Cowper’s Cut 420: Singing the Higgs Boson Blues with the Department Of Implausible Solutions
In English health policy and politics as in life, there are less important weeks. This one just past has been a less important week par excellence.
Maybe this is not surprising. We are badly stuck at present - in English health policy and politics, that is.
How could it be otherwise, when it is clear that the system’s national political leadership is going to claim a victory on 65% RTT 18 weeks that it has not yet achieved?
Zoe Tidman
This declaration of success seems likely to be particularly mauve, given that the latest NHS England performance league table found a record number of provider trusts in its bottom segment for performance. One must have a heart of stone not to laugh.
Local NHS leaders in England are being asked to navigate blind. There is no credible and effective plan for performance recovery, or indeed for improvement. Safety, quality and outcomes, you ask? So 2000s, darling!
Higgs Boson Blues
As credible visions of the English health and care system’s future go, there isn’t one. The omnibus of 2025’s Ten-Year Health Plan For England left its potential passengers behind as it trundled off into the NHS Long-Term Plan Graveyard. It really doesn’t enter into conversations any more.
For all their myriad imperfections and shortfalls, previous national strategy documents from (Delivering) The NHS Plan to Our Health, Our Care, Our Say to High-Quality Care For All to LansleyLand to the Five-Year Forward View to The NHS Long-Term Plan all had distinct periods where they were being taken roughly seriously across and beyond the system as a meaningful guide to what needed to be changed, done, started, stopped.
The same cannot be said of The Ten Year Health Plan For England: it is, in effect, the Higgs boson of English health policy. That is to say, it has “zero spin, even parity, no electric charge, and no colour charge. It is also very unstable, decaying into other particles almost immediately upon generation.”
The Department Of Implausible Solutions
Fans of the improbable will have enjoyed ‘Fit For The Future: Towards Population Health Delivery Models’: the new guidance published on Wednesday, in which NHS England announced that it “will expect integrated care boards (ICBs) to be able to set out how they will have begun implementing some outcome-based contracts within three years, with a view to integrated health organisation (IHO) contracts becoming the norm”.
ICBs have been given three years to begin implementing outcome-based contracts, including integrated health organisations.
OK, so what infallibly reliable delivery mechanism is going to drive these changes set out in ‘Fit For The Future: Towards Population Health Delivery Models’?
Ah, I see: commissioning.
Great.
That always works well. It’s not as if NHS commissioning organisations get redisorganised or abolished on a three-yearly basis or anything. So this is definitely bound to work.
Department of Health and Social Care
The only thing that could make the current reforms’ success even more certain would be if the Department For Health But Social Care set delivery targets for the new neighbourhood health schemes in its new Neighbourhood Health Framework (even though there is thus far no meaningful clarity about neighbourhood health funding models or range of potential organisational forms).
So hurrah for the news that these targets include:
- At least 25 per cent diversion rate from outpatient referrals through “single points of access” in at least 10 high‑volume specialties by March 2027;
- Reduce secondary care outpatient follow-up appointments by at least 10 per cent by March 2027;
- A 10 per cent reduction in acute outpatient appointments for under‑16s by March 2029;
- A new target date of March 2027 for GPs to see 90 per cent of clinically urgent patients the same day;
- A 10 per cent reduction in non‑elective admissions and bed days for people with mid to severe frailty, care home residents and housebound patients by March 2029;
- A 10 per cent increase in people identified as approaching end of life and a 10 per cent reduction in their non‑elective admissions and bed days by March 2029;
- At least a 10 per cent improvement in evidence‑based clinical outcomes for people with CVD, diabetes, COPD, mental health conditions and dementia; and
- A 10 per cent increase in patients with diabetes receiving all eight recommended care‑process elements.
Show me the money
This is all fascinating, but the key question for policy credibility remains ‘how is the money going to work?’
Neighbourhood Health Framework promises that the government and NHS England will take a “permissive” approach, allowing local areas to change how money flows as long as they have “credible plans”.
But these “credible plans” must be funded by “rebalancing existing resources rather than relying on new funding”. Mmmm. If not mmmmmmmmmm. Those with long enough memories to remember World-Class Commissioning might be thinking about the wonderfully mythical ‘Freed-Up Resources’. And we few, we lucky few may also remember that the primary care trust (PCT) commissioners of that era never saw a hair of FURs.
NHSE will also “develop financial mechanisms that support the establishment and scaling of neighbourhood health … (which may) include proposals to test more population, risk, or outcome-based contracting approaches”.
Now I’m reassured.
The Larry Ellison Institute: AI will save us all
The Larry Ellison Institute For Global AI Hype, ooops, sorry, The Tony Blair Institute has again embarrassed itself with another fawning commentary piece about how tech firms and AI will save us all. No, really. Yeah, I’m thrilled too.
Its latest hard-of-thought commentary, under the snappy title ‘Who Controls Access To NHS Care In The Age Of Big Tech?’, it suggests that “the likes of ChatGPT – general-purpose AI assistants … (are) being used for health care anyway, because they solve a problem that the NHS has failed to address: how to navigate an impenetrable and impossibly complex system.
“This matters more than most health leaders realise. Because what looks like a convenient consumer tool today could become the greatest threat to the founding principles of the NHS, should the system fail to engage.”
It’s all there for crap policy: hyperbole meets fear-mongering. The NHS is usually not “impenetrable and impossibly complex” at all. It is backlogged, rationed and often weakly administrated and managed. It doesn’t have to be, but this is where we have been for many years now.
Obviously the pandemic made matters much worse: this week’s publication of the report of Module 3 of the Covid19 Public Inquiry on the healthcare systems confirmed lots of things that we already knew. The section on overwhelm particularly repays attention.
But matters were already very bad before that. Winter crises got successively worse throughout the 2010s; the RTT backlog was already 4.4 million before the pandemic. The pandemic was the last straw that broke many of the most experienced staff in the NHS.
AI will help at the margins, with ambient voice recording technology and other demonstrable time-savers, but it absolutely won’t create or midwife a system that is curious about the root causes of good, bad and average performance; cares about and records outcomes; understands and acts on issues of patient flow and waste. AI won’t do a damn thing about the NHS’s poor culture and tradition of bullying.
The LEI/TBI piece continues with assertions that “these platforms (Chat GPT et al) are building something that the NHS has always struggled to create: a complete, structured, enduring history of an individual’s health. They don’t just know what’s been coded in your GP record, but everything else too: the back pain that comes and goes, the anxiety you’ve never mentioned to a doctor, the family history you’ve shared (and haven’t had to repeat ad nauseam).
“This creates genuine clinical value in the form of better risk stratification, personalised triage and dynamic symptom tracking. The assistant effectively becomes a private digital health record – one that’s often more complete and accessible than anything currently within NHS systems.
“Before too long, you won’t want to use another navigation tool. You certainly won’t want to start from scratch explaining your history to 111. The switching costs – in terms of both data and memory – are too high.
“This is classic platform capture. And it’s happening right now.”
I don’t wish to be more horrible than is strictly necessary, but this is pure anecdata. It is also bollocks.
It further asserts that “if citizens stop using 111 and ask ChatGPT where to go instead, the NHS loses the ability to shape demand digitally. National guardrails will get bypassed. The system’s capacity to “shift left” will be undermined. And the fundamental ability to manage a universal service that is free at point of use will be compromised.”
This is laughably silly. ChatGPT can do little more than tell people to go to their NHS GP or to A&E. GP practices increasingly have front-line digital gatekeepers to ration care before people get through to the key rationers of GP receptionists; A&E care is (as it always has been) rationed by waiting.
We segue on to fresh finds in this fiesta of nonsense: “Globally, health insurers understand this dynamic – often better than providers do. That’s why they’re racing to own triage and navigation: it’s the control point that determines downstream costs and utilisation patterns.
“Look at what these AI platforms already have: the consumer interface, the data layer and increasingly sophisticated risk stratification. All they need now are some contracts with providers and a monthly subscription and, before you know it, they’re a health system.
“At that point these platforms would effectively have the insurer stack. The NHS would become a back-end supplier of services, disintermediated from the citizen relationship that it was built to serve. Digital primary care could easily become a loss leader – a way to acquire and lock in users before routing them through a vertically integrated private health-care system. If platform capture were to be completed, the NHS would simply become one option among many, competing on convenience rather than principle.”
The assertions and assumptions of the young, healthy and tech-literate are rarely a good basis for thinking about public policy, and such is the case here. The piece displays virtually no awareness of who the NHS’s actual major users are in The Real World: the co-morbid; the very young; the elderly and the pregnant. Most of these people are not episodically ill. Some of them will like and be good at digital front door access: a significant number won’t.
Global health insurers want to avoid covering genuinely sick people at all costs. This is why the healthy young tech-literate are a highly attractive demographic for insurers. Such people are not the NHS’s real user-base. The NHS is for all its many faults a universal system.
Recommended and required reading
Money, influence and the NHS
Wednesdays Radio 4 3.30 pm / BBC Sounds
Dr Margaret McCartney’s three-part series outlines her 20-year “quest” to reveal the conflicts of interest and hidden influences inside our own medical system.
Writing for HSJ, NHS Confederation and soon-to-be NHS Alliance chair Lord Adebowale warns that the CQC must speed up its efforts to improve, or lose further credibility.