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Cowper’s Cut 177: There's nothing like an adult debate on funding the NHS but social care

Cowper’s Cut 177: There's nothing like an adult debate on funding the NHS but social care
'In the beginning were the Words'

In the beginning were the Words, and the Words were ‘NHS But Social Care Underfunding’.

The Words were with the Treasury Munchkins, and the Words were the Treasury Munchkins.

Blessed be the Treasury Munchkins.

Sometimes, there are almost entirely predictable weeks, and this past one felt very much like one of those.

We saw professional and well co-ordinated lobbying by NHS Providers and NHS Confederation for an extra £10 billion in funding for the NHS backlog and increased demands/reduced capacity.

We also saw lobbying for Covid19 vaccine booster doses and for 12-15 year old children, even though the JCVI came out and said that apart from the severely immunosuppressed, the case for them was not proven, leaving it deftly up to the Chief Medical Officer to decide.

Health But Social Care select committee chair and ex-HBSC Secretary Jeremy Hunt came out for boosting in this piece for the Mail. Epidemiologist Deepti Gurdusani also made a string of telling and fact-based points.

This could get gnarly, as Dr Duncan Robertson observes: “the UK is now an outlier in not recommending vaccinations for 12-15 year old children. Unfortunately even if a positive decision were made now it would have very little immediate effect given the reduction in mitigations in schools. It may well be another difficult winter”.

But the peak of political predictability came on Friday, when the Telegraph (Boris Johnson’s self-styled “real boss”, remember) was briefed the Government’s apparent plans for fund an increase in spending on the NHS and/but social care by the unprogressive means of raising National insurance contributions.

The ‘playbook’ here is wildly predictable: Johnson’s people brief out a semi-baked plan in the true spirit of ‘chuck it at the wall and see what sticks’. Chancellor Rishi Sunak’s people retaliate with punishment counter-briefings, explaining that if more money is to be spent, then taxes will have to rise quite a bit.

Political and media chaos ensues - and we know that this is actually the PM’s plan. Unreliable narrator and Barnard Castle oculist Dominic Cummings (yeah – we get what we’re given) told the world that Johnson told him (when The People’s Dominic was still the PM’s chief advisor in Downing Street) “I am more frightened of you having the power to stop the chaos than I am of the chaos. The chaos means everyone will look to me as the man in charge”.

I suppose ‘chaotic Machiavellianism’ could be A Thing. I just suspect that it’s not A Good Thing.

Longstanding HPI/'Cut; readers will recall that on the steps of Downing Street on 24 July 2019 in his first speech as PM, Mr Johnson promised that "we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve".

This plan, and indeed any discussions about this plan, have been notable by what the charitable might call their rhetorical nature, and the less-charitable could term their fictional nature.

So the War Of the Briefings is, at the time of writing, still under way. Saturday’s was the ‘Chaos’ vs. ‘Cabinet Backlash’ remix. It’s a roulette wheel, from the Times to the Telegraph (boss) to the Mail to the Guardian: faites vos jeux, messieurs/dames!

Could it get better on Sunday? Why, yes. Yes, it could, as these fine examples of the War Of The Briefings genre show.

BBC political editor Laura Kuennesberg popped up with a Twitter scoreline on Sunday evening: "part of discussion No 10 and No 11 had to resolve about paying for health and care seems done tonight - senior govt source says 5.5bn extra on the way  for winter + Covid backlogs - details of that likely to be confirmed tmrw, but social care deal still not clear.

"Sounds like haggling still going on over social care funding - delay in reaching agreement's created plenty of space for a backlash before the details have even emerged. Deal btw No 10/11, NHS and Dept of Health over the £5.5 bn important tho too, although most of the political heat is around social care - going to be an interesting 48 hours"

So we shall see. Possibly.

There’s nothing like an adult debate on funding the NHS but social care, and this is nothing like an adult debate on funding the NHS but social care. Sigh.

And how is social care? Not well, according to this big workforce survey by ITV News, which found that the sector faces its worth workforce problem ever. The resuklt of the social care workforce crisis is thousands of vulnerable people going without care.

It’s worth reading Robert Colvile’s comments about where social care funding should sit post-reform, and Richard Humphries’ responses.

As the smart Chris Giles points out in the FT, Sunak might be a lucky Chancellor, and tax receipts may well beat the current forecasts, leaving him more room for manoeuvre. But a consistent theme across the briefings and write-ups is Sunak’s opposition to continuing spending rises without tax rises to match.

Crap Government communications? You don't say!
It was amusing to see Cummings’ old mucker, ex-Downing Street director of communications Lee Cain pop up with this Institute For Government piece on the inadequacy of the communications capacity and capability within government.

Longstanding readers will remember how often I wrote about the inadequacy of the Government’s communications efforts when alleged campaigning genius Cummings and ex-hack Cain were basically in charge of it.

A wry smile may also be playing around the corners of ‘Cut’ readers’ well-chiselled features as they consider what former Government Communications Service boss Matt Tee thinks about the mark of Cain. They might find this interview that Tee gave Health Policy Insight in 2010 of interest.

Integrating care: does it actually deliver?
The Centre for Policy Studies is probably the most interesting of the right-wing thinktanks. Its new report, ‘Is Manchester Greater? An analysis of NHS integration’ by Karl Williams, is an interesting read about what integration initiatives had achieved pre-pandemic.

Williams observes of the reforms moving the NHS to an ICS-led basis, “while it draws on previous reforms such as the Better Care Fund, established in 2013 to incentivise health and social care providers to work more closely together, this change represents a distinct break with the decades-long trend towards seeing greater choice and competition as the best way to increase NHS efficiency”.

He adds, “the alarming truth is that, as with the Lansley reforms, this seismic reform of how the NHS works has had surprisingly little scrutiny. To put it bluntly, everyone is in such fervent agreement that the ICS model of integration and collaboration is the future of the NHS that hardly anyone appears to have looked properly at whether this approach works in practice. The NAO noted in 2017 that: ‘The Departments have not yet established a robust evidence base to show that integration leads to better outcomes for patients. The Departments have not tested integration at scale and are unable to show whether any success is both sustainable and attributable to integration’. That is still fundamentally the case”.

Taking Greater Manchester / Devo Manc as its primary case study, the analysis evaluates performance of local health systems against three criteria: how the area has performed against the national average; how local trends have shifted post-integration, either positively or negatively; and how the integrated service has performed against the explicit targets that were set for it, where they exist. The researchers “have then used this blended metric to assess whether performance in a given area has improved, deteriorated or remained the same”.

Their findings are broadly not fantastic news for integration fans. With all of the obvious caveats, the researchers conclude that “in spite of the significant amounts of time, energy and money that have gone into creating new structures and processes, outcomes for patients and populations under the ICS model have been at best mixed and at worst outright negative, both on a regional and national level. In our two primary case studies, they are linked to weaker clinical outcomes and significant bureaucratic bloat”.

They find that “the data that is available does not justify the speed and scale of the change that is envisaged. And given the extraordinary impact that this latest top-down transformation of the NHS will have, the burden of proof must be on supporters of the ICS model.

“It may be argued that the poor performance of the early ICSs, and the inconsistency in performance between them, reflects temporary disruption caused by the implementation of the reforms. But the data from Greater Manchester indicates that the problems may be more deeply rooted. There is a risk that, by putting ICSs on a statutory footing, the Health and Care Bill will create a new, parallel structure of formal healthcare bureaucracy sandwiched between the NHS and local government.

“The result, in a worst case scenario, is duplication, confusion, a general lack of accountability – and worse outcomes for patients”.

These are significant data and findings, and should and will cause significant debate. The report goes on to make some sensible-looking recommendations, albeit the first – to suspend statutory status for ICSs in the new Bill – will create as many problems of budget-holding as it solves.

Perhaps the unarticulated case for integration is the re-creation of ‘grabbable’-sized units of health but social care planning and delivery. Population health management is probably a good idea, too.

Towards euthanising FOI
Another worthwhile read this week is Christopher Cook’s return to the FT piece on the Government’s deliberate and long-standing abuse of the legally-mandated Freedom Of Information process. Chris obviously has form with senior figures in the Government and their (ex-)advisors on FOI: he knows whereof he writes.

It’s also worth a look at this British Journalism Review article, which exposes NHS England’s communications control-freakery during the pandemic from the perspectives of many of the better investigative journalists around today.

Covid19 update
The latest data shows small increases, hopefully signalling proximity to plateauing, of the leading indicators, as well as predictable rises in the lagging ones. The latest Public Health England surveillance report seems to confirm this.

With an anti-Hardingesque predictability, the return of children to schools will hit this in about a fortnight’s time, and universities effect will follow after about another fortnight. We can only guess about how hard.

The creaking system
This UCLH piece by The Guardian’s Denis Campbell gives an interesting overview of the impact of the backlog on one high-profile hospital.

It’s interesting to see this contracts finder announcement of new offers of work for people who can manage PFI contracts: a theme we have discussed in these columns. KPMG’s the winner, to the tune of £500,000.

Sexist culture of the medical trades unions
I mentioned the revelations of ongoing problems in the Royal College of Nursing in last week’s ‘Cut’, and Nursing Times reveals that the RCN’s response will be a QC-led independent inquiry.

Yvonne Coghill is pithy on this: “Another review of the culture of the RCN, that as well as the EGMs and changes of council and exec in recent years. I guess the real question is do its 450k members care enough about it to want a different kind of organisation”.

Yvonne knows a fair bit about this, I’d say. They should be talking to her early.

Cronyvirus and Coronamillions update
The Independent’s Adam Forrest revealed that the Department For Health But Social Care is in potential legal dispute with suppliers over £1.2 billion worth of inadequate PPE. He reports a DHBSC spokesperson as saying that 7.6 per cent of the government’s overall PPE stock could not be supplied to frontline healthcare settings. “We are currently pursuing many options to repurpose and recycle items that are in this category”, euphemised said spokesperson.

Lord Bethell’s reply about the scale of this problem came in a written response to Lib Dem peer Lord Lee, who asked how much had been reclaimed from firms providing equipment found to be “not fit for purpose”.

The health minister replied: “The department is working through all its personal protective equipment (PPE) contracts to identify instances where products have not been delivered or failed quality tests and will seek to recover the costs for undelivered or substandard PPE …

“As of 27 July 2021, the department was engaged in commercial discussions – potentially leading to litigation – in respect to 40 PPE contracts with a combined value of £1.2 billion covering 1.7 billion items of PPE”.

Getting the Bill (Health and Social Care)
Bill Committee action starts this week. Fun, fun, fun!

Other important things
Would appear here.

Recommended and required reading
The Wolfson Prize shortlist of the five selected entries to design the hospital of the future, organised by Policy Exchange, is here.

Health economies affected by the collapse of Carillion, particularly in its NHS hospital-building work, will be interested in this Times piece on KPMG’s alleged failure to provide the regulator with inadequate information. The Financial Reporting Council has made a formal complaint about the information provided by KPMG, which self-reported the concerns.

It’s good to see ADPH boss and Tameside DPH Jeanelle De Gruchy appointed as a new Deputy CMO, as LGC exclusively revealed: she and her follow directors of public health have had a very good pandemic. Well worth re-reading this interview with her from The Guardian last year.

Alan’s comeback plan got both barrels in the Telegraph (boss) from `Team Alan’s Ex-Wife’. Karma, innit?