Cowper’s Cut 419: You mean people don’t like having their jobs abolished incompetently and without any real plan?
It doesn’t seem remarkable that the Health Foundation’s newly-released interviews with integrated care system leaders found a cohort of very unhappy people. The report observes that “changes introduced by the Labour government involve shifting ICSs back to being more traditional NHS commissioning bodies. A mix of other proposals in the government’s 10-Year Health Plan also signal a broader return to more market-style approaches to managing the health service, diminishing the focus on ‘systems’ as the organising principle for the NHS in England.”
Well, maybe. It’s not wholly obvious in the current Operating Framework or in the loose proposed incentives for ‘new Foundation Trusts’ that there is anything that meaningfully amounts to a return to more market-style approaches: particularly in the area of incentives and surpluses.
Show me how your financial flows will work and I’ll tell you what your values are. Oh: you’re not going to say how your financial flows will work?
Health Service Journal gave it a good write-up, with the word “shitshow” prominent.
It’s not the wrong word. While the HF report’s subtitle discusses “the evolving role of ICSs and policy changes needed”, it can’t really articulate either because of the absolute vacuum of clarity at national level on whether integrating care remains a priority.
The report does mention this, albeit in slightly punch-pulling terms: “Labour’s reforms to the health service are still under construction and legislation is expected on the NHS in 2026 to help deliver the 10-Year Health Plan.
“To avoid the fate of previous reforms to NHS commissioning, policymakers will need to actively construct the ‘strategic commissioners’ that it wants ICBs to become – developing skills and capabilities within local systems and backing them up with broader changes in policy to make a reality of ambitions to shift resources out of hospital …
“Better planning and communication of the government’s reforms are now needed to avoid further disruption and distraction at a local level”.
You could argue that integration’s role expanded from the Five Year Forward View onwards. As NHS England boss Simon Stevens said in our 2015 interview, "our future lies in networks and health systems, not individual go-it-alone institutions ... a circle has to be squared here, between ensuring proper organisational autonomy and accountability; while also ensuring that the broader NHS acts more as a system. We need to be more than the sum of our parts.
"As I say, our future lies in networks and health systems; not individual go-it-alone institutions. On too many procurement and workforce issues it has felt the opposite of that. That’s going to change."
Clearly, the NHS has long balanced a tension between the forces that tried to balance and control local systems (take your pick by age and preference from regional health authorities, strategic health authorities, regional NHS England presences) and those of national and usually ministerial direction.
In 2026, the balance has clearly swung massively back towards the vesting of all power in the Secretary Of State For Health But Social Care.
This may not be a good thing, with Team Milburn-Streeting in charge.
I feel I have been writing too much about Young Master Wesley Streeting: a 2000s man in a 1990s suit. His scepticism about NHS managers, discussed with HSJ editor Alastair McLellan before the 2024 general election but only revealed a couple of weeks ago, might make this a good time to revisit this 2015 HSJ piece debunking myths about NHS managers.
But that would involve thinking about what is actually the problem.
James Illman
And Team Milburn-Streeting are, as HSJ reported, about to declare victory on the 65% 18-week target thanks to the elective sprint. And as I pointed it last week, elective sprints have a bit of a habit of not actually fixing problems, as the 2015 iteration showed us.
The very long waiters will, as those who talked to HSJ on and off the record all noted, carry on waiting.
Rob Findlay
The latest monthly RTT data found a small improvement in the 18-week achievements, but as the essential Rob Findlay analysis in HSJ confirms, it is not near to the order of magnitude of improvement required to deliver Labour’s manifesto promise by 2029.
Still, I’m sure there will be another elective and/or validation sprint along shortly.
Muscle memory matters
The issue of patient flow through hospitals got an airing this week via the Commons Health Select Committee hearing on corridor care, the key lines of which HSJ wrote up here. Evidence from Health Minister Karin Smyth and from NHS England executives suggested, in Smyth’s words, that hospitals fail at “recognising what should be pretty basic and is known but doesn’t happen now”.
This has been triggered, Smyth suggests by “muscle memory loss about how to do things right”, with Covid and senior staff exits as factors contributing to the problem. What would make this argument persuasive would be some research from hospitals who have got on top of the problem.
But we didn’t hear about that. The English NHS’s lack of curiosity about the drivers of performance - good, bad or indifferent - remains a remarkable thing.
Even more remarkable is its lack of any serious improvement capacity. Such a high priority is NHS Impact (the attempt to do an NHS Modernisation Agency without any proper resources or organisation) that its board page lists at least two people who no longer work in the NHS.
NHS Impact’s output remains stuck at these four undetailed and rather underwhelming case studies that I wrote about at least a year ago. Perhaps its name is ironic.
Unhappy staff: unhappy patients
The latest edition of the national NHS Staff Survey scarcely makes for happier reading. This is one of the key documents that lets organisational leadership teams know how they are doing. In terms of attempting to manage the English NHS as a system, it is also very under-used.
The most useful and un-masking question in the survey has always been ‘would I want a friend or family member to be treated by my organisation’. This question has, regrettably, been tweaked as the survey has, erm, evolved - but in its current iteration as “if a friend or relative needed treatment, they would be happy with the standard of care provided by the organisation”, 62.84% answered in the affirmative (2024: 64.26%; 2023: 64.94%; 2022: 62.88%; 2021: 67.72%).
The advocacy results (respondents’ answers whether patient care is their organisation’s top priority, and if they would recommend it as a place to receive care or to work at) fell below its 2021 peak (which may have reflected a now rarely-remembered positivity about the NHS’s response to the pandemic).
Pertinently, 71.8 per cent said patient care was their organisation’s top priority: a notable fall from the 74.4 per cent last year. Overall staff engagement score (answers to the survey questions about motivation, involvement, and advocacy) is the lowest since the earliest available result in 2018.
NHS England’s own staff survey also makes for a salutary read. You feel quietly confident that those temporarily in charge of it won’t care.
Recommended and required reading
A NHS England report leaked to HSJ (clearly by disgruntled NHSE staff) states that NHSE was ‘repeatedly blocked’ from extracting savings from IT suppliers and from setting up national support with installing different patient record systems. It suggests that millions of pounds might have been saved if EPR market had been better managed. This is funny, because at a Cambridge Health Network event last summer when I asked Ming Tang about the collapse of performance when EPRs are installed, she claimed that this just didn’t happen. This is an actually important story about NHSE’s lack of, well, everything: it deserves wider pick-up.
New report from Cancer Research UK outlines increasing survival.
The Global Health Workforce Programme (GHWP) health project in Africa, which UK ministers said would play a vital role in protecting Britain from future pandemic threats, is being axed due to aid cuts, The Guardian revealed.
The Times picks up on a Royal College of Surgeons paper about private sector surgery as boys’ club.
The Guardian on a new report outlining the ’worryingly thin’ pipeline of new drugs to fight superbugs.
Also The Guardian: health records from UK BioBank project exposed online.
A non-insane piece about the rising tide of anxiety referrals for therapy (and the NHS campaign for yet more) in the Boris Johnson Fanzine.
Interesting and thoughtful LinkedIn piece by IPPR head of health policy Sebastian Rees on changing the health system’s funding model to the Dutch one. (Tl,dr - don’t: it’s not the issue.)
Sam Freedman’s piece on the rise of tech monopolies and the future of the nation state. Also worth reading: his answer about the threat from Palantir’s UK government contracts, including the Federated Data Platform.
In the context of which, David Allan Green’s piece on six concerns about public procurement is also excellent.