The fine art of being found out

The only possible way to start this column is with a simple, short message to every person in the NHS at every level who have been working flat-out since the covid-19 crisis hit a poorly-prepared nation. Thank you very much: you have saved many lives and risked your own.

Without highly reliable data on new covid-19 infections of the kind that an effective testing regime would enable, we cannot be certain that the first wave is yet at its peak. But it seems probable, even though we know that covid-19 death numbers will continue to rise, as the sickest patients go through the system.

This feels like a valid moment for some reflection and review.

The first point on which we should reflect is that an NHS and care system badly hobbled and harmed by the pointless Lansley reforms and a decade of funding austerity has performed magnificently. This has largely been a series of local and regional triumphs, with national-level co-ordination and contributions of varying value.

Perhaps least helpful has been the worst of NHS England’s New Labour tradition of communications control-freakery and wannabe bad news management: this is something which neither helps nor works in a crisis, other than to make those trying it look silly and superfluous.

Front-line clinicians and managers worked together to deliver this, redesigning, redeploying and effectively remaking the system to cope with the peak of covid-19 demand. This NHS Providers briefing is a good overview, and summarises some shrewd, well-informed thoughts about where the system may go next.

There have been criticisms of the new Nightingale pop-up hospitals (particularly for London’s, with their recent demand for more clinical staff when patients are transferred there, where patient criteria and acuity are not yet clear). Nonetheless, their creation was fundamentally a sensible decision because the peak of covid-19 demand could easily have overwhelmed even the expanded and reconfigured traditional acute sector. We have been lucky there.

Now the Nightingale pop-ups offer us capacity and therefore choices about how we re-open more of the traditional capacity. They were a good decision, well-realised.

The media/political Rorschach tests

Many readers may have seen comment articles in national media asserting the inflexibility, lumbering, un-adaptable Stalinist nature etc of the NHS and wider public sector, and wondered on which planet their authors have been self-isolating. Answers on the back of a Boris Johnson fanzine, please.

Speaking of which, another diverting genre of national media content has been the recent comment pieces reflecting on how Mr Johnson’s character, illness and recovery tell us something about something (in reality, it’s the authors’ ideologies and desperate need for insider access).

Ventilator Blues

To these set of media/political Rorschach tests, we should add two detailed articles: the Sunday Times ‘Insight’ on the Government’s general handling of the crisis, and in the Financial Times on the specific topic of ventilators. (The Cabinet Office has taken the highly unusual step of responding to the Twitter thread highlighting this article.)

The Sunday Times piece shouldn’t be treated as gospel. There is some Cabinet infighting for Mr Johnson’s leadership rivals in play, and the identity of one of the main sources is screamingly obvious. General backside-covering is at work here too, but broadly speaking, these pieces are as accurate as they are damning about the government’s preparations.

And they are very damning indeed.

Professor Alison Leary makes telling additional points about the lack of consultation on PPE and ventilators.

There is, of course, complexity in this. As we saw in the debate among epidemiologists, there are diverse views on the science. Adam Oliver of LSE has done valuable public service for the Health Economics, Policy & Law journal. He observes that “it will be a long time before anyone knows what the best approach is/was for dealing with this pandemic (indeed, it may never be known, due to the multifarious factors that have to be balanced against each other) … given the complexity of the challenges that the pandemic poses, we cannot yet know – and we may never know – what is/was the most effective strategy for dealing with it.

“But we might speculate that it might have been most beneficial to very quickly close the borders to those coming from high risk countries, and to implement aggressive contact tracing/digital tracking”.

He rightly goes on to warn of the risks of “creeping authoritarianism and a surveillance culture” from digital solutions. Trade-offs are a very real thing in complex public policy.

(UPDATE: The Government has released rebuttals to both the Sunday Times and Financial Times stories, the detailed and lengthy nature of which may not be entirely unfamiliar to readers of the PM’s chief advisor Dominic Cummings’s blogs.)

The fine art of being found out

Caveats apart, the government’s revealed lack of competence is genuinely striking.

It is not, however, surprising. British media went to shit first. British politics followed.

Our media and our politics both suffered from the same rush towards cheapness and emotion, and away from expertise, experience and reflection. The inevitable consequence has been that much of both became a realm of entertaining, emoting, posturing and simpering.

It would feel almost cruel to point out our work experience health and social care secretary Matt Hancock’s copious form in this regard, were it not for his breathtakingly inappropriate comments to the Commons Health Select Committee meeting this week that “I would love to be able to wave a magic wand and have PPE fall from the sky in large quantities, and be able to answer your question about when the shortages will be resolved”.

“Magic wand”? At a time when patients and NHS staff are dying of this? That’s a grown-up’s answer, is it?

It is in the same league of shallowness as home secretary Priti Patel’s classic Non-Apology Apology that “I’m sorry if people feel there have been failings” over PPE supply.

These daily televised covid-19 briefings have been a fascinating exercise in letting the process of British political journalism get wide coverage. ‘The Lobby’ has not stood up well to daylight being let in on its magic: its pack-hunting, line-agreeing tendencies have become screamingly obvious.

Specialist health correspondents and regional news journalists have been notably the best questioners, but this format has given the politicians too much of an armchair ride. Questions have been too imprecise, too long and too overlapping: as a result, responding has become a learnable, performative skill; perfect for this generation of political automatons.

Too much of the media, like too many of the politicians, are undergoing the fine art of being found out. Good. They have chosen it, and they deserve it.

Three thoughts

The late Bob Sang was a great advocate for public and patient involvement in health, as well as a trusted confidant to many NHS leaders, whom he would often phone with ‘just three thoughts’. In his memory, here are three to conclude this column.

One of Bob’s policy taxonomies has been on my mind a lot recently: a four-quadrant matrix model of effectiveness (high-low) versus certainty (science-faith). It can be simply expressed as follows: ‘things we hope will work; things we know will work; things we hope won’t work; and things we know won’t work’.

We may need to use this repeatedly, as we plan for the next stages of these events. As I have previously written, there will be unsubtle government attempts to shift blame onto the experts and the NHS. The NHS may become vulnerable, as it starts the trajectory towards resuming a more normal pattern of operations and services.

The second is linked to this: once more normal service resumes, a lot of people are going to be scared of going to a hospital for a long time. This situation, alongside the huge RTT and non-RTT waiting lists, will need to be managed. Former NHS manager and management consultant John Bennett observes on this latter theme that there are clear consequences to and requirements from this: “total transparency on the data. Clinical risk management and harm process agreed. Then, sequencing of interventions. All with understanding of consequences. Don’t forget diagnostics … be ruthlessly simple, objective and transparent. Work together on the sequence of actions, and over-communicate”.

Third, but not least, is social care. covid-19 is taking a deadly if very predictable toll on the sector, the extent of which we will not know for some time. There will be consequences for the sector’s capacity, and indeed its risk-aversion as regards who will be accepted. Professor David Oliver’s 2017 article on the crisis in the sector bears re-reading.

However, it is perfectly plausible that the legal consequences of these death rates, on top of the sector’s assorted failing business models, including that of private equity, may mean that the NHS ends up having to nationalise social care more or less completely.