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Editorial Thursday 11 February 2016: Dung, bungs and autodidacts

First, the dung: to the considerable surprise of absolutely nobody, the latest waiting time data shows that 18 weeks has officially been breached. Waiting dynamics expert Dr Rob Findlay has been consistently noting that this was inevitable for some time.

Deeper in the dung, the doctots' strike went off without obvious patient harm, following the doctots' leaking to The Independent that Jeremy Hunt had vetoed a proposed agreement.

A further exchange of letters from Sir David Dalton and to Jeremy Hunt was leaked at the end of the day.  The plumbing merchants near BMA House must be having a field day.

Picking a fight with doctots is slightly mystifying. As I have pointed out before, there isn't an alternative workforce available. The fact that some trust can successfully and affordably roster seven-day cover suggests rather strongly that the problem may be more in terms of local relations with clinicians than to do with the national contract.

The latest talking point is about the rights or wrongs of imposing the new contract. Imposition is the kind of thing that a Health Secretary who knew he was on his way out of the departmental door would do. To paraphrase Dr John Reid's line to Cabinet colleagues, "Don't touch health; I've spent all the goodwill".

Poll tacks
The Ipsos MORI/HSJ poll of public opinion about the doctots' strike found that overwhelming support remains in favour of the doctots. I've done the trust issue and the bad communication and negotiation issues previously.

Meanwhile, the latest edition of the three-decade spanning British Social Attitudes survey found a significant 5% decline in public perceptions of NHS performance.

Now of course, as its name implies, this is a survey about British social attitudes, which asks people to reflect on their voting in the general election. There is an element of politics in this, as the commentary by chief economist of the Kings Fund, iridescent Professor John Appleby, notes.

Nonetheless, a survey of social attitudes that has gold-standard methodology and spans decades tells us useful things, should we be inclined to listen. The Government's record on listening is far more tactical than it is strategic.

In fact, 'more tactical than strategic' will probably be this Government's epitaph.

The first bung is the weakest
The estimable Anita Charlsworth of the Health Foundation is ex-Treasury, and so knows where to look, which is how they noticed the Treasury bungling the DH some more money (almost a billion pounds), in the hope it will avoid breaching the Departmental Expenditure Limit.

The vast bulk of this is permission for yet more capital-to-revenue transfers, which are in reality spending cuts on vital estates development and procurement. A smaller part is from the Pharmaceutical Price Regulation Scheme delivering less than it should.

It looks like quite a lot, until you note that the suggested NHS provider sector trading gap (not overspend) is about the £3 billion mark.

The slightly concerning issue abut all of the current issues is the lack of a clear theory and indeed practice of change. How do we get there from here?

We have looked at the Carter Review assumptions. The history of efficiency savings in the NHS is not a cause for wild optimism, is it?

Oops upside your head
The Health Foundation also point out that provider productivity has been falling.


The Nuffield Trust's recent QualityWatch work says that winter pressures in A&E are now a year-round event.


Mergers and acquisitions? The brilliant success of Frimley Park in taking over and turning around Heatherwood and Wexham is impressive - yet highly talented NHS provider leaders who have tried turning around remedial organisations know that there are none so deaf as those who will not admit they have big, big problems.

This next bit will be NHS organisations doing messy things to themselves, as I wrote in 2014.

Once NHS Improvement exists, it can play an important role in midwifery of change and learning what works and is transmissible - but this will take capacity, communication, imagination and humility.

NHS Improvement have an excellent leadership team in the practical, shrewd Jim Mackey and the formidable Ed Smith. That gives them a good chance.

Of course, it would be nice not to be relying on 'a good chance'. But we are where we are.

In the dung.

Out of money.

And threatening to impose a contract on the doctots.

Update - Mr Hunt has announced the imposition of the new contract in the House of Commons. His statement to Parliament is here.

Light the blue touch paper and retire immediately.