Editorial Thursday 5 November 2015: Money, power and ownership in the NHS: the bonfire night of the vanities
Money, power and ownership are central to the politics and policy of the NHS.
They're also often misunderstood.
Money is back in the news this morning with Virgin toilet misuser Jeremy Hunt apparently offering junior doctors an 11% pay rise as part of changes to the junior doctors' contract.
This largesse seems surprising, given the Chancellor's July commitment to a 1% public sector pay increment for the next four years, and while I'm no workforce expert, it wouldn't be totally unusual for a pay offer to be slightly less straightforward than it initially appears.
Full Fact are usually pretty good on this.
The junior doctors' contract issue is obviously key to the Government's plans for greater consistency of seven-day working across the NHS. Mr Hunt moved on from money to power, telling BBC Radio 4 that he has no power to negotiate on seven-day working because it was in the Conservative manifesto.
This is an intriguing point, because notably absent from the Conservative manifesto was a commitment to cutting working tax credits. Which they have since tried to do.
It would require some round objects on the part of journalists to have pointed this out to Mr Hunt. Don't hold your breath.
Equally, it's worth taking a moment to review the amount of the 2010 Conservative manifesto that was not implemented across all areas of public policy. The misses are far more than can be accounted for by the compromises of coalition; most notably paying down the bulk of the deficit in one Parliament.
Supply, meet demand
The issue of junior doctors' pay - the most obvious, but not sole sticking point for the new contract - takes us neatly to the issue of agency spend. NHS England's Sun King Simon Stevens has this down as a 'unit price' issue.
It's nothing to do with our old friends supply and demand, then? Where clinical staff (who let's remember are trained, in-demand internationally and frequently - especially early in their careers, highly mobile) are in high demand and short supply, their value, and thus price, increases.
It's unclear whether the failure of pro-market people to understand this is naive, ironic or wilfully blind. To borrow the lovely phrase of former Homerton medical director John Coakley, "how very odd that if you introduce a market in healthcare, you get a market in healthcare".
Now clearly, it's marvellous that Monitor will permit trusts to breach the agency staff cap. It's almost as if there had been some kind of three-line whip and associated review, which had been the impetus to ensure that providers were adequately staffed.
It's almost as if hospitals were having difficulties recruiting full-time staff.
Money vs power
The money in the junior doctors' dispute unambiguously sits with the government, mediated via NHS Employers.
The power, however, sits with the junior doctors.
This isn't immediately apparent, of course. The BMA are doing their usual job of failing to advance simple arguments in a winning fashion.
The issue, however, is that junior doctors are at a point in their lives and careers where they are uniquely mobile - as well as in high demand internationally. They don't need to give up their clinical careers. They could easily go and work in a country which is resourcing its healthcare system appropriately.
We're not, as the Kings Fund pointed out, and in the latest OECD health research, it shows.
No-one misunderstood power in the NHS like Andrew Lansley. He saw it as a zero-sum game, where for others to gain it, he had to lose it.
The result of this, mixed with his Titanic ambition to create an unsinkable set of NHS reforms, was a power vacuum, later filled by Simon Stevens deciding that he was in charge.
True power in the modern world (and so the NHS) is not a zero-sum game. It is distributed and it is networked. And its distribution and networking can be amplified by trust.
Power is also like shit: if you pile it up in one place, it stinks to high heaven, but if you spread it around, it can help things to grow.
Win power. Use power. Lose power.
Power may also be understood as a sine wave. It has three stages.
The uphill slope of the wave from the low point to the median line is the 'win power' stage.
The rise above the line to peak stage is the 'use power' stage.
And the descent from peak to trough is the 'lose power' stage.
The misunderstanding of money is as significant.
The NHS's money is not really spent by chief executives or finance directors, or even tariff setters and contract negotiators.
The NHS's money is really spent by the clinicians of the service and their decisions about how to plan and provide services.
And as I have said before, almost no clinicians went into their profession motivated to save money for HM Treasury.
So our current mania for discussing the efficiency £22 billion, or the extra £10 billion, or the Carter £5 billion is a bit odd. Because it simply doesn't motivate the people who spend all the money.
So we need to start talking to clinicians about why we need to change. In their language.
Quietly, the NHS has already begun its provider-side consolidation.
Whether in Devo-Manc, or in Dame Julie Moore taking over Birmingham's non-womens'-and-childrens' hospital sector, or in Northumbria's nascent ACO, or in the many emerging chains of GP practices, the traditional ownership form of standalone FTs is being not-particularly-subtly undermined.
When the bulk of them drop through the ground, the Secretary Of State might even notice.
The purchaser-provider split is not quite dead, but is most certainly no longer fully alive. It is on a weird, loping, looping Liverpool Care Pathway.
Accountable care organisations, or something like them, feel like one version of the future, and will work more quickly in some geographies than in others. We cannot know which ownership forms will flourish and which will wither.
But we return to the same issue of who spends the NHS's money: its clinicians. The likelihood of success of any ownership form without their consent and participation and co-design is slender.
Remember, remember, the fifth of November: if we don't get clincians to light the blue touch paper and retire immediately, we could see an unforgettable bonfire of the vanities.