Cowper’s Cut: Which is the justice and which the thief?

“Look with thine ears: see how yond justice rails upon yon simple thief. Hark, in thine ear: change places; and, handy-dandy, which is the justice, which is the thief?”

King Lear, Act 4 Scene 6

Understanding the NHS is like understanding any complex adaptive system of high public utility and value: you need to understand the plumbing of two things.

The money, and the power. 

“Money doesn’t talk; it swears”

The money is hugely significant. Those who are not fans of NHS Commissioning Board chief executive Simon Stevens fail to articulate how any alternative candidate would have won comparatively generous financial settlements for the NHS.

As Institute for Fiscal Studies’ director economist Paul Johnson rightly says in the latest instalment of HSJ’s new interview series The Bedpan, the high likelihood is that we will need to spend more money on healthcare in coming decades, and it will not be possible to do so without taxing all of us – rich and poor – more.

So, the money matters. And promises made as part of the deal for the money, like the NHS long-term plan’s ambition to save 500,000 lives, or the infrastructure (under)spending backlog, onto which the Sunday Times put a number of £3bn, are going to start being noticed.

The money issue is better than it might have been, but very far from being resolved. And there are a lot of other parts of the public sector which will have strong claims on public spending/taxation increases.

And make no mistake, tax is a real issue. Then Treasury’s changes to lifetime allowance pension taxes on the highest earners continue to hit senior figures in the NHS as well as experienced clinicians – the very people from whom the NHS is going to have to commission more work if it is to dent the growing waiting lists over the coming years.

Struck off and die

But the plumbing of power is just as important. And in this regard, the decision of ’Appless Matt ’Ancock to ignore five of the seven recommendations of the Kark Review.

The Department for Health But Social Care’s plan, instead, is that “training and support would be offered to managers who fail to meet a new set of minimum standards. There will be a new database holding information about senior NHS managers’ qualifications and previous employment history”.

The regulation of NHS managers has come up again and again as a possibility. It happens every time there is discontent about someone who has failed (possibly in an un-doable job, or one given too early) who gets a second chance in the system.

The problem is that there is a down-side to the unspoken NHS management omerta of rehabilitation. It is easy to name people whose defenestrations were absolutely bloody stupid ideas.

The NHS Commissioning Board’s acting chief digital officer Tara Donnelly is one highly obvious one. Matthew Hopkins is another.

People like Tara and Matthew are not by a long way the hard cases that inevitably make for bad law. The problem arises when individuals who have been culpable of terrible behaviour are not addressed, and are recycled through the system in the same way as the unlucky or the over-ambitious.

It remains notable to this day that there have so far been no successful prosecution over the Mid-Staffs scandal, or more recently Morecambe Bay’s midwifery scandal or Liverpool Community Health Trust. Or the cardiac surgery team at St George’s.

And that applies as much to the senior clinicians who were responsible as it does to the chief executives and directors.

Of course clinicians face professional regulation that NHS managers currently do not. They are scientists. 

Where the NHS has a deficit in these matters is probably not in regulation. I think that too often, regulation has become a proxy for addressing the root causes of bad performance. That is our old friend culture, to a huge extent. It is human factors. It is the complexity of modern healthcare.

But sometimes it is also outsized egos, and sometimes it is cover-ups, and sometimes it is scrabbling to hit ludicrous targets. And almost always, it is an ugly belief that one is engaged in a virtuous pursuit, and one in which the ends justify the means. 

Are we comfortable that regulating NHS managers would solve these problems?

I for one am not. Which leads me to a conclusion that I have not tended to make in these columns before, and one that I might not make again: The Appman has got this one right.