A Platonic dialogue between a health secretary and a chief executive with performance problems.

“The unexamined life is not worth living” – Socrates

A MONDAY MORNING IN A MANAGEMENT OFFICE OF AN NHS PROVIDER. THE PHONE RINGS BALEFULLY.

CHIEF EXECUTIVE: Hello?

SECRETARY: It’s Jeremy (the health secretary one) on the line for you.

CHIEF EXECUTIVE: Thanks.

THE CALL IS CONNECTED.

CHIEF EXECUTIVE: Secretary Of state, what a delightful surprise to hear from you! And of course congratulations on your re-reappointment. Now you’ve won the job three times, do you keep it for life? Or is that just the European Cup trophy? (Sorry to mention Europe: must be a sore point.)

HEALTH SECRETARY: Is that a football joke?

CHIEF EXECUTIVE: Possibly.

HEALTH SECRETARY: Yes, well, I’m afraid the latest figures on your organisation’s performance are no laughing matter. And that’s what this call is about.

CHIEF EXECUTIVE: You astound me, secretary of state.

HEALTH SECRETARY: I’m afraid these figures are pretty astounding. Let’s start with the money, because your run rate appears to be almost 6 per cent off trajectory for Q1, so what are you doing about it? 

CHIEF EXECUTIVE: I’m very glad you asked me that, actually. We have ambitious land sales plans, inspired by the Naylor Review, which we feel sure are going to get us back into a healthy albeit non-recurring financial surplus.

HEALTH SECRETARY: That’s great! So what’s your approach?

CHIEF EXECUTIVE: Well, as you know, we’re across three sites, and the Anytown DGH has long been difficult to staff safely in several departments, which we think is having an impact on some of our outcomes. And our past plans to downgrade Anytown have come up against fierce local opposition, usually led by the sitting MP worrying about the next general election. But thanks to the Prime Minister’s strong and stable orange majority, this time we think we’ve got the perfect solution: it’s an STP solution.

HEALTH SECRETARY: STPs do seem to be the answer.

CHIEF EXECUTIVE: Exactly. The NHS’s latest and greatest acronym: Sell The Premises. We’re in late-stage negotiations with NHS PropCo to sell Anytown to them as a prestigious country home and driving range.

HEALTH SECRETARY: But Anytown is in Chris Grayling’s constituency. That won’t do.

CHIEF EXECUTIVE: I don’t understand, Secretary of state. At your King’s Fund appearance last week, you were very keen to see the system getting on with some innovative thinking backed by intellectual rigour. And we’re still outspending primary care, so we’re clearly making best use of resources. Can’t have wasteful surplus estates. 

HEALTH SECRETARY: But what do your clinical commissioners think about this?

CHIEF EXECUTIVE: Our imaginary friends? They’re quite interested in our demand management proposals: that they set up a private company to hire their GP receptionists, whom we can call to act as locum front doormen and doorwomen across our remaining two sites’ A&Es. I’d say they’re quite confident that this can help us manage rising demand locally.

HEALTH SECRETARY: But won’t that prevent people who really need A&E accessing services? 

CHIEF EXECUTIVE: Primary care deals with the mismatch between available appointments and public demand every day, secretary of state. The provider sector can’t be too proud to learn from our economic and political inferiors.

HEALTH SECRETARY: I’m also hearing about some rumblings of discontent from the LMC and the royal colleges about your workforce turnover and morale, and the risks to making the NHS the safest, most learning healthcare system in the universe.

CHIEF EXECUTIVE: If the rumblings aren’t just indigestion from gorging on their members’ astronomical exam fees, I’d probably be slightly concerned. But we’ve taken our lead from you on this, to be fair. You’ve been an inspiration to get Britain exporting again. Of course, exporting the NHS’s junior doctor workforce to Australia, New Zealand and the USA is a lateral, not to say novel approach, but we feel that any medical malcontents being misled by their trades unions to think they should work humane and sensible rotas will benefit from the experience of other health economies.

HEALTH SECRETARY: I’m not sure I’m absolutely comfortable with this strategy.

CHIEF EXECUTIVE: That is a shame, but since I’m working my last six months before I take early retirement, I’m sure we’ll find a way to live with one another on this. And I’m seeing Ian Katz for dinner tonight, who as you know is the producer of Newsnight. The duty of candour is always at the forefront of my mind, secretary of state - as is Gary Kaplan or Virginia Mason’s line to you that “the path to safer care is the same one as the path to lower cost”. Was there anything else you wanted to talk about?

THERE IS A SHORT PAUSE, FOLLOWED BY A MUCH LONGER PAUSE. THE PHONE LINE GOES DEAD.

Andy Cowper is comment editor of HSJ