Cowper’s Cut: How to spend it best: theft, teaching and toxin-taming

We all know that the NHS is rhetorically cash-rich, since sub-prime minister Theresa May was skilfully walked up to the inevitable on increasing NHS funding by some smart work from Jeremy Hunt and Simon Stevens.

Jam tomorrow. Hurrah.

We don’t know much at all yet about the potential scale of any boost for 2019-20 and beyond, and as my colleague Lawrence Dunhill pointed out of the extra £240m promised for 2018-19, Parliamentary Questions end up leaving us neither wiser nor better-informed about its provenance. Mr Dunhill is right – next summer could be very tight indeed.

So, once the new money comes, how should the NHS spend it most effectively and least wastefully?

“There is always a well-known solution to every human problem: neat, plausible, and wrong.” (H L Mencken)

Commentators can generate a lot of heat and very little light. In an effort towards increasing the latter, I’m picking three themes that I think should inform the NHS turnaround strategy.

The holy trinity are theft, teaching and toxin-taming.

Theft

The NHS crisis is very much about the workforce. And the notable thing about the healthcare workforce is that there doesn’t seem to be much of it that is trained and woefully underemployed in the UK. And nurses take three years to train, and doctors much more like 10.

And the problem is that we will waste significant sums of any new money if we only buy salary inflation.

So, we are going to have to go and get staff from elsewhere in the world. And our chances of doing this will not be helped by Brexit, and the government’s pandering to angry nativism, and dimwittedly insular policy towards importing trained clinicians that the NHS seriously needs.

Oh, and screwing up junior doctors’ offers of placements is scarcely pouring oil on troubled waters. More like onto a bonfire.

I am given to understand, by the way, that the real current impediment to importing workforce that I wrote about in last week’s column is the chancellor.

My source suggests that the prime minister did hold the anti-importing position about a month ago, but was swayed by actually having things explained to her properly. Philip Hammond is trying to hold a line across all sectors.

Well, it won’t hold. It may be a bit morally queasy, but the market for trained healthcare talent is now a global one.

Teaching

That is obviously not to say we shouldn’t be training more clinical staff. We absolutely should. It is a nonsense trying to do serious management when there are so many gaps in the workforce.

Sure, there are promising initiatives, but the scale of the problem is significant.

In the short term, theft from elsewhere will be necessary. In the medium term, we are going to have to step up training more clinical staff. We need to look at an oversupply of about 10-15 per cent.

Yes, that will take time AND be expensive. Can you feel the waves of love emanating from the Treasury Munchkins? (Waves.)

But there is also the demand side to address. Alastair McLellan’s excellent editorial looks at the vital importance of investment in primary care and mental health, but also flags the vital importance of public health.

We are not going to make the best of any extra resources, unless we address the widespread problems of health illiteracy.

I think that some of the NHS’s extra money needs to go into education – and specifically into primary schools. There have been big improvements in what is delivered in personal, social, health and economic education, and when children are at primary school, their parents are often at a coachable moment.

Toxin-taming

You would expect me to mention NHS culture, and I will not disappoint you. A service created to deliver the right answers to the centre is likely to face a range of perverse incentives. I suspect it is also likely to develop problematic cultural traits, including bullying, an over reliance on lawyers and a candour deficit.

All three of these things are much more present in the NHS than they should be. 

People can do Very Bad Things when they believe they are acting in the interests of the greater good. They can also get accustomed to using power badly, as the Stanford Prison Experiment proved – and they can fall victim to Stockholm Syndrome. 

It’s hard to account for some depressingly common bad behaviour in the NHS without thinking of these two things.

Inhaling the heady aroma of hand rolled reality, we should admit that there will not be less pressure on the NHS to deliver the right answers to the centre(s) any time soon. But these toxic behaviours need to be recognised and called out, consistently and clearly.

Culture matters.

As I have frequently stated, the NHS needs a Chief Anthropologist more than it needs any chief inspector. To adapt Paul Krugman’s famous line on productivity, culture in the NHS isn’t everything, but in the long run it’s almost everything.