Cowper’s Cut 398: Only really bad ideas can save us now
My variations on the theme of Labour’s clue-deficit on health policy and politics are, alas, with us yet again this week.
Sorry, innit. I’ll stop writing about it as soon as it stops being true.
In last week’s column, I covered Health Service Journal editor Alastair McLellan’s salvo against Team Milburn-Streeting’s staggeringly casual attitude towards managers. Reflecting on the likely consequences, I wrote “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 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.”
Well.
Alastair McLellan
Blow me down if someone in Team Milburn-Streeting hasn’t given Alastair an unattributed briefing about what Team Milburn-Streeting are really trying to do.
And God bless them: it’s genuinely funny.
Although not intentionally.
This year’s model
This briefing individual, one presumes, must be the most senior member of Team Milburn-Streeting: so that rules out Wes.
And their proposal is that “there is a third ‘model’ central to the NHS which the government is just as determined to change but speaks a lot less about: the service’s ‘business model’. This government believes it should not prioritise increasing health spending”.
(The government’s other two NHS reform ‘models’ in question are the wholly wafty ‘triple shift’, and the not-happening-at-all-even-slightly “reversing the trend of centralisation and giving greater autonomy to local organisations”; so arguably this is just more public policy spitballing.)
The briefing also informs us that “this administration is convinced only it has the competence and public support to dash the “begging bowl” from the service’s hands and say, “no more”. Within this broad mission is a sincere belief that NHS finances have become inherently unsustainable as a result of an approach which has relied on continual bailouts, constant use of accounting ‘tricks’ and the stealing of funds intended to drive transformation to shore up the broken care model”.
Mmmmmmmm.
The line of causation being proposed here - that the tricks used to hide deficits (one or two of which are accurately named here) made NHS finances unsustainable - is nonsense. Here in The Reality-Based Community, the causation lies the other way around.
Financial lying has become a routine and unremarkable fact of life, as the NHS struggled its way through the decade of lowest funding growth in its history. Like a lot of other people, most notably the Nuffield Trust’s Sally Gainsbury, I’ve been writing about NHS financial lying for a lot of years now, such as here from 2019 or here from 2016.
So, how is this going to work?
Alastair reports on being briefed that the ‘business model’ the government wants the service to adopt “is one in which patients are enabled to take greater responsibility for their own care, and one where patient choice drives poor quality services to extinction …
“The vanguard of this push will be the NHS App, which has already become the most effective way to engage with 111 services. The App’s role as the service’s “front door” will be accelerated through integration with hospital electronic patient records and GP equivalents, and the expansion of proxy controls which will allow everyone from parents and careers to manage the care of the very young and the very old.
“But there are bigger and more controversial changes in development (personal budgets and “patient power payments”) … giving patients the ability to wield financial influence is seen as a key incentive to get them to accept more responsibility for their own care (and its costs).”
One must have a heart of stone not to laugh at this utter nonsense.
Do I really have to point out that the NHS’s biggest users - those with long-term conditions and the frail elderly - are not likely to suddenly become the aggressive, go-getting commissioners of their own care that the NHS has serially failed to be on their behalf for the past thirty years?
Yes, it seems that I do.
Sigh.
The clue about long-term conditions is in the name; and this [coughs] un-named briefer evidently has zero experience of seeing frail elderly people try to navigate the NHS of 2025.
It is a fact of the user demographic that, now as in the 2000s, the NHS’s biggest and most frequent users are its least assertive. Culturally, if this tactic of ‘weaponising patients’ were ever going to have worked, then it’d have been pre-global financial crisis - and only with a white-collar, educated and assertive subset of the population.
Proposing this approach, after the UK population has lived through the global financial crisis, austerity, Brexit and Covid, is remarkable. This is an heroically ill-judged time to expect fictitiously-assertive patients to run the NHS system better than those already in charge know how to. If you want a consumerist analogy, this is the equivalent to asking the woman or man on the street to become the specialist buyer for Tesco. (Other supermarkets are available.)
Oh yeah, it would also be worth this individual’s while getting off their arse and bothering to read the literature on patient choice.
And the NHS App will drive it all? That’s just splendid, as long as there’s no truth to the reports I’m hearing that the current overspend on the Federated Data Platform is being recuperated from the NHS App budget, which itself has already had cash from hospital IT budgets massaged into it, as HSJ’s Joe Talora reported back in September.
If the NHS App is going to be the Vanguard of all this, then I’m very relieved. Because nothing could conceivably go wrong.
Things get even better, when we read that “2025 Labour policymakers see the country’s leading pharmaceutical and technology companies as the key disrupters rather than private healthcare providers … Alan Milburn, the most influential voice in Labour health policy circles, sees them as valuable providers of healthcare within an expanded NHS ecosystem.
“The role of the Department of Health and Social Care will be to ‘make the market’ by setting standards, opening the system up to new entrants, increasing transparency so patients can choose well and, critically, ensuring that whatever money is available is rewarding services which boost patient control and responsibility.
“Central to this drive is removing the default starting point that even the frailest patients must be treated as “dependent” on the NHS and care – instead they, too, must become more autonomous”.
Where is the evidence that pharma and tech companies will be any good as providers?
And the evidence that DHBSC knows how to and can ‘make the market’ in these ways, when every single previous iteration of commissioning has utterly failed to come close to doing so?
Policy thinking as narcissism
This specious and unserious rubbish looks like nothing more than policy thinking as narcissism. ‘How would it suit me as a tech-literate, wealthy late middle-aged person to have the NHS redisorganised around my needs?’
Those responsible for this shit need to think about NHS patients as they really are, and not about themselves and what they’d prefer.
The assumptions behind this rely on fictitiously-assertive patients making NHS commissioning, choice and competition work for the first time ever. This is basically what I wrote about in this column two weeks ago: waiting for Wes Streeting’s Imaginary NHS Friend to turn up and fix everything.
This really is the health policy version of going, ‘and then A Miracle happens!’
Last week, I wrote that “Labour manifestly does not know what it is doing on health policy and politics”. What has been briefed here is at least, to be fair to them, some new ideas.
These are, however, dreadfully bad ideas.
And they will not work.
Only Wes Streeting can save us now
“I described Mr Streeting as an Alan Milburn tribute act: he has proven to be all that and less, with the flywheel narcissism of Johnny Mercer and the reforming resolve of Mr Stay-Puft The Marshmallow Man.
“Like much of this government, Mr Streeting has failed to evolve from the nature and operating system of opposition, which is essentially about saying things.
“Periodically shouting ‘REFORM OR DIE!’ at the NHS in England seems to be Mr Streeting’s idea of a good time, but it does not advance the cause of correctly identifying and then improving the many basics that remain badly deficient.
“Like, let’s say, providing proper urgent and emergency access during the third of the calendar year that is ‘Winter’. Or like maternity.
“Mr Streeting looks like a performer, not a reformer”.
Young Master Wesley has been at the ‘Tanks On Lawns’ Juice again, with a comical response to a Boris Johnson Fanzine editorial pointing out that, as NHS reformers go, he’s a performer.
OK, YMW didn’t write the ‘I Alone Can Fix This’ headline, but his piece is here.
First things first: a Secretary Of State For Health But Social Care such as Young Master Wesley who’s spending his time bothering to argue with BJF editorials (consistently the least well-informed in the national media by a huge distance) is a man who is failing to do his job properly, or indeed at all.
Young Master Wesley needs to realise that he has been in office for the past fifteen months. Arguing with the BJF about its ill-informed bullshit might conceivably have been a valid part of the role of the Shadow Health Secretary: doing it while in the substantive job just shows an embarrassingly crass sense of priorities.
And most of Young Master Wesley’s arguments are truly bad.
“GP patient satisfaction is rising for the first time in more than a decade”, but full-time equivalent GP numbers are still falling, even though the primary care team are doing more appointments: a situation which clearly cannot hold.
“Waiting lists are down 200,000 since the general election and are due to fall further”, but after some reductions via well-funded waiting lists validation, they have risen for the last three months in a row, all of which were summer months, when NHS waiting lists traditionally fall.
“League tables will drive competition, accountability, and improvement”: there is no compelling evidence for this, and the NHS last league table system was abolished in the wake of the Mid-Staffs Public Inquiry Report.
NHS in ‘retaining its experienced staff’ shock
Charlotte Gifford
I love the Boris Johnson Fanzine, and so do you. We’re all in this BJF love thing together. Which is nice. And just to keep us all shiny and happy, this week the BJF reported on the NHS retaining its experienced staff on purpose … and managed to make it a bad story about public sector terms and conditions.
No, me neither.
Recommended and required reading
The Times’ Eleanor Hayward reports on entryist splinter group Doctor’s Vote being voted out of key positions in British Medical Association committees.
Another well-argued piece by Sam Freedman on what is actually, operationally wrong with the English NHS.
The Financial Times on Novo Nordisk’s ‘lottery ticket’: can obesity drugs help treat Alzheimer’s?
The FT reports on Big Four management consultancy-cum-accountants EY being accused of misleading the sector watchdog over its NMC Health audit.