Cowper’s Cut: The new Nicholson Challenge – moving on from David to Viv

In the light of the NHS Rhetorical Spending Review turning into an actual almost-sort-of-promise of jam tomorrow, the NHS leadership groups face some interesting questions.

The first question for the service is how it can best move on from what Stephen Dorrell cleverly dubbed “The Nicholson Challenge” (saving money through centralised changes, which as I noted last week, has never really ended), to what we could call “The Viv Nicholson Challenge”.

What is the most effective and efficient way to “spend, spend, spend”?

The second question, obviously, is how much more money to ask for, and what to promise in return?

The blinker and the banker

The government has been playing austerity poker with the NHS leadership, and has blinked first. We should be crystal clear that prime minister Theresa May has been walked up to this decision by clever teamwork and no small amount of cojones on the parts of Jeremy Hunt and Simon Stevens. I wrote about Mr Hunt’s “don’t mention the funding” tactics in last week’s column: it wasn’t subtle, but it was effective. And that is what counts in politics.

The reason why our strong and stable prime minister blinked first is not hard to find. You can look at Slide 7 of the latest Economist/Ipsos MORI Issues Index, or follow the time series of trends in the public’s views on the best party on healthcare.

It was interesting to read the excellent Isabel Hardman, one of the most accurate chroniclers of the Conservative party, suggest in the Spectator that the consensus on boosting NHS funding was wobbly. Smartly, Ms Hardman also noted just how effective Mr Hunt’s campaigning for more money has been.

Ample room for error

There are a lot of ways in which this can still go wrong. And a lot of them have to do with the Treasury (or, as people who read the Treasury at their own inflated self worth have taken to calling them, “Treasury”. I’ve always thought of “Treasury” as a rather sweet term of endearment – “ah, Treasury, give me a little kiss-y!”. Hence my habit of referring to them as “The Treasury Munchkins”.

“Treasury” (ugh!) see themselves and would like to be seen as semi mythical Mistresses and Masters of the Financial Universe.

Well, they’re not. They’re the bank.

They are a utility function for government finances.

Drop the dumb buzz-phrases

So, if we can stop all this false reverence, that can prevent the NHS leadership from the corny cultural cringe of trying to conceptualise the NHS as “an investable proposition”.  That is yet another nonsense phrase that we should consign to the dustbin of public policy history.

Most of the money we use on the NHS is not invested: it is spent. And that’s a feature, not a bug: we want it to be spent, because it buys healthcare things that we want and need.

As soon as we get captured by nonsensical pseudo Universe Mastering rhetoric like “an investable proposition”, we stop being able to think clearly.

And when there’s a possibility of being able to get some more money for the NHS, which blatantly obviously needs it, we need to be thinking very clearly indeed.

Already we have siren voices calling for a hypothecated tax to fund the NHS: the iridescent Professor John Appleby dissects the reasons why this is Still A Bad Idea for the BMJ. TL:DR – hypothecation is a ring-fence ultimately made of loopholes (see the road fund licence), and offers no protection in economic downturns.

The offer and the ask

I’m slightly less nauseous about the retail derived language of “the offer” and “the ask”, which I associate with the “triangulation” political theories first expressed as such by Dick Morris, political advisor to Bill Clinton.

What the NHS leadership needs to get together in very short order is basically a priced menu. Mrs May, Chancellor “”Spreadsheet” Phil Hammond and the Treasury Munchkins should be offered a costed version of what it will require to get the NHS back to meeting national waiting standards. I asked colleagues about this on Twitter yesterday, and got some useful responses.

Waiting time dynamics expert Rob Findlay of Gooroo has suggested that the price of restoring 18 weeks alone would be of the order of “£2.1bn in 2018-19 and £350m in subsequent years if other pressures and enough mainstream capacity are funded… (If they are) not funded… the total cost is £4.2bn in 2018-19 and £1bn in subsequent years”.

That doesn’t include accident and emergency, cancer, or mental health. They need (variously) management and flow capacity; physical capacity (buildings); technology; staff and high-tech drugs and kit.

Nor does it include social care, which is one important part of hospitals’ flow problems that manifests in long A&E waits.

And just to put all of this into a tax raising context, the reduction in the tax base caused by a) the global financial crisis and b) the ongoing raising of various tax thresholds and reductions in corporation tax means that where 10 years ago, one penny on the basic rate of income tax got a government £6bn, it now gets about £4bn.

Get crunching, number people. Keep politicking, political people. To get the “ask”, the NHS needs an “offer”.

This is not yet a done deal, by any means.