Cowper’s Cut 416: Greige Expectations and Stuck Record Syndrome
The past couple of months of more or less uninterrupted rain and lack of sun has amounted to greige weather. I assumed that the word ‘greige’ was just a neologism from ‘grey’ and ‘beige’ (which indeed it is), but this 2013 letter to the Times Literary Supplement states that “in English, ‘greige’ is the rag-trade term for unbleached and unfinished cloth … MerriamWebster dates it to 1926. We're told it was borrowed, via French, from the Italian greggio, meaning "untreated, raw" and applicable to silk”.
Bear with me: there is a point coming here.
I’ve been trying to work out why the general atmosphere around the NHS in England is as poor as it currently is (and has been for quite some time now). Clearly, the past couple of years’ worth of these columns outlined my hypothesis that Labour came into office with absolutely no coherent and deliverable plan for NHS recovery and reform.
Greige Expectations
I would say that given the current state of the RTT backlog and broader performance problems, and the glacial rate of progress, this reading has been proven accurate. This absence of coherent and deliverable plans has led us to the current state of greige expectations.
There is not a widespread belief among members of The Paying Attention Community that ‘Things Can Only Get Better’. Which is obviously a major problem in itself.
It is also a huge failure of leadership. I have for some time now had no hopes of seeing any political leadership. Health But Social Care Secretary Wes Streeting had always outsourced thinking about NHS reform wholesale to Alan Milburn, who was last genuinely au fait with the NHS’s real problems when he was Health Secretary, from 2000 to 2003.
That is a generation ago. Today’s problems are not the same.
In the wake of Mandygate, whatever there may be of Young Master Wesley’s attention to detail will be focused relentlessly on how he can get his Labour leadership / Prime Ministerial ambitions back on track.
This will not, for the avoidance of doubt, involve Young Master Wesley and his team displaying a hitherto-unseen forensic attention to what is or isn’t working in attempts at English NHS reform; nor fresh attention being paid to what has worked in the past. It will involve doubling-down on briefing friendly journalists. To borrow a timeless line from Russell Hoban’s classic ‘The Mouse And His Child’, “one does what one is wound to do”.
Interim Jim
Taking national leadership over from Amanda Pritchard’s tenure was doomed to be a particularly ugly hospital pass.
Crispin Dowler
Yet it is as telling as it is worrying that once again, Sir James Mackey has stressed repeatedly and publicly that he has no interest in doing the substantive post.
Zoe Tidman
Interim Jim proved himself a highly capable leader at Northumbria: their hospitals’ A&E reworking, rebadged as a ‘New Care Models’ PACS, was an extremely astute concept that was also well-delivered; likewise their PFI buyout. He has hired or retained mostly capable people at the national level.
And his understanding that financial balance is vital is correct. But it is also incomplete: organisations have, on the whole, not missed financial balance because they are incompetent or lazy. They have missed financial balance because there has been a long tradition of national and political leadership incentivising NHS financial lying, and complaint, clean-nosed organisations could quietly be bailed out.
Core management competencies have been devalued in the English NHS, from queueing theory over waiting lists to financial run rate information being cascaded down to operational levels in coherent and comprehensible formats.
Stuck Record Syndrome
This makes it unsurprising that we keep seeing Stuck Record Syndrome in terms of how national leadership broadcasts its messages.
A prime recent example was the national guidance that orthopaedic cement shortages must not impede improved elective performance, as HSJ reported.
James Illman
The elective sprint fund for the final month of 2025-6 is going to be £130 million, we also learned this week. That is better than nothing, and it should help slightly at the margins. But it is far from game-changing. It is a bit of economic and political theatre.
This kind of overclaiming also feeds into Stuck Record Syndrome, as did the leadership overclaims about the achievements of the ‘crack teams’.
Zoe Tidman
And the news that seven ICSs now forecast a worsening total overspend of £400 million, together with 15 providers reporting financial deterioration against plan, also plays in to SRS. NHS England’s chief financial officer Elizabeth O’Mahony told the board meeting that the English NHS was “broadly balanced”, thanks to underspends in national budgets and non-delegated specialised commissioning. Well, we’ll see.
In the meantime, the scandal of maternity services quality and safety sits in very public view. This Financial Times report by Laura Hughes offers some serious analysis, but maternity services have been harming and killing people in excessive amounts for years without concerted and effective national action to systematically improve quality through personalisation and clinical standardisation.
The FT article rightly cites Professor Mary Dixon-Woods, director of The Healthcare Improvement Studies Institute, saying “one issue is that there are simply too many recommendations, creating the problem we call ‘priority thickets’ — action is paralysed by lack of clarity on the most important things to be addressed”.
People’s expectations of safe maternity care are probably quite a lot worse than greige. Losing public trust in the NHS will quickly make it unsustainable.
And then there is the capital drought, deeply exacerbated by raids in the incentivised financial lying years: just look at this BBC News report about St Mary’s in Paddington, part of Imperial.
I wish I had a clear line or magic bullet to wrap up all of this. But I don’t believe that there is one.
None of the NHS’s major management, quality and safety problems are at all impossible to solve, but it does not look to me or to anybody I know as if anybody is really currently trying to solve them.
I am shitlessly bored of sounding like a stuck record about all this. And yet it remains important to describe reality as it is, rather than as we would like it to be.
Recommended and required reading
BMJ data briefing on the collapse of unpaid staff overtime in the NHS. This is a thoroughly good thing: no proper service can routinely expect and try to run on staff goodwill in the way that the NHS has for so long.
Fascinating Financial Times piece looking at an innovation of getting mental health patients to do stand-up comedy. Is laughter really the best medicine?
Yet another first-rate ‘Mythbuster’ for HSJ by Steve Black.
The Boris Johnson Fanzine exposes a concerning business model whereby the Liaison Group gets 1/3 of the money saved if their reviews remove people’s NHS Continuing Healthcare payments.
The FT on the Boots reboot.
The mother of one of the 2023 Nottingham mental health murder victims, an NHS communications manger, speaks to The Guardian about her expectation for what the inquiry will reveal.
Are we really overdiagnosing mental illness? The academic psychologist author of this Guardian piece has no idea, thus rendering it slightly pointless.
Interesting Sunday Times piece from Robert Colvile, one of the right-of-centre political commentators who actually knows a bit about the NHS.