in English NHS health policy.
There have been other things, such as the blame attribution of the Darzi Review.
There has been the announcement that it was official Department For Health But Social Care policy that the NHS is “broken”: a thing which the British Social Attitudes health questions show that people had very much noticed.
Wes Streeting
There have been what feels like hundreds of Wes Streeting briefings, interviews and comment pieces for the Boris Johnson Fanzine, insistently shouting that the NHS must ‘reform or die’.
Taking the f out of The Triple Shift
Oh, and there has been much reiteration of Labour’s plan for The Triple Shift: from treatment to prevention; from hospital to community; and from George to Ringo.
That lot has amounted to political noisemaking, with a few lofty, wafty aspirations thrown in for good measure.
It has not in any way, shape or form amounted to a narrative.
Wes’ whim of the week is not a narrative. Indeed, recent weeks have offered us unsightly personnel churn among those supposed to be in charge of the NHS Ten-Year Plan; now rebranded as The 3:7 Forward View.
It is less easy to draw a veil over Mr Streeting’s end-January statement to Health Service Journal that he had no plans to abolish NHS England, and his pivot by mid-March to doing just that.
Why we are fucked
The absence of a narrative for the NHS in England is an increasingly big problem. It is irresponsible national leadership that there is no cogent, credible narrative about how things will improve.
Without that narrative, there is a general lack of trust. It’s high time to rediscover Baroness Oonora O’Neill’s 2002 Reith Lectures on that topic.
Some of this big, real problem is absolutely down to poor leadership from NHS England.
NHSE’s first and second chief executives David Nicholson and Simon Stevens each had their fair shares of admirers and detractors, but both men could and did tell effective stories about where the NHS in England was going.
Nicholson was a shrewd, tough political operator, and Stevens was a magus of political power and weathermaking. It is ironic that the fiscal aims of the £20 billion ‘Nicholson Challenge’ were largely delivered as stated (due to wage freezes, capital-to-revenue transfers and tariff cuts); but its objectives of service delivery transformation, much less so.
Meanwhile, Stevens’ Five-Year Forward View did not succeed in its stated objectives of transforming care delivery models. There was no “radical upgrade in prevention and public health”; patients did not “gain far greater control of their own care”; the NHS did not “take radical steps to break down barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care”.
(Where the Five-Year Forward View absolutely succeeded was in its unstated aim of subtly subverting the Lansley reforms. It also marshalled a consensus on the value of moving towards integrated care systems, which currently looks like coming comprehensively unstuck.)
In both of those eras, that wasn’t because people weren’t trying to achieve these service transformations: it’s because those changes are remarkably hard to make and to sustain. That’s a valuable lesson for The Triple Shift true believers, if they are into things like paying attention (which certainly isn’t yet evident).
It would be tempting to draw a veil over the leadership of Amanda Pritchard over the now-being-abolished NHS England during her time in charge, but it would be wrong. Mrs Pritchard’s decision in May 2022 to appoint Chris Hopson as NHSE’s national director of strategy was the point at which I realised that she was going to be bad at the job.
I was not wrong about that.
But there is also the question of national political leadership, or more accurately, the lack of it.
In this fascinating Economic Innovation Group interview, Professor Krugman cites comments by economist Robert Solow (famous for the Solow Residual) about Britain’s economically lagging behind post-World War II: “every attempt to explain this ends up in a blaze of amateur sociology”.
I don’t have the qualifications in amateur sociology to do more than observe that Health But Social Care Secretary Wes Streeting’s period as President of the National Union of Students has not been far from mind, as reports and anecdotes emerge about how local and regional NHS bodies are trying to respond to Mr Streeting’s reinvention as a highly non-Venetian DOGE.
There is a hearty whiff of Stockholm Syndrome in the air, and nowhere more so than in NHS England. Some of this is predictable career survivalism.
Tempers are fraying over ‘missing’ invitations to the ‘behind closed doors: invite-only’ sessions running during NHSConfedExpo. Some of this is seeing admin screw-ups attributed to being managed out, and some of this is the opposite of that. It isn’t making for a great atmosphere: nor are the hastily re-started ‘task-and-finish’ committees and groups.
These displacement activities are understandable, in a ‘Jesus is coming’ ‘Look busy!’ kind of way. But they aren’t helping the individuals in question, nor their systems.
Narrative needn’t be simple, by the way. And it absolutely shouldn’t be simpering. People are mostly smart enough to accept (if not love) some challenging stuff in a narrative, if they think the leaders driving it have 1. an actual, deliverable plan, and 2. good faith. It needs to rise well above the level of fortune cookie mottos.
Here’s hoping.
Living in foundation times
Jason Dorsett
I was motivated to think about the importance of narrative by this excellent short essay on LinkedIn by Oxford University Hospitals chief finance officer Jason Dorsett. Its title is ‘Why did Monitor fail?’ (Dorsett was on the staff of foundation trust authoriser and regulator Monitor 2006-11 and 2013-16), and it is an honest look at the regulator’s strengths and weaknesses.
The foundation trust movement provides a strong microcosmic proof of the need for effective narrative in health policy and politics. Foundation trust status was an innovative solution to a real problem of over-centralisation of power in the top level of the Department of Health. The FT assessment process in the early period had sufficient rigour, and intellectual underpinning.
But the FT system and its regulation relied on very high-quality local leadership; and on the market mechanisms that were possible in the 2000s era of 6% real-terms year-on-year NHS cash growth.
Dorsett is accurate on the fact that genuine innovation was rare and surplus-squirrelling was common: “a few brave leaders made visionary investments (think Northumbria under Jim Mackey and UCLH under Robert Naylor). Most did little with their hard-won independence.
“When austerity hit, there wasn’t much to show for 10 years of FT freedom.”
Pay day
The topic of staff pay is back with us.
Department of Health and Social Care
Cue delighted whooping by the medical trades unions?
Erm, no. The BMA are not happy, and resident doctors voted to vote on taking further industrial action. The RCN is likewise unhappy.
It is going to be fascinating to observe how this develops.
The Treasury looks like it’s being forced to U-turn on the winter fuel bribe, and perhaps even on the two-child cap on child benefit: they are likely to want to hold the line on public sector pay even harder.
Resident doctors’ leaders seem to remain convinced that they can achieve ‘full pay restoration’. Time, and the ballots, will show us which side’s interpretation of the sunk cost fallacy holds water.
Recommended and required reading
Sunday Times reports that doctors who trained in the UK will be given priority for speciality training jobs under the 3:7 Forward View.
FT piece on the complexity of NHS data systems.
The Times on a new fast diagnostic test for brain tumours.