Cowper’s Cut: The two NHS cultures

Bear with me, because this is relevant to where the NHS is right now, as the pressure of covid-19 is reaching the first of its peaks. We need to think about the cultures active within the NHS right now, and in particular how their strengths and weaknesses can be recognised, in order that the right bridges between them can be respectively built and burnt.

Broadly speaking, the government’s recognition of reality – that as the funder and lender of last resort, it must do (in European Central Bank ex-boss Mario Draghi’s memorable line) “whatever it takes” – has driven and enabled an unprecedented pace of change in the NHS.

(Social care has, as usual, been largely ignored, but this can’t continue for long.)

At the moment, the NHS is morphing from its ‘business as previously’ culture into a ‘military-style centralised command-and-control meets act-first-and-ask-permission-later’ culture.

Centralisation’s strengths and weaknesses

One certain result of this is that the NHS will not return to ‘business as previously’ completely. Professor David Oliver’s latest British Medical Journal column is thoughtful on this as it relates to secondary care. It seems probable that primary care will be largely ‘digital as default’.

Centralisation, when combined with the “we’re on a mission from God” motivation that a respiratory pandemic brings, sees stunning rates of change, including (but very much not limited to) the new regional capacity additions in exhibition centres and sports stadiums.

However, we know that centralisation has also resulted in screw-ups. The supply of personal protective equipment will surely be a major focus of the inevitable upcoming Royal Commission or public inquiry; so too will testing capacity and planning.

The wash-up on all that is, as I have consistently written in these columns, a matter for another day.

Idiots in ‘still idiots’ shock

But the warm-ups for the blame game have started already. Perhaps this isn’t surprising: the government has just seen its honeymoon period turn into what the French call ‘la lune d’absinthe’ – the month after the honeymoon (‘la lune de miel’).

Efforts from the government and its SpAds to blame the NHS are already under way, as made clear in Tim Shipman’s well-informed piece for The Sunday Times. It’s one to watch.

The herd immunity hokey-cokey

The silliness is widespread. Having first advocated and then disowned ‘herd immunity’, it was again being advocated over the weekend.

Leaders should bear in mind that the temptation to use ancient-system tactics of bullying and browbeating staff who have publicised the poor availability of adequate PPE and testing will rebound on them publicly and spectacularly, once all this is over.

It is a fantasy to believe that having these issues raised in ‘discreet meetings and back-channels’ would have put the issue as high up the media and political agenda as it has recently become: for proof, witness Boris Johnson fanzine the Telegraph’s recent headline ‘Questions Without Answers’.

Justice, like revenge, a dish best eaten cold

It doesn’t take very much thinking to realise that once all this comes out, the public are always going to come down on the side of doctors and nurses – the most trusted professions. Nor indeed to remember that the NHS will still have massive workforce shortages after all this is over.

Equally, we must hope the leaders of the representative organisations are not on one hand displaying a publicly emollient ‘not yet’ face on the system screw-ups while privately encouraging NHS leaders to pursue a ‘feet-to-the-fire’ policy. That would be as disclosable as it would be unwise, which is to say, very.

Centralisation seems attractive and effective when you have to do a relatively few things fast and at great scale. Indeed, it’s probably the only way to do such things.

Yet we should also remember that the trajectory away from centralisation also took place for various reasons. Not all were good, but not all were bad either.

There are clinical priorities to resolve, which must rank far higher as a leadership priority than ‘blame game’ power politics. At the right moment, that will be an easy debate for the NHS to win.

Things to fix

For now, there are still important things to fix, like data requirements which are being poorly handled. The data on covid-19 deaths is poor. It started with just bald numbers of cases, offering no way to look at or for trends. The Public Health England dashboard is not viewed by data scholars as a triumph.

Moreover, the official data releases only outline the number of deaths and indeed recoveries that take place in hospital. That is not providing the surveillance data that we are likely to need.

Oh, and wasn’t it fun to see in Matt Hancock’s Thursday speech that the government was granting a “£13.4bn debt write-off” for the NHS? The proper headline for this should, of course, have been ‘Government Writes Off £13.4bn Of Its Historic Underspending On The NHS’. You’re welcome.

The data day

The results of the latest British Social Attitudes health and social care survey were released this week. It found that “after falling for the past two years, public satisfaction with the NHS overall rose significantly in 2019. Overall satisfaction was 60 per cent – a 7 percentage point increase from the previous year”.

This did not get much media space, but will probably risk being hijacked by political hacks once this crisis is over.

The obvious thing to say is that the research for this survey (July-October 2019) took place after the new money for the NHS had been announced (and announced and announced), first in June 2018 by prime minister Theresa May, and almost immediately after the election of Mr Johnson to replace Mrs May as prime minister.

You will not forget that Mr Johnson announced on his victory that there would be 40 new hospitals and 50,000 more nurses for the NHS.

He said, “My job is to protect you or your parents or grandparents from the fear of having to sell your home to pay for the costs of care and so I am announcing now – on the steps of Downing Street – 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”.

Nine months on, there is no sight of this plan for social care.

The 40 new hospitals is in reality, six partial redevelopments and some seed funding.

While 19,000 of the 50,000 more nurses are actually existing NHS staff members who the government now assumes will not quit.

We also know that NHS performance was at that period of time slipping to record lows (and has since fallen yet further).

These inconvenient truths got far less airtime than they should have done because so much of our national media is, frankly, shit at its job.

Anyway, it is brave of the King’s Fund and Nuffield Trust to back the BSA survey. The Department For Health But Social Care stopped funding it years back: without the think-tanks, a vital data set would have been lost.

Politics: an Opposition re-takes the field

Members of the idiot Trotskyist community will doubtless be weeping about the departure of Labour’s former leader, serial general election loser Jeremy Corbyn. Members of the reality-based community can breathe a sigh of relief that Labour’s membership elected the most obviously capable candidate by a huge enough majority to win on the first round.

Time will tell whether Sir Keir Starmer, Labour’s new leader, can establish himself positively in public perception during this crisis. Opposition leaders get only the one shot at defining themselves to the electorate. We shall see how former lawyer and then director of public prosecutions fares.

Sir Kier (as I predicted) has sensibly chosen to continue with Jonathan Ashworth as shadow health secretary. Mr Ashworth’s persistent and polite style, devoid of pyrotechnics and dogma, has been very effective in content and tone at delivering constructive and measured opposition during this crisis. He emerges as an enhanced figure.

Competence and grasp of detail are going to matter massively in our politics, just as they haven’t in years.

Meanwhile, the first peak is almost on us. Look after your people, and after yourselves, and good luck.