Week Commencing 27th November 2017
5 Insights You Need to Know
Welcome to the inaugural WEEK THAT WAS, a Monday synopsis of the most important things that happened last week, with a degree of interpretation. No waffle, no minor news – just the significant stuff to ensure you are current. Enjoy!
This was a very BIG news week, with items signalling a huge top-level battle and quite possibly the approaching end of the Health & Social Care Act 2012. Yes… THAT big! There isn’t a single news item below that doesn’t touch somebody in a very major way and most of them have implications for everybody.
1. NHSE VERSUS THE TREASURY
Following a budget that could best be described as non-descript, in which some money (£1.6 billion) but not enough money was given to the NHS for 2018/19, in a rare departure (but becoming much less rare) from its normally politically-guarded self, NHSE came right out and said that the NHS could not deliver on the Government’s expectations (and constitutionally guaranteed) targets.
This is enormously significant at so many levels.
Firstly, DH has always flatly refused to entertain the notion of not providing or even limiting what it sees as a core responsibility, so this pitches NHSE and the DH/Treasury at loggerheads. The fact that it has happened at all, given the possibly career-limiting consequences for NHSE top brass, should tell us just how dire the situation is perceived to be – sufficiently dire that career risk is seen as the more palatable option.
Secondly, the discussions around it signal an NHS that provides certain core things well, and other things not at all, something I have been predicting for some time, signalled too by the narrowing of STP funding criteria to just A&E and finance. This will likely leave some things free at the point of delivery and universally accessible, whilst other things end up being limited or accessible privately to those that can afford it.
I want to stress that this ‘inevitable restriction’ is the NHSE position, swiftly rebuked by Mr Hunt (hence the loggerheads). Simon Stevens was very publicly clear what was needed financially and equally clear that what we got fell far, far short. Mr Hammond’s office allegedly said that the reason it was £1.6bn and not £3.0bn (still not enough) was because Mr Stevens tried to publicly bully the treasury, something we just can’t have, according to Mr Hammond. The truth in the story is difficult to verify but if points of principle, not assessments of need, are now driving policy, we are in big, big trouble.
I personally think that it is far more likely that it was a sum Mr Hammond couldn’t afford to give but didn’t want to admit. Mr Stevens handed him an excuse. Either way, we are in deep, deep do-do and Mr Stevens may even be counting his days. The symbolic consequences of such an outcome i.e. removing Mr Stevens because he says it isn’t all possible (a line that NHSI have flatly refused to entertain from providers too), are difficult to comprehend. The message sent to the millions of NHS employees would be stark, to say the least. What I don’t see the likelihood of is the treasury suddenly finding more money.
At the NHSE-level, discussions on what to cut and what to protect have started. A&E, Cancer Services, Mental Health (already wildly under-funded) and Primary Care seem to be secure but that leaves a VERY big list as of yet undiscussed. I don’t think I have to stress the importance of following this, or the implications, but the uncomfortable question to keep in mind might be “just which list is my work on?”
2. END OF THE MARKET?
If the implications of the above weren’t eye-watering enough, in an interview with Health Service Journal, Mr Hunt came right and said that the NHS internal market and the autonomous nature of Foundation Trusts stood as a barrier to standardisation and thus safe care. The huge question is whether this signals an abandonment of the Health & Social Care Act 2012, in which these principles of structure and function are enshrined… in law!
Perhaps my favourite quote by Mr Hunt was “If we know something works we should just get on and do it” (I kid you not…). Whereas very few would disagree with his apparent support for evidence-based medicine, almost everybody at the coalface would express some degree of concern on the interpretation of evidence, not to mention how you control for whether the resources are available or whether the otherwise untested intervention works. After all, Mr Hunt is adamant that 7-day services are clearly supported by evidence. If he didn’t have his barriers, it would be very easy to see us ‘just doing it’ and without additional funding and quite possibly without any evidence that it will make a blind bit of difference.
I do not believe this is remotely about safety and evidence. If you examine the safety performance of Foundation Trusts versus those without foundation status, you would more likely conclude that FT status is associated with greater safety. Whereas you couldn’t claim it is because of FT status, you absolutely could not conclude that FTs stood in the way of safety. But why let the data sway you… surely, we should ‘just do it’ because Jeremy says so. And that highlights the most likely reason for the rhetoric. Autonomous status and an internal market create a series of conditions that the SoS does not like:
- You can’t just tell people what to do
- You can’t just change things on a whim
- The market-maker has to be neutral (and we already see huge bias from the DH and NHSI)
Sustainability & Transformation Planning is a fine example of market-maker bias, hidden behind the apparently neutral act of making support available to everybody… just as long as they hit their financial control targets… which are set individually by… the market-maker. Of late, we have seen a rapid escalation of NHSI and the DH wanting to just tell people what to do and an increasing degree of push-back from acute trusts who realise it isn’t possible. But that’s not what Jeremy wants to hear.
So, returning to the bigger question, it is at least possible that the DH may be considering a move away from the market, requiring a legislation change and probably a plethora of law suits from those that invested based on the principle of market forces and protection of competitive interests. Before you all start cheering, I would urge you to consider the most likely reason for this change, uttered from Mr Hunts very lips… because we should just get on and do just what he says. With that in mind, and recent experiences including the junior doctor contract and 7 day services, I do urge caution in what you wish for. The market & FT status might suddenly appear more like an insurance policy.
3. GOVERNMENT SECRECY
In what might sound quite minor and somewhat ‘conspiracy theory’ but I suspect is more major, we have seen multiple instances in that last week or so whereby the Government has deemed discussions and information ‘too commercially sensitive’ to release.
The one you may be aware of is that refusal to disclose the substance of the Brexit divorce bill. Presumably if this was a triumph of superior negotiation, Mrs May would be only too happy to shout it from the roof-tops. Consequently, we might be safer concluding it is likely to cause an outrage and therefore safer to keep quiet. That it might cause an outrage is super-bad news for the NHS and certainly doesn’t suggest £350m a week extra coming our way anytime soon.
The other case in question was the Health Committee being forced to ‘demand’ reports from the Department of Health, over the issue of universal meningitis vaccination beyond 12 months of age and whether it should be funded. Again, the assumption has to be that if the decision was clear and evidence-based, then the evidence shouldn’t be something that is withheld.
So, what does this mean? It might be a storm in a teacup but it could also be a ragged Government, with insufficient money and an increasingly dissatisfied electorate, trying to take decisions or avoid spending money but without what many would consider a normal democratic process… or ‘losing it’ would be the simpler description.
So, at a time when perhaps stability should be considered critical, are we seeing the collapse of Government at a critical juncture for both Brexit and the NHS? If that isn’t the answer… phew… but… hang on a minute… it then means that we have a Government that now thinks we should ‘just do it’ without evidence or oversight. At least Mr Hunt and Mrs May seem aligned on that one. I am watching for further evidence…
4. PAY FOR PERFORMANCE & CHANGE
Mr Hunt has been very busy this week but then if you chuck out so much news, maybe someone will miss the significance in the scatter. Well, the juniors have had their contract changed (imposed), the consultant one is under discussion and so now it is time for ‘everybody else’ or, more accurately, Agenda for Change (AfC) staff. So what did he say? The gist of the statements are:
- Automatic increments are bad – we should reward attainment of performance goals and standards
- The NHS works 24/7, so contracts ought to reflect weekends etc as normal days
- In exchange for losing automatic increments, you’ll have fewer grades and you’ll reach higher amounts earlier, allegedly
- A pay rise and additional funding for it will be made available but only if progress on the contract is made
- It’s absolutely, definitely, 100%, totally and unequivocally not about taking money away, Gov… honest, trust me
He said that the juniors contract “was sensible” (no, honestly… he said that) and would provide a good model (presumably with riots, strikes and then impositon to match).
So, how do we interpret this? My top line conclusions would include:
- Regardless of insufficient money, the 7-day service agenda is full steam ahead
- The DH would like to move away from an automatic, crystal-clear, unambiguous set of criteria for grade progression, to one that is locally set, based on performance and thus totally subject to bias, especially in times of austerity
- Agree, or there’s no pay rise or funding
I don’t think I am being cynical when I say that the long absence of a pay rise is being used to gain a superficially thought through (by those subject to it) agreement of new terms that have very considerable long term implications, even if they might appear palatable (not least because of the pay rise) in the short term. But what are the implications?
My belief is that the more difficult ones to address lie in the difference between the ideals set out in a new set of terms and the reality on the ground. With sluggish recruitment and arguably little growth in things like nursing numbers, if the contract averages out the week i.e. 7-day becomes the reality, the too few staff we currently have will be ‘encouraged’ to work even more on bank, which will now be at a… lower, normalised rate. Additionally, with the increasing use of more junior staff e.g. healthcare assistants, for routine day-time work, it is also entirely possible that nurses find themselves increasingly picking up the nights, weekends etc at this lower average pay rate.
The more immediate effect of a switch to performance criteria for advancement is that bias will likely creep in to decisions and yet the diffuse, local nature of the proposals will make it more difficult to spot. If we operated in an financially abundant system, this might be less of a risk but as we already see significant perversions at the hands of insufficient funding, why would we think this wouldn’t be subject to the same effect? It would be just too tempting.
Ultimately, and we have to consider that I am making many assumptions here that are as of yet unconfirmed, I am concerned that the staff will agree, the reality will emerge and they will feel cheated by stealth. That may well be the final straw on the back of an already extremely shakey camel – staff loyalty to the NHS. Again, the news might be about AfC but the implications will touch everybody. Another space to watch closely…
5. NEW PERMANENT NHSI BOSS
We have known about the entirely scheduled departure of Jim Mackey back to the North East for some time. However, this week saw the end of the hunt for a new boss of NHSI. And the winner is… Ian Dalton CBE, just a few months into his new post as CEO of Imperial College Healthcare NHS Trust, who now have to find yet another CEO.
Mr Dalton was David Nicholson’s deputy CEO and chief operating officer at NHS England until he left for the private sector (as President, BT Global Health) in 2013, and at the time the hot favourite for the NHSE chief role. That may now become a reality given earlier news. Really? Why?
We already know that the normally quiet Mr Stevens has stuck his head firmly above the parapet, in direct conflict with the Treasury and thus, by default, Mr Hunt too. That tends to be career-limiting and the early signs are that neither Hunt nor Hammond are happy. We have to throw into the mix that there is considerable discussion about the potential merger of NHSE and NHSI too, something that would require only one big boss.
I know, I hear you saying that the news also said that the ‘constitution’ prevented merger and thus ‘closer collaboration’ would have to be the answer. What, you mean closer collaboration like a single, shared chief officer, like some STPs, Trusts and numerous other agencies across Government? We have also to remember that My Hunt, this very week, perhaps signalled the imminent demise of the very legislation that prevents that merger. These are NHS tectonic plates and they are shifting. I think we can expect some earthquakes, given the tremors we are already getting.
Mr Dalton says he is looking forward to a new era of support and oversight. However, the longer term implications just may be a return to a Nicholson-esque style of leadership, with a leaning somewhat to autocratic control. Nonsense, not in today’s shared, collaborative NHS surely? Well, I like to be evidence-based and given that Mr Dalton’s appointment could not have been passed without the endorsement of the SoS himself, we’d probably have to look to Mr Hunt’s latest leadership mantra to get a steer. That would include… imposition of the junior’s contract, a desire to just flippin’ do it because he says so and a stated move towards the dismantling of legislation that allows for autonomy. Just saying…
In Quick Summary
So, putting all of these things together, it seems to play out one of two ways. The proof of the pudding will emerge as either elation or indigestion downstream. To me it looks like some months from now, either:
Mr Stevens wins, the NHS gets properly funded, we finally lose the not-quite-real internal market, a return to the seemingly more workable regional health authority type structure, gain a new era of collaborative support from NHSI and the hard-working nurses get a pay rise… or…
It’s curtains to Mr Stevens, NHSI and NHSE get merged under a new old leadership regime akin to Mr Nicholson’s era and any last semblance of autonomy, and thus resistance to lunacy, is crushed by the crushing of legislation that protected it. The nurses do get that pay rise but then realise it was ‘virtual’ not real, then leaving in droves to work in Australia… or Tesco.
Place your bets please… place your bets.