Cowper’s Cut 441: On the three broken psychological contracts and the many unresolved tensions affecting the English NHS
I’m sort of on holiday at the moment: instead of a column this week (and since there have been two recent ‘extra’ columns), what follows for your entertainment and edification is the text of my recent speech to the R L Datix ‘Connected Health And Care’ Summit.
I was surprised and pleased to be asked to speak at this event, although perhaps not so surprised to find that I had a lot to say. (No comments from the cheap seats, please.)
I’m grateful to various friends and colleagues whose comments on my initial draft helped improve this greatly.
On the three broken psychological contracts and the many unresolved tensions affecting the English NHS
RL Datix Connected Health And Care Summit, 10 July 2026
“I’ve never made predictions about the future, and I never will.” That beauty of a quote has been widely attributed, from Tony Blair to Paul Gascoigne to American baseball coach Yogi Berra.
Predicting what a new Prime Minister is actually going to do in public policy is rarely straightforward. It’s even less straightforward when the incoming individual hasn’t had a campaign or a challenge to become their party’s new leader. This means we know very little about Andy Burnham’s plans, and that’s very much how Team Burnham will want it: they have made no real commitments, which leaves them a lot of room for manoeuvre.
One reasonably safe bet is that Andy Burnham is going to use that freedom to the full. There’s a longstanding Westminster joke (which Burnham himself now apparently tells): a Blairite, a Brownite and a Corbynista walk into a pub and the barman says “what’ll it be, Mr Burnham?”
Is health and social care going to be a big priority for the UK’s first Prime Minister ever who has previously been Health Secretary?
The Manchester-based journalist Jennifer Williams of the Financial Times has been writing about Andy Burnham for a long time. She describes a man with a yogic level of political flexibility. Williams writes how in February 2015, Burnham told her that he “was so incensed at the Manchester devolution plan — it would lead to complex reorganisation and punch holes in the NHS “like Swiss cheese”. If Labour were to win that summer’s general election, Burnham said, “I wouldn’t be offering this deal”.
“ … less than a year later the same issue came up again. This time, in the upstairs room of a boutique city centre hotel, where Burnham was announcing his ambition to become Greater Manchester’s first mayor. Slightly jarringly, that pitch included big plans for the devolved health system he had been so upset about before. Social care, he was now telling me, would be renationalised under his 10-year leadership vision.”
This isn’t much of a surprise. Those of you who pay attention to politics will recall that a certain Sir Keir Starmer, when standing for the Labour leadership in 2020, essentially promised his party that he’d deliver competent Corbynism without Corbyn.
A new leader for the Labour Party not being wholly clear about his real plans for power? In the words of health policy guru Tom Jones, it’s not unusual.
Political consistency has not as yet been Mr Burnham’s strong point: I am tempted to rebrand him from The Mascara Kid to The Kama Sutra Kid, so diverse have been the range of his positions.
The Financial Times recently published a long read about The Mascara Kid’s Westminster political past and his track record in jobs in the New Labour era. A couple of quotes from Mr Burnham’s Cabinet colleagues stick out: one recalling that “he’s a people pleaser. He is very effective at saying what people want to hear but there was never any question at all of Andy saying or doing anything difficult, and that’s a huge problem.”
Another former minister said: “Some ministerial colleagues recall encountering him as a not very good administrator: there was disorganisation, an inability to make decisions, particularly difficult decisions, and him just wanting to be popular. He’s someone who wanted to be loved rather than someone who was driving forward cultural change in his departments ... he’s more comfortable being oppositional than taking tough decisions.”
Something worth remembering is that in 2009, Health Secretary Andy Burnham made a speech to the Kings Fund think-tank in which he said that he wanted the NHS to be the ‘preferred provider’ of services, in total contrast the the market-oriented approach of most of the New Labour health reforms of that decade. He was very publicly criticised for this about-turn by the former New Labour health secretary Alan Milburn, who as many of you may know was the brains behind Health Secretary Wes Streeting, and who is currently lead non-executive director of the Department For Health But Social Care.
It’ll be interesting to see if Mr Milburn stays in that role: he has certainly been in active conversations with Team Burnham about his worklessness report and task-force on NEETs (people not in education, employment or training).
The NHS waiting list for measured RTT care increased again in the latest data published yesterday, to 7.28 million. A&E waiting times and ambulance response times also got worse, reversing the modest gains seen earlier this year.
Labour’s 2024 manifesto had one quantified commitment on health and care, which was that the NHS would return to delivering 92% performance on the RTT conditions within 18 weeks: it is not currently on, or indeed near, the trajectory required to deliver this.
Social care
Social care is means-tested in the English and Welsh systems: if your assets are over £23,250, you are classified as a ‘self-funder’ and must pay for the full cost of your care yourself. If your assets are between £14,250 and £23,250, you will pay a sliding scale contribution, and the council will help cover the rest. If your assets are below £14,250, your local council covers the majority of the cost, but you are still required to make a contribution from your regular income (like your pension).
The system is different in Scotland: personal and nursing care is generally free for everyone who is assessed as needing it, regardless of their income or age. You only contribute toward accommodation or living costs if you enter a care home
One thing we do know from Andy Burnham’s time as Health Secretary at the tail-end of Gordon Brown’s government is that he made the last serious attempt to get a ‘National Care Service’ happening, funded like the NHS through general taxation.
Burnham was having secret cross-party talks about this proposal, and as the 2010 General Election approached, Conservative leader David Cameron ordered shadow health secretary Andrew Lansley to pull out of those talks and go on the attack about ‘Labour’s Death Tax’. The direct consequence of this was that when Theresa May came up with social care reform proposals in her 2017 manifesto, Labour attacked them as the ‘Tory Dementia Tax’.
Karma, innit: what goes around, comes around.
Social care has, unexpectedly, had a moment this week - Baroness Louise Casey, whose report on social care funding reform was due in 2028 (but Andy Burnham has said he now wants it by the end of this year) announced that she wants to start a Big Conversation with the public about who should pay for adult social care.
We have, of course, been here before: quite often. The Andrew Dilnot commission for the Coalition Government led by David Cameron recommended a lifetime cap on individual costs of £35,000. Chancellor George Osborne announced that the figure for the cap would be £86,000: The cap was legislated for in the Care Act 2014.
It was originally planned by Chancellor Rishi Sunak that the proposed reforms would be funded via a new Health and Social Care Levy, the revenue from which would be ringfenced for investment in health and social care. However, in September 2022, Chancellor Kwasi Kwarteng announced that the levy would be cancelled. At the November 2022 Autumn Statement, Chancellor Jeremy Hunt, announced that introducing the levy would be delayed for two years until 2024: conveniently, the year of the General Election.
On 29 July 2024, in her first Budget, Chancellor Rachel Reeves announced that the Conservative-planned social care funding reforms would be abandoned.
So it is highly likely that Andy Burnham will drive some serious movement towards some kind of National Care Service. The Health Foundation think-tank estimated in 2024 that an NHS-style model of universal and comprehensive care could cost around £17 billion in additional funding by 2035/36.
I couldn’t tell you what he’ll do about funding it. Mr Burnham’s previous reform plans were that national social care would be funded by income from replacing inheritance tax with a 10% levy on all estates, with no allowances or exceptions. It is unclear whether his thinking remains that this would fund a cap on care costs (the level of which cap is unknown), or a full-on ‘free at the point of use’ service.
Social care matters in its own right, of course. Its availability also has a major effect on the throughput of hospitals: the problem of patients who are medically no longer ill or receiving treatment, but who cannot be discharged home safely because of no available social care, is well known for creating bed blockages, which makes it very hard for hospitals to admit new patients.
And any fellow politic-followers might recall Andy Burnham was shadow health secretary, in which role his 2015 ten-year plan based around ‘whole person care’ was, as social care expert Richard Humphries rightly noted at the time, worryingly light on detail.
Manchesterism and devolution
What else do we know about Andy Burnham? Well, like Dick Whittington was in That Southern London Down South, Mr Burnham was three times elected mayor of Greater Manchester. This was in the era of Devo Manc: the devolution, of which ‘Manchesterism’ seems to be the proof of concept.
The more serious people who have written about Manchester’s devolution have pointed out that Manchester City Council’s leader Sir Richard Leese and chief executive Sir Howard Bernstein were very important to the economic and regeneration successes there. Andy Burnham’s popularity as Mayor is at least in part the reaping of credit for the successes of those two knights.
What can we learn from Mr Burnham’s recent time as Manchester mayor? The Manchester model is about joined-up public services, locally accessible. This means not just health in the high street, but co-located with the citizens advice bureau, the job centre, etc.
The University of Manchester study of the region’s health and care devolution published in 2024 found significant improvements in health from 2016-2020, but Houston, we have a problem.
The problem in question being that devolved Greater Manchester blew up the money.
The ICB’s top-slicing of all the acute budgets for allocation directly to Manchester Foundation Trust and Northern Care Alliance without any connection to the places or commissioning was material here. Those hospitals overspent, and did not deliver the reductions required in waiting in moving towards 18 weeks either. Spending more money than you have is no driver of quality.
This led to NHS England imposing legal undertakings on the Devo-Manc area, mandating local authorities and NHS bodies to execute massive savings (branded, of course, as productivity programmes) to bring the system back to a sustainable medium-term footing.
NHS Greater Manchester rolled out a New Operating Model to streamline governance. This recalibrated how decisions are made, centralising some operations away from individual local partnerships to manage costs more efficiently, effectively limiting the ‘free rein’ Greater Manchester initially had over its transformation funds.
So what do we learn from this? That devolution is the freedom to make and learn from your own mistakes, right up until you overspend massively. There is a big lesson here for Andy Burnham, if he is amenable to learning it. We shall see.
If Mr Burnham wants devolution from national government once he is Prime Minister, it is unclear to whom and with how much money, given that there is a big and unfinished local government reorganisation already under way. And local government has already been stripped down to the bone by the austerity financial reforms, while demands for social care continue to grow.
Will a devolved system have the leadership, culture or bandwidth to succeed? There appears to be no real attempt to understand and support how local government and the NHS need to work hand in glove to address multi-morbidity and deprivation as drivers of healthcare demand by the current administration. Instead, lots of supply-side interest and provider-driven solutions abound. Are national politicians and leaders appropriately concerned about the impact of local council political changes on the NHS (rightly so) to move meaningfully towards closer working?
There is a big point about devolution and politics: the NHS Modernisation Bill currently going through Parliament is a centralising bill. Whatever, you think about Andy Burnham, he’s a localiser now. We shall see how much political capital he is prepared to spend on a NHS bill that he instinctively won’t like.
Psychological contracts
So having touched on politics and social care and devolution, I want to turn to some less tangible, but equally important issues.
There may be nothing less legislatively and physically tangible than a psychological contract, but psychological contracts exist. And they matter. A psychological contract is a deal between parties that is not written down, and so clearly is not legally enforceable.
The Chartered Institute for Personnel and Development says that “the psychological contract describes the relationship between employers and workers and influences how people behave from day to day. Unlike the legal contract of employment, the psychological contract is not tangible. It’s built on the everyday actions and statements made by one party, and how they are interpreted by the other.”
A lot of what I’m now going to discuss is about culture issues. It is a long-standing line of mine that the importance of culture in the NHS is vastly under-rated, and is seriously analysed and discussed too rarely.
The NHS has a lot of tribal behaviours: between clinical professions; between clinicians and managers. And it’s not always good, and workplace behaviour impacts hugely on care quality and safety.
For many years now, I’ve been saying that the NHS needs a chief anthropologist much more than it needs any chief inspector (and I will be touching on health and care regulation, which is badly broken).
Three broken psychological contracts in health and care
But regulation is not the only thing that is badly broken in the English NHS. I suggest that there are three important broken psychological contracts.
The first is the psychological contract with the staff. You will probably have heard the line that ‘the NHS runs on goodwill’, although you might not have heard it much recently, and there are good reasons why not. I’m not alone in observing that the goodwill that used to be the unofficial NHS operating system has been fairly comprehensively withdrawn by quite a few staff in quite a few places.
In 2024, even former Health Secretary Wes Streeting told the Nursing Standard podcast that nursing and other staff cannot continue to be “emotionally blackmailed” into keeping the NHS going.
So, what happened to the workforce?
Austerity is one thing that definitely happened to them. You can read various reports from the House of Commons Library, the Institute for Fiscal Studies, Nuffield Trust, King’s Fund and Health Foundation that all confirm that the period from 2010-19 was the lowest period of funding growth per capita in the history of the NHS.
It would be delusional to pretend that this austerity decade did not have an impact on the psychological contract between the health and care system and its staff. In particular, what ex-Health Secretary and Commons Health Select Committee chair Stephen Dorrell dubbed ‘The Nicholson Challenge’, of making do without £20 billion of planned financial growth, was almost entirely achieved by the ultra-centralised method of holding staff wages down year after year.
The Covid19 pandemic also happened to the staff who worked through it. In many cases, risking their lives to go to work and do their jobs, and sadly in some cases being permanently disabled by Long Covid - or dying from Covid19 infection.
The pandemic was a lot, hitting a nation that had already been through the consequences of the 2008 global financial crisis; of the 2010 austerity era; and of a highly divisive 2016 referendum on EU membership.
Some of you may remember Professor Kevin Fong’s evidence to the Covid19 Public Inquiry about the impact of the pandemic on the workforce: if you did not watch it, I recommend doing so.
We have not really recovered the staff from the pandemic, I believe. There are some staff in health and care who, if a conversation starts about or turns to the pandemic, they just - put their hands up and they can’t talk about it. Still. There is very real trauma.
I don’t think that we have yet begun to fully process the psychological effects of the pandemic on ourselves as individuals and as a nation - and if this topic interests you, I would strongly recommend reading emergency planning and disaster recovery expert Professor Lucy Easthope’s book ‘When The Dust Settles’.
While the data for this is not crystal-clear nor very easy to get, there is ample anecdotal evidence that although the NHS clinical workforce has been growing significantly over recent years, the most experienced staff are leaving in greater numbers. That is a huge problem, because the most experienced staff are usually the most valuable in terms of their understanding of how to make the system work - and just as importantly, what has been tried and failed in the past.
You can certainly see significant discontent in the NHS staff survey, which is also the source of one of the most useful bits of information available about the service, which is the responses to the question ‘would you be happy for your friends and family to receive treatment in your organisation?’.
Disputes over pay are another marker, with the latest rounds of resident doctors strikes just settled as the consultants have voted for strike action on a turnout of just over the required 50%. An entertaining side-aspect of the doctors’ industrial disputes over pay is that the British Medical Association now explicitly and frequently describes itself as a trades union: it’s not many years ago that using this phraseology was explicitly forbidden for BMA council members or staff.
Money is important, clearly: research from the Nuffield Trust has shown that medical staff are not paid particularly much worse in the NHS than they are in comparably-sized economies. Side note: Australia, New Zealand and South Africa are all prime hunters for NHS doctors currently because they’ve trained far too few of their own, so those countries are paying an awful lot.
While comparably-sized economies may not pay much more than the UK, that’s not what the nurses, residents and consultants look at. They’re eyeing Canada, Australia, New Zealand and the USA: the English-speaking countries to which our staff are most likely to flee.
And those countries pay shedloads more: partly because they (like us) didn’t train enough people domestically, but partly also because even they can’t keep hold of the ones they have. All of the above ‘anglophone havens’ have substantial retention issues.
Which itself illustrates something else: that the job of healthcare appears to be a uniquely difficult and complex job which - on all the available evidence - increasingly appears to lead to moral injury and/or burnout long before careers have come to their natural end.
These departing medics are smart enough to know that: 1. they do a job of care, for less than the English-speaking world’s market rate; 2. they do so with what often seems to them like not enough fellow staff, and is certainly not enough equipment; 3. they therefore take risks in good faith to keep the show on the road because ‘productivity’; and 4. if those risks are realised, then not only does nobody reliably have their backs, but there is also a significantly non-zero chance that they will experience loss of livelihood - and maybe liberty.
Better, then, to escape to another country and earn a fortune for taking on that responsibility: that’s what they seem to be telling us.
The Olden Days’ psychological contract on the pay deal with the NHS used to be that you got pretty modest pay at the start of your career; but for all medical staff (yes, including nurses), the second decade could be much better if you got more skills and qualifications; the third decade was really pretty well-paid; and the NHS pension is literally to die for. The excellence of the NHS pension deal seems to be very poorly understood by younger staff.
The other side of the psychological contract with the staff back in The Olden Days was that the NHS might not be the biggest payer, but that it would stand by its staff when things in healthcare go badly wrong (as things in healthcare do). The medical profession and regulation industry used to be fairly collegiate in not hanging people out to dry: in certain cases, like Richard Neale, Rodney Ledward, Harold Shipman, Ian Patterson and Yaser Jabbar, it was far too collegiate. Dangerously so.
Then came the Hadiza Bawa-Garba case. A six year-old boy with Down’s syndrome and a underlying heart condition, Jack Adcock, was admitted to Leicester Royal Infirmary in 2011, and he died that day: in part, due to errors in his care. Hadiza Bawa-Garba, the resident doctor who treated him (under supervision by duty consultant Dr Stephen O'Riordan) and a nurse, Isabel Amaro, were subsequently both found guilty of gross negligence manslaughter. They were subsequently struck off their respective professional registers, although Bawa-Garba had that decision overturned at appeal.
There are ongoing debates about the judgements against Bawa-Garba: partly around Bawa-Garba's personal culpability versus a context of systemic failures; and partly around the use of her reflective notes about her own practice as court evidence.
A lot of medics looked at the Bawa-Garba case, and decided that the system no longer had their backs.
They now act accordingly.
High-functioning teams deliver safer and better-quality care: we know this from the academic work of Professor Michael West and colleagues. Michael West’s pillars for high-functioning teams are Psychological Safety And Trust: creating an environment where staff can speak openly, raise concerns, and share diverse perspectives without fear of blame; Shared Objectives: aligning the team around clear, patient-centred goals; Constructive Conflict And Inclusivity: treating diversity across professional boundaries as a strength to challenge assumptions and drive radical improvements; and Regular Time To Reflect: taking intentional breaks (such as team time-outs, regular huddles, or away-days) to review performance and discuss how people are feeling.
The second broken psychological contract is with the public: service users, potential service users and taxpayers. It’s incredibly clear in the latest British Social Attitudes survey’s health questions that public confidence in the reliable, NHS cradle-to-grave system is dangerously low.
In 2025, 26% of British adults were ‘very’ or ‘quite’ satisfied with the way in which the NHS runs – a statistically significant 6 percentage point increase from 2024. Around half of respondents (51%) were dissatisfied with the NHS in 2025, a statistically significant fall of 8 percentage points compared to 2024 when it was 59%.
So there has been a year-on-year improvement, but it’s small. Despite this increase in satisfaction, only 16% of all respondents thought the standard of NHS care would improve in the next five years, compared to 53% who said they expected care to get worse. Among those who said they were satisfied with the NHS, 30% still said they expected NHS care to get worse or much worse, and 39% said it would stay about the same.
This level of public pessimism about our health and care system’s performance doesn’t seem sustainable.
There are improvements in NHS performance. Primary care has got more productive, and is adopting new technology. It is essential to the current vogue for neighbourhood health, yet primary care is not treated as an asset, only a problem. This needs to change.
Satisfaction with access to GPs has risen slightly in the latest national survey, and despite a falling share of national funding for many years now and no significant workforce growth, GPs have greatly increased the number of appointments they offer.
But patient demand seems to keep outrunning that supply increase, and that is partly because of the very large number of people who are waiting and deteriorating on waiting lists.
The third broken psychological contract is around paying for social care out of housing wealth. The golden generation and the baby boomers were able to buy their houses for relatively modest sums: house price accumulation since then, boosted by financial deregulation and exacerbated by failure to build enough new houses, has seen many of those generations enjoying enormous amounts of equity in their bricks and mortar.
For those older people who own their houses and develop major social care needs (and this isn’t most older people: between 5 and 10% of the elderly population develop significant needs for social care, which is probably why we have left its funding as a means-tested lottery), our revealed preference as a society is that we have found it acceptable that some of their property wealth windfall gets used to fund their social care needs.
But that solution looks time-limited. As subsequent generations come through who have paid much higher house prices, and have proportionately less unearned equity in a static or in real terms falling property market, I don’t suspect the current pragmatic workaround on funding social care will remain acceptable to the general public.
This one is a broken psychological contract waiting to happen: one that our system, our politicians and our providers need to address.
Unresolved tensions
The English NHS is also being pulled about and apart by a number of unresolved tensions.
Some of the health service’s culture is dysfunctional, and parts of it are deeply so. There is a big problem with embedded bullying, which was clearly described in the 2022 Messenger Review of NHS leadership - although very little has been done to address this.
You’ll have seen the media reports about NHS staff inappropriately accessing the medical records of the victims of the Southport knife attacks and of the victims of the Nottingham mental health triple murderer. And this wasn’t one or two staff members: it was clearly quite widespread in the trusts in question. The moral imbecility of those staff considering it acceptable to do this is really quite striking. NHS England chief executive Sir James Mackey’s instruction that such NHS staff who view patient records without valid reason should be sacked and prosecuted does rather make you wonder what the hell local trust managements have been doing. But Sir James was quite right: the staff in question should have been out of the door on the instant of the discovery of their activities, for gross misconduct.
Some people suggest that ‘no-blame’ cultures are what health and care providers and staff need to deal with system and human errors that cause patients harm. I don’t agree with that at all: I think ‘just accountability’ is a far better operating principle than ‘no-blame’.
But for just accountability to work, it needs the system to be good at looking at the root causes of problems, and in particular to look at the ‘human factors’ elements of why errors are made.
The health system is not systematically good at either of these. As the maternity inquiries of Baroness Amos and Donna Ockenden have again shown, there is still a massive tendency to cover problems up, deny, delay and try to legal it away. That is not healthy or helpful. The famous NHS duty of candour in the case of error or harm is essentially notable by its absence.
At this conference, delegates heard Dame Ruth Carnall’s interesting comments about the difference between the NHS hospital staff and the social care workforce: specifically, that social care staff have a much lower level of cynicism. We also learned about Chris Turner’s ‘Civility Saves Lives’ initiative, set out in his talk on culture at work: “culture is the way we do things round here” - and in the trust where Chris trained, surgical culture apparently included the consultant surgeon doing the operation stabbing a junior colleague whom the consultant perceived to be not performing ...
Racism is still a big problem in the NHS. Look at the work of the Race and Health Observatory, or Roger Kline’s work. It is under-discussed. The 2025 NHS Staff Survey showed that instances of staff experiencing discrimination at work from patients, their families and the general public, managers or other colleagues, had increased again - and are higher among ethnic minority staff, compared to white staff.
What drives problematic culture?
Lack of transparency is obviously a big feature. And cultures can be microclimates: problems can be confined to specific teams.
I am repeatedly struck by the lack of any serious and sustained interest on the part of regulators and national bodies in the root causes of good, bad or indifferent performance by organisations. NHS IMPACT, the new body set up by NHS England to try to recreate what worked about the NHS Modernisation Agency in the New Labour years, is notable for its lack of impact: it has published four short and weak case studies, which are now almost two years old.
I’ve talked about the Manchester devolution, but one notable feature of the English NHS is that it is an extremely centralised system that has been trying to do without a reliable intermediate tier between its national headquarters and its local organisations.
If you are as old as me, you may remember strategic health authorities; if you are older than me you may remember NHS regions. These organisations were crucial (although not always popular, of course, but certainly crucial): they could hold the ring and arbitrate in disputes in a local health economy; they could explain local health economies’ idiosyncracies and peculiarities to the national HQ (and vice versa); and crucially, they were developing grounds for leaders who could go on to national system roles.
The system has lost those proving grounds, and this loss is a big problem.
In a national health service that is inevitably almost completely locally delivered, tensions between the political and practical centrifugal and centripetal forces are both a feature and a bug.
There is no one definitive answer able to resolve the tensions between the valid arguments to centralise and those to decentralise. The dynamic tension between these two forces must be calibrated and managed carefully and wisely.
Regulation
We still haven’t got regulation in the English NHS anywhere near right, either of finance or quality and safety.
The Care Quality Commission was already a joke to many of those in the know by the middle of the last decade: the 2024 report by NHS England chair Penny Dash outlined its failings starkly, but what’s striking is that the CQC had been merrily failing along in plain sight for years without anybody doing anything about it.
I’m not alone in having been shown CQC reports from the mid-2010s which contained passages describing a hospital’s services when the hospital in question didn’t provide those services, and never had. Copy-and-paste inspection reports were quite the thing: maybe CQC staff aspired to become management consultants, and copy-and-paste slide decks?
Monitor was originally and justifiably well-regarded as an economic gatekeeper and regulator, but when the Lansley reforms foolishly lobbed quality regulation into its remit, that vital clarity of purpose was diluted.
I’ve written about the regulatory approach of the mid-2010s era being like a constellation of regulatory Death Stars, which was how many chief executives of that era experienced them. As regulators’ remits were merged and/or power was accrued to NHS England, they became decreasingly effective: they turned into a constellation of shit regulatory Death Stars. A change, certainly, but not an improvement.
It’s difficult to talk about quality without discussing measurement. And unfortunately, one of the best measures of quality of care - patient-reported outcome measures (PROMs) - were introduced, and measured nationally, and the data published - and was then reduced to just hip and knee joint replacement surgery. Up to September 2017, data was published on varicose vein and groin hernia surgery in England.
In terms of quality, measurement and transparency, arguably the private sector is now ahead of the game here, as you can see from the work of the Private Healthcare Information Network.
So we, as users of health and care services, remain disturbingly short of information about the quality of care we may receive. A system that was serious about quality and transparency would have expanded its data collection and publication on care outcomes. This data is too inaccessible, and often relies on the goodwill of clinical professions in their membership bodies.
And goodwill is not a sensible basis on which to try running any system. Let alone something as complex as a health and care system.
NHSE interim deputy CEO, UCLH’s well-regarded chief executive David Probert told Health Service Journal that his fellow executives atop NHSE have “tried to do is ensure that we are running the most transparent health service in the world … this is about transparency of message.” This is a solidly good ambition - and it is also a long way from where NHS leadership has usually ended up.
Here’s a further problem: transparency is usually uncomfortable, and so is major service change. Those with long memories may think back to the London stroke reconfiguration under Ruth Carnall, or to Bruce Keogh’s campaign to publish cardiac surgeons’ outcomes data. Those were huge battles that had to be tenaciously fought to deliver greater transparency that demonstrably led to higher quality.
Medical self-regulation is not doing much better. Look at the utterly incoherent and failed approach taken to physician associate roles by the Royal College of Physicians. Talk to any group of doctors and nurses and midwives about what they think of the GMC and the NMC: you will not hear high praise.
Trust and risk perception
The Chinese philosopher Confucius said that “three things are necessary for government: weapons, food and trust. If a ruler cannot hold on to all three, he should give up weapons first and food next. Trust should be guarded to the end: without trust, we cannot stand.”
I think that public trust in the NHS may currently be very low. The staff survey and the British Social Attitudes health questions that I’ve highlighted certainly indicate so. And as repeated care quality scandals like those in mental health, child and adolescent health services, maternity and secure accommodation show, the system seems to lack obvious safeguards in areas where it knows its track record of providing consistently safe services is weak.
The health and care system can survive a lot, evidently, but it isn’t clear that it can survive a big and sustained drop in public and indeed staff trust.
The system also fails to help itself in its tendency to cover up and lawyer up when it has made mistakes, as maternity scandal investigators Bill Kirkup and Donna Ockenden would be the first to tell you.
Corporate jargon
A deeply unwelcome development over recent decades of NHS management has been the pandemic of business jargon. Take your pick between ‘deep dives’ (that never are); ‘circling back’ (like Sisyphus, right?); ‘solutioneering’ (bless!). Oh, and unless you are Levi Stubbs or a member of The Four Tops, you are forbidden by Cowper’s Thirty-Seventh Law Of Everything to ‘reach out’ to me.
It’s a shame how few people realise how ridiculous using this kind of language makes them seem: as Shakespeare’s contemporary writer Ben Jonson wrote,“language most shows a man: speak, that I may see thee”. The guilty corporate jargonistas should be force-fed George Orwell’s ‘Politics And The English Language’ and The Economist‘s style guide until they desist.
Cornell University researcher Shane Littrell’s study published in the Personality And Individual Differences journal discusses a tool he built and tested called the ‘Corporate Bullshit Receptivity Scale’. The CBRS measures people’s susceptibility to nonsense business verbiage.
You may not be surprised to learn that this research confirms that being taken in by corporate bullshit is linked with lower levels of analytical thinking, and poorer work-related decision-making.
The NHS must implement the CBRS as a matter of urgency: put it on the Federated Data Platform forthwith!
I suggest that these three broken psychological contracts and many unresolved tensions are much more significant dynamics in health and social care than the Triple Shift and the NHS Ten-Year Plan. Thank you for listening.