What is to be done?
There is no plan. So what can we do?
The Government’s ambition to increase NHS hospital activity by 30% from pre-pandemic levels is a delightful aspiration.
What it most definitely is not, however, is a plan.
Such a capacity increase is a nice idea in theory, but it falls over in practice because of NHS and social care staff and training shortages.
Health and social care are in a massive mess. Despite significant efforts across the system to start reducing the backlog that was already creating a 4.4 million-long waiting list before Covid19 due to the austerity policies that gave the NHS the lowest decade of funding growth in its history 2010-19 (and due to Covid19 exacerbations, this figure is now over 5.7 million), the ongoing high rate of Covid19 hospitalisations; associated ongoing infection control and prevention actions; and simple staff exhaustion in many cases mean that insufficient traction is being achieved.
I doubt I’m alone in being concerned by the lack of anything that looks like a plan of action, either on waiting times or on workforce. The documents published with the NHS And Social Care Levy do not amount to a plan; the primary care rescue plan is equally platitude-rich and evidence-light; and the Interim NHS People Plan does not count because it is utter nonsense with no actual targets.
The problem is workforce availability. New capacity for diagnostic scans and tests will require people to run them and to read them. If the Government wants 50 million more GP appointments, we're going to need more GPs. We’re short of about 10,000 nurses. New research from Ipsos MORI shows that the fact of NHS workforce shortages has cut through to the British public.
Whether you’re more of a Tolstoy person or a Lenin person, the question is the same: ‘what is to be done?’
The prospect of a journalist having the answers is pretty laughable. Then again, so is the absence of a backlog plan or a workforce plan. This might at least start a discussion.
Anyway, here goes.
The number one thing that can be done at the national level is creating incessant pressure for the Treasury to take action on the pensions taper tax and annual allowance.
There is simply no way the NHS backlog gets cleared without making it possible to pay existing NHS staff more to work more sessions in their organisations at evenings and weekends without generating ridiculous uncertainty over their future tax bills.
It is obvious that our dear friends the Treasury Munchkins don't want to do this.
It is equally obvious that they’ve been forced to make an exception for judges, and so they can be forced to make an exception for the NHS as well. This is something about which every senior leader across health system needs to be speaking out loudly and repeatedly.
The second action that should be national is a convening and co-ordinating function for whatever international recruitment is possible in the now-global market for healthcare staff. It is vital to prevent the ‘robbing Peter to pay Paul’ inflationary effect of organisations or regions on one another.
The third national function should be an immediate resumption of the work that former NHS workforce director-general Andrew Foster did at the start of the pandemic about preparations for getting retired clinicians to return to practice. This made considerable progress, but was halted once the first wave of infections in 2020 was not believed to have demonstrably overwhelmed the NHS.
That decision was a big and foolish error, and it should be fixed.
The fourth national function is around co-ordination of access issues. It has been clear for some weeks that ambulance services have been overwhelmed by demand.
The Foundry database used by the top level of NHS England needs to be used/adapted to ensure that emergency access co-ordination is as well-matched to capacity as possible. This should also be used to create a public-facing dashboard, to let people know about which parts of the system are under most pressure.
The other obvious national review would be of available overseas capacity to treat patients.
At regional level, the top priority should be to resource the directors of public health with greater analytical capacity and capability. This is because I would suggest setting DPHs up as the regional system leaders.
This is not only because population health management is an evidently sensible idea, but also because the regions are going to have to be at the forefront of co-ordinating demand and supply across their populations. This is too big a task for either an individual organisation or a national body. We have known for decades that the Inverse Care Law is A Thing in health systems, yet it is not A Thing in how they are led.
I was also impressed by DPHs’ resolve in telling NHS England where to go when it tried to interfere in their remits during the pandemic. While not all DPHs will want to be system leaders, my instinct is that they need to be firmly at the top level of local systems if we are to see consistently good decisions made at the regional level.
Regional leadership needs to be a convening function, rather than a baronial one – particularly at a time when the crisis is evidently going to be a long-term condition rather than an acute one.
Regions (ICSs, if we must) have the very challenging task of nurturing openness and trust across health systems at scale. They need to do this in a culture in which most of the organisations were forged in the New Public Management cultures of autonomy, competition, growth and organisational self-interest. If they become part of a performance management infrastructure, then their promise will never start to be realised.
In an improving system, the regions would as a group function like a networked version of the old NHS Modernisation Agency. They would be a solutions-focused resource of knowledge and change management, drawing hard and fast on the Health Innovation Networks. The proudest boast of a region or ICS would be ‘we’ve stolen and adopted all these bits of good practice!’. We are rather definitely not there yet.
Communication is one of the key tasks for local organisations. They need to face and speak to their communities in unprecedented ways, as performance is likely to remain troubled for some time.
Organisations should get a leader (ideally a clinical leader) to front a short, fortnightly bulletin for their populations. They should provide a run-down of local demand and activity, including mental health, primary care and community nursing. This probably needs to be done by the best-resourced local organisation, so in practice, almost everywhere it’ll be the acute hospital.
The purpose of this will be to engage a local population directly, using easy and widely-used digital channels (record it on Zoom; broadcast it on YouTube). Its cost is next to nothing, other than in the cost of adequate data preparation – which you're all doing anyway, right?
Simple graphs of the peaks and troughs of demand may help focus the minds of users and managers alike. It doesn't seem real to many people hearing that there are 5.7 million people on NHS waiting lists: the sheer size of the number is too big. It’ll seem much more real when it is related to people's local area. It'll also out regional disparitites.
Of equal importance to local organisations is a renewed effort to look after their staff as well as possible. If organisations have been foolish enough to take out obvious pandemic improvements like free car parking and provision of good access to food, then put them back immediately. Looking at staff rostering for junior doctors is a classic proxy-check for how well organisations value their workforce.
Whether local organisations have individuals with dedicated job titles or not, they need to make staff wellbeing a board-level reporting function, and a top priority. There has been some excellent practice in this regard, but it is not consistent.
The picture at the top of this piece is a pair of paintings of 'The Steadfast' and 'The Magnanimous': well, most NHS staff have been plenty of both. We need to treat them as such.
Local organisations should also look to mine their safety, workforce and bank, agency and staff rota data to see what things they can learn from that.
The ongoing collapse of adult social care won't be turned around any time soon. Acute trusts with significant numbers of medically-optimised patients who can't be discharged need to start local system-level conversations about whether there are ways to source or create capacity. We know that hospitals are not the best places for such people.
Local organisational leaders also need to use their contacts with their local MPs to reinforce the national message about the pensions issues (see first point above). This needs to be coming at the Government from across as much of the Commons as possible.
There are no miracle cures. The current policy approach is a strange mix of Picardism (‘Make It So!’) and England mens’ football tactics pre-Gareth Southgate – faith in a miracle long ball over the top for a tall lad to head into a hopefully open goal. Fantasy of either such kind is no use to us. Some better ideas might be.