The NHS leadership doesn’t seem ready to openly discuss the problems besetting the NHS, especially the workforce crisis, let alone seek meaningful solutions, notes Andy Cowper

We live in remarkable political times.

As if it were not good enough news that Lord Ashcroft and Isabel Oakeshott (they of the famous David Cameron pig anecdote biography) plan a “no holds barred investigation into the NHS”, the BBC’s agenda setting Andrew Marr Show featured a 10 minute interview with Health But Social Care Secretary Matt “The App” Hancock, in which he was asked no questions about the NHS.

Not one. (There was one on social care.)

It is almost as if very few people in the world of mainstream political discourse have serious curiosity or consideration about what’s going on with the NHS.

Perhaps the NHS’s future has been put in the “Too Difficult” box; perhaps this is another effect of what I have frequently observed is the reality bonfire of Brexit sucking all the political air out of the room.

If I am correct in these observations, these are not the conditions of production which will lead to a serious attempt at creating a 10 year plan for the NHS. Far less are they the conditions of consumption – let alone successful delivery – of such a plan.

Regardless whether it is Mr Hancock’s 10 year plan for patient safety or the NHS Commissioning Board’s Sun King Simon Stevens’ reform proposals, any effective medium to long term plan for the NHS needs three things: realism about the problems; engagement of stakeholders from the outset; and a sense that it is credible and possible.

If these three things are present, they are in impressive camouflage.

Towards counting properly

Last week, I wrote about the chancellor’s wildly inaccurate suggestion in his party conference speech that the NHS budget was going to grow by almost three quarters in the coming period.

Despite my inquiries, I must report that the combined might of the press offices of the Conservative Party, Her Majesty’s Treasury (hello, Munchkins!) and the Department For Health But Social Care have failed to come up with an explanation of the maths involved.

So, it is with some pleasure that I noted that the excellent Full Fact’s Claire Milne is trying to get to the bottom of this. (“Getting to the bottom” could scarcely be a more fitting metaphor.) 

Remarkably, “Sumproduct Phil” (as the Nuffield Trust’s John Appleby wittily renamed him) got the NHS funding increase figures (just under £21bn a year by 2023-24) right on Friday night’s BBC News At Ten, when interviewed by the grown up economics correspondent Kamal Ahmed.

“Special Maths”

If the reality of the chancellor’s numbers is contingent on the environment in which they are delivered, this gives the NHS a perfect off the peg riposte to the overspending/underfunding psychodrama that is surely going to continue. The script can read:

TREASURY MUNCHKIN: You are a bad naughty overspending NHS manager, and we are going to come down on you hard for your deficit and missed control totals.

NHS MANAGER: But I reported inaccurate and unrealistic figures, as I was incentivised to do. It’s like when your boss tells his party conference that the NHS is getting £65bn extra. It’s “Special Maths”.

TREASURY MUNCHKIN: The Prime Minister has announced that austerity is over: that means you’ve got to stay within budgets.

NHS MANAGER: That’s fine: we’ll stop payroll for the staff and business rates payments to the council, and stop paying suppliers and utility companies (especially clinical waste). Your move.

(They do not move.)

The gap between NHS activity and funding is going to continue because as ICHP boss Axel Heitmueller points out, there is no clear theory of change (and he rightly notes that the Cabinet Office’s last 2006 iteration remains worth a look).

But it’s more than that.

The NHS system leadership community has been so busy trying to minimise the hardness of the landing and net off commissioner underspends against provider overspends that some of the big factors sitting underneath the consequences of the NHS activity/funding gap to patients, staff and service users alike are not really being openly discussed; let alone solutions meaningfully addressed.

There is a widespread failure to grasp the nettles.

The driver of rising demand is in no small part demographics. Outwith a serious flu epidemic, that is unlikely to change.

The number of older people will continue to grow, not always ageing more healthily. Our ability to bend the demographic demand curve downwards is probably not great. There isn’t an app for that.

Probably the biggest crisis in the NHS is the workforce crisis. I wrote about this in June 2017.

We keep on seeing the myriad ways in which the cocktail of angry nativism, Theresa May’s “Hostile Environment” policy and Brexit are throwing impediments in the way of importing the staff the service needs. I wrote about this in July 2017.

Pulling out the nettles

This column’s title is about grasping the nettles, but of course you need to be wearing gloves before that is advisable.

Assuming the system leadership and the political classes want to don those gloves and grasp the workforce nettle, it’s useful to know how you pull up the nettles so that they don’t come back.

You have to grasp the nettle as close to the base as you can, and pull gently but firmly so you can see (literally) the root of the problem.

Once you can see the root of the problem, then you have to get your fingers around that root, and pull it out of the ground intact, slowly and firmly. It is a case of inexorable and unrelenting pressure. And the roots are a network, which can range quite a way.

Pulling up the roots takes time. It is uncomfortable, and you are on your knees in poor quality soil. You are inevitably going to get stung at points.

And you are not going to get up all the roots in one go. The roots that stay in the ground will flourish forth new nettles next year, and you’ll have to do the same thing again. After repeated years of effort, you may have got most of them. 

Doing this is not a quick fix. It is hard, unpleasant and unglamorous work, and it often hurts. There isn’t an app for it.

This is a job for the long term. Any takers?