Cowper’s Cut: The silly season

The combined effect of our current sustained heatwave and the August “silly season” of Parliamentary recess has aligned to create a solstice of silliness in the world of health policy and politics.

So we have had the deeply special experience of health minister Steve Barclay telling the once serious Telegraph newspaper that Brexit might lead to doctors being able to qualify sooner than at present.

The folly of Brexit is well known to regular readers, but workaday political fantasising by a cadre of politicians (who have spent most of their life preparing for the current “opportunity” yet have absolutely no idea how to actually do Brexit) scarcely cuts through any more.

It takes a special kind of denial and witlessness such as Mr Barclay’s to cut through the morass of Brexit related daftness, and perhaps we should reward him with a round of Bronx cheers for this truly special effort: evidently, we can bank on Barclay’s Brexit benefits. For members of the reality based community, this debunking by Dr Dominic Pimenta is concise and elegantly explained.

Meanwhile, NHS Commissioning Board’s national director of primary care Arvind Madan has had a lively week winning friends and influencing people. He has been posting pseudonymously on GP message boards statements suggesting that GPs were greedy and lazy, and under his own name told Pulse that GPs should be glad when small practices close.

Ahem. His subsequent apology looks like a textbook example of “too little, too late”.

Parity of esteem for primary care probably feels fairly distant to many in the sector. (Between the time of my writing this and sending it to the web, Dr Madan resigned, in one of the most predictable events of recent times.)

The dignified and the efficient

Any of these would make for an acceptable column, but instead I want to write briefly about the very big picture in the NHS. The distinguished editor Walter Bagehot wrote perhaps the seminal text on  The English Constitution, in which he argued that the branches of English constitutional government can be divided into the “dignified” and the “efficient”. In Mr Bagehot’s view, the dignified “excite and preserve the reverence of the population”; the efficient are “those by which it, in fact, works and rules”.

I suspect that taxonomy could be useful for thinking about the NHS.

The 2012 legislation that NHS Commissioning Board’s absolute monarch and subtle subversive Simon Stevens has so roundly ignored gives us the dignified part: an entirely theoretical NHS driven by patient choice, competition and clinical commissioning.

It was always a bracing theory of dear old Lord Lansley’s, quite impossible to deliver on a collapsing envelope of financial growth and planning relative to rising demand and falling workforce… and surprise, surprise, it has never actually happened.

The efficient part has been levels of centralised control undreamed of even by the biggest fans of grip there are. The national tariff has been used to drive the NHS deficit into providers and out of (most) commissioners, forcing foundation trusts all to spend their legislated for surpluses (the work of a certain Simon Stevens circa 2002-03) and driving obedience across the provider sector through the means of tariff driven debt; control of sustainability and transformation funding and system control totals and monies that have incentivised widespread financial lying; and loans to the most underwater providers at 6 per cent that will never, ever be repaid (the NHS equivalent of payday lender Wonga).

Absolute, not absolution

It is certainly arguable that centralised command and control in the NHS has never been so absolute. Nor is it surprising: that is what an absolute monarch will do. Absolution, not so much.

Our problem arrives when the efficient system that Simon Stevens made up gives rise to a plethora of fictions and ghosts.

That would be an ecumenical matter

It also arises because the legislative incentives for the NHS are parochial, while the current mantra of the “system problem” and the like from national bodies is asking for the NHS to work as if everything were “an ecumenical matter”.

Where legislation is parochial, and the alleged system is ecumenical – where sustainability and transformation partnerships and accountable care organisations are non-statutory and cannot hold budgets – we are surely in danger of losing our religion. Here endeth the lesson… for the time being.