Cowper’s Cut 397: Indirections
“And thus do we of wisdom and of reach,
With windlasses and with assays of bias,
By indirections find directions out.”
Hamlet, Act 2 Scene 1
Secretary Of State For Health But Social Care Wes Streeting is not Prince Hamlet, nor was meant to be.
Mr Streeting wants to be thought of as a young man in a hurry. Bless him.
In reality, he is thought of as an Alan Milburn tribute act in a world that is, in the recent, public words of his department’s second permanent secretary, “not 2001 any more”.
Indeed it isn’t 2001 any more.
In June 2024, just before the General Election, I wrote in this column that “the NHS has not been the subject of serious debate or discussion over the past six weeks. We know very little (other than headlines and vibes) about Labour’s detailed plans for NHS reform. This is probably because they don’t have any, but if they do, they have been subjected to zero public scrutiny or consideration”.
Indeed, Labour did not, and still do not, have any detailed plans for NHS reform.
As such, the mess that the incoming administration made of current English health policy and politics has not been a surprise - although naturally it has been a disappointment.
As I noted in last week’s column, Labour do not have a theory of change, giving us “the prevailing sense that national policy is being idiosyncratically made up as Team Streeting goes along. Or put another way, that the NHS Ten-Year Plan is a means of buying time for Wes Streeting’s Imaginary NHS Friend to come along and do all the hard stuff to just make everything happen”.
Schrödinger’s NHS England
We have Schrödinger’s NHS England, which exists in a quantum super-position of simultaneously being imminently abolished and directing everyone and everything to drive a return to financial balance.
Quantum mechanics is exciting stuff, and perhaps one could construct an argument that this attempt at quantum NHS management is also exciting.
It is, however, not exciting in a good way.
Labour manifestly does not know what it is doing on health policy and politics.
Its leaders cannot, as I have been describing in these columns, articulate what kind of a system they want the English NHS to be. They are putting back in place such cosplay costumes as league tables which indicate the second or third coming of yet another NHS internal market for which there is neither the essential funding abundance, nor any sign of preserving, translating or creating an effective commissioning function.
Labour has just one solid thing, which is its manifesto commitment to return RTT to 18 weeks by the next General Election in 2029 (and the latest data shows a second consecutive month’s rise in the RTT backlog, as well as a 4% rise on urgent and emergency care demand, as compared to September 2024).
So that one thing is not going well.
Other than that, there is the waftiness of the ‘triple shift’, which is simply an ambition. There is no mechanism to deliver it.
Alastair McLellan
Health Service Journal editor Alastair McLellan’s editorial this week again points to the absurdity of the abolition/redundancy non-process for NHS management. Online comments often add very little, but the tsunami of endorsing comments below this piece are as lacerating as they are telling.
This will drive further embattled and defensive behaviour in Team Streeting towards NHS managers and management, just as any criticism of Alan ‘Bouncer’ Milburn did back in his distant era. Milburn was a very determined but limited Health Secretary, whose personal style contributed significantly to entrenching the bullying culture in the world of NHS management. Any rosy view of the Milburn era is largely due to the advent of very significant extra real-terms cash, year-on-year. Bouncer has, in Talleyrand’s reported phrase, “learned nothing and forgotten nothing”.
Milburn and Streeting have failed to learn a very obvious lesson: if you are going to make enemies or sell people out in your politics, then before you do so, make sure that they cannot harm your prospects.
If you’re going to rip up the management infrastructure of the NHS (something that there was actually a valid case to do), then you first need to know a) how you will abolish it, and b) what you will replace it with that will function better.
Team Milburn-Streeting evidently have no answers on either front.
There are fundamental questions which they do not seem to have asked themselves, let alone reached solid and durable conclusions.
What do Team Milburn-Streeting want the return of quasi-market mechanisms to do for them? How do they want it to rub up against the imperatives for much greater system working and co-operation that are the only conceivable effective operating system for a more preventative, more neighbourhood, more digital and above all, a more Ringo health and care system?
They do not know.
It is possible that they care, but it is not evident.
In the context of the uncertainty over the future of the national and regional management institutionsfrastrucvture, we are instead seeing relentless turnover of staff (much as we did in the authorial team of the NHS Ten-Year Ambition Masquerading As A Plan).
I am assured that this week’s news of the departure of Sir John Oldham as Mr Streeting’s key advisor on the Neighbourhood Health Service stuff is not freighted with meaning.
That may be so - but given that neighbourhood-ing and digital-ing are such huge parts of the Labour [coughs] ‘plan’ for the NHS, it sure looks curious.
Dave West
Almost as curious as Mr Streeting’s hiring a delivery advisor (as a direct ministerial, political appointment), Matt Hood, with no health experience, with HSJ being told that ministers wanted “someone without health experience, so they would look at the challenges with a fresh pair of eyes and not be swayed by orthodox thinking among NHS managers”.
Or as the appointment of Jules Hunt as DHSC tech, digital and data lead, coming from (Alan Milburn-linked) management consultancy PWC. Mr Hunt’s thoughts about digital and tech transformation can be read in this New Statesman advertorial.
Perhaps Messrs Hood and Hunt will both prove very effective at marshalling durable and evident improvement. Let’s hope so: it is sorely needed, and any sense of the ministerial team being meaningfully in charge is hard to come by.
Oh, the irony
Joe Talora
Blanket defensiveness is becoming almost a status symbol among national leaders: NHSE’s interim chief digital officer Ming Tang publicly embarrassed herself in her keynote at The HETT Show by asserting without evidence that the overspending implementation of the Palantir Federated Data Platform is being held up not due to the widely-noticed failures to plan … but rather by local leaders’ egos about their own tech.
Mmmmmmmmmmmm.
(My regular COI dec here: I used to do paid consultancy for Palantir’s Health Advisory Panel, prior to their FDP contract win.)
She asserted, “the biggest challenge to the adoption of technology in the NHS I’ve seen over 15 years is egos”. The news report in HSJ adds that “in her role leading the roll-out of the national Federated Data Platform programme, Ms Tang observed that she had come up against considerable resistance from some areas which already have mature data platforms in place. (All ICBs and most trusts have now agreed to use the FDP at some point, though it remains unclear to what extent some of those resistant to the platform will use the system.
“Commenting that too many people involved in NHS technology “love their thing”, Ms Tang added that when faced with what she considered a sub-optimal solution she was “quite comfortable” with telling its supporters “you’ve got a really ugly baby”.”
Ahem. Once again, the informed-seeming comments below this article are lacerating, and this is nothing compared to the feedback I hear privately about how the FDP rollout is going. Tl,dr: not well, and overspent.
I’ve said this before, and I’ll say it again: the Health Advisory Panel on which I sat told Palantir in the clearest terms possible that they’d have to put more effort into the rollout and implementation of the FDP than they had into winning the contract. Palantir were amply and repeatedly warned about the NHS’s potential for Gandhi-esque passive resistance, where the case for technological change is weakly made, or merely asserted.
You can tell people things, but you can’t make them listen.
More to the point, Ming Tang appears remarkably reluctant to consider how well she performed in her role as the NHSE chief information officer during the FDP contract negotiations and award, before liberally and publicly spraying around the blame for the fact that the FDP rollout is going sub-optimally.
It is also worth knowing that NHS England’s lawyers did not recommend that the Palantir contract for the FDP should be signed.
The BMA embarrass themselves yet again
Happily, it’s not just been NHS England’s digital leadership embarrassing themselves this week.
Eleanor Hayward, Health Editor
In a remarkable exclusive, Eleanor Hayward of The Times reported on a leaked letter from senior BMA LMC leaders suggesting that GPs overwhelm A&Es with referrals in order to subvert Pharmacy First.
The piece reports, “the letter was written by Dr Becky Haines, a member of the BMA’s national GP committee. The co-author was Dr Paul Evans, a Gateshead GP who is a member of a radical BMA faction and sits on its UK council. It set out responses GPs could text to patients who have tried to book appointments online. One told patients to “attend your nearest emergency department/A&E immediately”.
“The letter … told GPs not to direct any patients to pharmacies, which offer support and prescriptions for urgent issues, such as urinary tract infections and shingles.”
One must have a heart of stone not to laugh at the BMA’s responses to getting caught out here: the letter’s authors claim that it was a draft issued in error, and the national leaders Tom Dolphin and Katie Bramall-Stainier claimed that “the letter had been sent by a local medical committee which was independent of the BMA”. Magnificently, pharmacy trade mag Chemist And Druggist parroted this BMA line hook, line and sinker.
Recommended and required reading
Politico report that the pharmaceutical industry’s campaign for a UK drug price increase, probably via higher NICE thresholds, is becoming A Thing. The Times seems to agree. Here’s the ABPI banging on about it in The Times, and AstraZeneca doing threats about it yet again. And here is the Nuffield Trust calmly making sense of the whole pharma pricing ‘conversation’.
Will UK taxpayers get their £122 million back from Everybody’s Favourite New Noble Baroness Michelle Mone -linked PPE Medpro? David Conn in The Guardian is not optimistic.
The Times reports on allegations that the NHS is ‘failing to protect Jewish patients from racist doctors’.
First, choose your sinking ship wisely: New Hospitals Programme boss leaving to lead finances on HS2, HSJ reports.
The Royal College of Nursing tells The Guardian that Labour’s plans to change visa rules for health staff would mean that “health and care services would cease to function without migrant nursing staff”.
The Financial Times on the medical quest to make young blood into a drug.