With things looking quite dark in the NHS, we can only hope that the forthcoming Budget will improve the situation even as we try to put a quart of healthcare demand into a pint pot of healthcare resource, says Andy Cowper

‘The tragedy of the commons’ was a concept and phrase proposed in an 1833 essay by economist William Forster Lloyd. He proposed (in the context of unlimited animal grazing on common land) that within a shared resource system, self interested individual users may act against the common good by depleting or spoiling that resource through the totality of many such selfish individuals’ actions.

Well. Forster Lloyd may remind us of another 19th century Forster: E M Forster, author of Howard’s End and A Room With A View. The former book’s key character Margaret Wilson, proposes that we need “only connect the prose and the passion, and both will be exalted, and human love will be seen at its height. Live in fragments no longer. Only connect, and the beast and the monk, robbed of the isolation that is life to either, will die”.

If we assume there is some hope to be had, then that hope needs to be marketed and retailed. We have to be able to sell it, to realistic commissioners.

“What the bloody hell has this got to do with health policy?”, you might be asking.

It’s not a bad question: regulators ask worse.

Perhaps the issue is whether anything that appears in a column by a commentator can offer anyone some hope.

Real hope, that is. False hope is the pyrite/iron sulphide of commentary.

Retailing hope

If we assume there is some hope to be had, then that hope needs to be marketed and retailed. We have to be able to sell it, to realistic commissioners.

(Have you met many realistic commissioners lately?

Mmmmmm. Me neither.)

I would like to be retailing hope. Honestly, I would prefer to be retailing hope. That sounds like a worthwhile job. Somebody needs to do that. 

You want it darker 

Things are looking quite dark in the NHS. There is the deliberate seeming, enormous screw up in the finance of Barking, Havering and Redbridge.

There are A Lot Of Comments about that article.

And we are still asking real, living, breathing human beings to carry on being the accountable officers for the NHS as we carry on with the pyrites charade that things are OK.

We are still asking real, living, breathing human beings to carry on being the accountable officers for the NHS as we carry on with the pyrites charade that things are OK.

Things are not OK.

In the NHS, indeed in any closed system, you have two options when things are fucked on the supply side.

The Institute for Fiscal Studies is reasonably unambiguous that things are indeed Really Quite Donald.

I have discussed Mr Hammond’s fiscal predicament before.

Pertinent impertinence

It would clearly be impertinent of me - a mere commentator - to suggest how NHS system leaders should try to fiscally ambush the Chancellor of the Exchequer of the day.

(That said, if religious authorities were either less or more authoritative than they apparently are, that impertinence would have found traction hitherto.)

So, the facts of the pertinent impertinence which Simon Stevens (the NHS Commissioning Board’s Sun King of Skipton House) already knows are as follows.

The system has started down the ‘Management By Admonishment’ route. Which will not work.

NHS performance has been holding up well in some areas, but not in others.

NHS management capacity and capability is not what we need it to be.

And the system has started down the ‘Management By Admonishment’ route. Which will not work.

One of The People Who Really Know summarised the reason why MBA management fails in the NHS in a recent conversation with me as follows: “I know it doesn’t work, because I’ve tried it. You just get people lying to you. And then you don’t know where the real problems are”.

The 10 types of people in the world

It is neither contentious nor insightful to observe that the chancellor needs to be told that he is going to have to increase NHS revenue funding. One side or the other of an overt, unignorable quality scandal. 

To reheat the classic joke, there are 10 types of people in the world: those who see everything as binary, and those who don’t.

Following this logic, there is one type of leader at work in the NHS right now: that, dear reader, is you.

That is the type who, despite everything, is trying to do their best for patients and the public with the available resources.

There is one type of leader at work in the NHS right now: that, dear reader, is you. That is the type who, despite everything, is trying to do their best for patients and the public with the available resources.

You are doing this, staring down the knowledge of the accountable officer contract leaving you (as it does) morally exposed and legally responsible.

That is not a great place to be, especially now.

That is a hard job.

So, thank you. It is a quiet, understated heroism to try to put a quart of healthcare demand into a pint pot of healthcare resource. Commentators don’t come close to trying to meet that kind of challenge, ever.

We just sit back and wait for the Budget on 22 November, when we will find out whether chancellor Philip Hammond – known as ‘Spreadsheet Phil’ – is a stupid person’s idea of a clever politician; or whether he listens, hears and gets it.

Tick tock.

Tick tock. 

Tick tock.

“Hope is like the sun, which, as we journey towards it, casts the shadow of our burden behind us. …Hope sweetens the memory of experiences well loved. It tempers our troubles to our growth and our strength. It befriends us in the dark hours, excites us in bright ones. It lends promise to the future and purpose to the past. It turns discouragement to determination” - Samuel Smiles