Cowper’s Cut 425: The monkey and the organ-grinder
It’s almost a pleasure to be writing this week about Alan ‘Bouncer’ Milburn, the organ-grinder of Team Milburn-Streeting; rather than my more usual recent subject of the monkey (said simian being Health But Social Care Secretary Young Master Wesley Streeting).
Almost a pleasure, but not quite.
Longstanding readers are aware of my views about Mr Milburn, whether here or here or here, spiced down with Bouncer’s tired old trope of the NHS being in what I characterised as being ‘the world’s biggest last chance saloon’.
(Oh yes, the NHS was still there in 2024, just as Bouncer had also asserted that it was in 2014, and even back in the day in 2001. That’s one hell of a saloon, no? I’d hate to have to clean it.)
No new clichés!
Clearly, Mr Milburn is not a man who likes to trouble himself by coming up with new clichés.
Alas, the text of Milburn’s 2014 NHS Providers lecture was deliberately taken offline. This is a shame, because its poverty of argument is highly relevant to Bouncer’s remarkable return to the policy spotlight.
‘My generation thought in argument’
Sam Freedman
Mr Milburn has been interviewed for Sam Freedman’s impressive ‘Comment Is Freed’ substack, and oh my word.
What Bouncer has to claim about his role in health reform is quite something. Many are demonstrably ridiculous or untrue. But then, this is Alan Milburn we’re talking about here.
Some of Bouncer’s claims about health reform are so crass, I almost got a whiplash injury from cringing.
Sam Freedman is one of the brightest political writers currently active, but he’s not a health specialist. I kind of am, and so here is an analysis of Bouncer’s assertions, together with evidence about why they are utter nonsense.
Hit the ground (it can’t hit back)
In the interview, Mr Milburn claims that there was “thinking behind the scenes. Wes Streeting did that and could hit the ground running as a result”.
As ‘Cut’ readers are all too well aware, the notion that Mr Streeting had done the work and so hit the ground running is not widely held.
This claim is not evident in delivery, where RTT waiting list reductions (Labour’s one quantified 2024 manifesto commitment on health) are happening, but desperately slowly: far too slowly to hit their pledge for 2029.
Neither is Bouncer’s claim evident in policy, where Mr Streeting’s major change in abolishing NHS England is something that he said he would not do just ten weeks beforehand.
Nor is it evident in strategy, where the recent NHS Ten-Year Plan is essentially a specious hallucination of a wish list, without any means of delivery.
Mr Milburn also claims that “with something like the [health department] 10 year plan, that ended up being written by a small group of people, me included, with the mainstream machine largely exempted from that process, which is just an odd thing to do”.
This is a particularly odd statement. As in, bullshit-flavoured odd.
Department of Health and Social Care
Here in The Real World, there was a very large and lengthy consultation exercise, which lasted many months.
If what Bouncer is actually trying to tell us here is that, after this costly and lengthy use of taxpayers’ money, the NHS 10 Year Plan was then written by a small group led by a certain Alan Milburn who largely ignored the output of the public and professional consultation, it would certainly explain a lot about the NHS10YP’s many and obvious deficiencies.
I’m not certain that sending such a message was his goal, but it’s certainly the outcome.
Political philosophy as self-flattery
Mr Milburn’s political philosophy is outlined in the section where he asserts, “what the government’s got to be is an agent for change. You do it through strategic clarity and narrative creation. The biggest job of leadership today in any setting, corporate or politics, is a job of explanation. What is going on in the world. Why is it happening? What are the choices before us?
“You create narratives and one of the things that worries me most is when people say: the answer to all of this doesn’t lie in any of that stuff, strategy or narrative but in delivery.”
Oh … how long have you got for this one?
The New Labour health reforms of the 2000s had a coherent narrative, sure. They were largely based in ‘New Public Management’-style incentives for more activity; helped by earned autonomy for providers; spiced up at the margins by competition; but largely lubricated by a huge amount of extra money.
That is what verifiably happened in The Real World.
The NHS’s annual budget went from £49 billion in 2000 (news.bbc.co.uk/1/hi/in_depth/uk/2000/budget2000/684419.stm) to £131 billion in 2010.
But Bouncer is trying to tell us about what government needs to be doing today.
I beg his pardon?
Apart from some wafty rhetoric about a triple shift that is clearly not happening and some ‘tough’ rhetoric about failure not being tolerated, it is extremely hard to discern what the current Milburn-Streeting era’s NHS strategic clarity and narrative creation is meant to be.
Ahem.
Team Milburn-Streeting weren’t going to abolish NHS England, but then they did. Team Milburn-Streeting wanted GPs to stop being independent contractors, but then they didn’t. Team Milburn-Streeting think we need much fewer and smaller NHS management organisations, who should then become brilliant strategic commissioners (despite strategic commissioning being a thing which nobody in the NHS has done at all well, ever).
Now that’s what I call strategic clarity and narrative creation.
Perhaps the most telling statement of Bouncer’s in this interview is when he bids readers to believe that, “what did I do every day when I was the health secretary … I had an argument. I had an argument with the BMA, with the NHS, with the civil service, with the unions, etc, etc, because change begins with one thing. It begins with an argument.
“The genius of politics is to construct an argument that connects with the public. And when that happens, that’s when you buy patience. You buy time, because change always takes longer than you think”.
Oh.
And to think that lots of people whom I know quite well, who encountered Bouncer when he was Health Secretary, suggest that a more plausible explanation of why he used to have an argument every day back then was because he was a rude and bullying arsehole of a person, who developed and propagated a rude and bullying arsehole culture in NHS national leadership.
The biggest bits of delivery of the New Labour health reforms came in the second half of the decade, which rather negates Mr Milburn’s argument that it was winning an argument with the public wot won it.
As the definitive 2011 Kings Fund report by Dixon, Jones and Mays makes clear, what worked for New Labour was about policy stability and consistency; and about having put in place the right incentives and systems - but it was also very largely about year after year of lots and lots and lots more real-terms money.
Lots of people seem to have forgotten this inconvenient truth: Mr Milburn is simply one of them.
One of the English language’s finest demotic idioms is the phrase ‘don’t piss down my back and tell me it’s raining’ (its origins date back to the era of standing football terraces, pre-match beer drinking and inadequate toilet access). Team Milburn’s-Streeting’s fondness for asking people to believe their rhetoric ought to provoke a revival of this expression.
Recommended and required reading
Times health editor Eleanor Hayward is one of the national journalists worth trusting, which makes her account of how BMA resident doctors’ committee leader Dr Jack Fletcher shook hands on a pay deal with Wes Streeting two days before announcing the recent six-day doctors’ strike well worth reading.
The House of Commons Public Accounts Committee’s new report updates the picture on the New Hospitals Programme: it is grim, but vital reading.
A study published in the British Journal of Anaesthesia of elective surgery at 91 English NHS trusts found that 10% of operations were cancelled the day before the planned surgery date; while 9% were postponed when patients had their pre-op appointment. If the findings were replicated nationally, that would equate to approximately 300,000 cancellations or postponements. Yet nearly 40% of cancellations could be avoided, the authors concluded. They also found that nearly two-thirds of operations postponed at the pre-op appointment were because patients needed further tests or specialist clinical review. The Guardian writes it up here.
Both Steve Black’s latest ‘Mythbuster’ for Health Service Journal and Alastair McLellan’s latest editorial are first-rate.
The FT reports that US health secretary Robert F Kennedy’s son launches a new investment fund tied to the health movement #nepobaby.