Andy Cowper on the lack of mandate, workforce plan, capital/maintenance plan and social care plan in healthcare 

“We all say ‘don’t want to be alone’;

We wear the same clothes ‘cause we feel the same,

We kiss with dry lips when we say goodnight.”

Blur, ‘End Of A Century

Everything ends, sooner or later: the good, the bad and the ugly. For most of us, our names are written in water. Nothing is permanent - except maybe art, and maybe love, if we can do it right.

Living in a post-religious age has made us no less frightened of The Great Inevitables: decay and death. Maxwell’s Laws Of Thermodynamics are pretty hard to buck. Entropy increases.

Healthcare has such meaning now because, here in late-period digital capitalism, we are uncomforted by dreams of eternal life and we are just as afraid of our inescapable biological destiny as ever.

In the face of these facts of life, we comfort ourselves with what we can: new kitchens, old cars, good food and wine, families and friends. We look after our bodies as best we can, or have learned how.

And healthcare has the fearful meaning that it has not only because of our fear of decaying and dying; and not only because one day, we know we’ll need it to be there for us. It has such meaning because it is about helping other people. In the end, that’s what life is really about.

Known unknowns

I’ve always enjoyed Donald Rumsfeld’s taxonomy of the knowns and the unknowns. At the time of its articulation, I found the rhetorical contortions of ”unknown unknowns” quite funny. Yet on proper reflection, there’s an intellectual sophistication at work. From the Johari Window concept of knowns/unknowns to oneself and to others, through to Taleb’s “Black Swan” theory, it describes some essential ideas.

Right now, the NHS is awash with very high-profile “known unknowns” about almost every major part of operational and strategic planning. As I wrote last week, we are now one-12th of the way through the year without having the mandatory mandate. Did the Conservatives’ credibility on health policy die in vain over the 2012 Health And Social Care Act?

We are also running late on the national workforce implementation plan. Baroness Harding told the Royal College of Physicians’ recent conference that NHS workforce planning had been a game of “guessing how many tractors we need to manufacture in each part of the country across maybe a thousand different variants … unsurprisingly, they (Health Education England) get that wrong”. You’ve got to love a nice Soviet metaphor, eh, Comrades? We’ve been sorely lacking in Communist imagery since David Nicholson’s departure as NHS Commissioning Board chief executive: it’s ironic that Conservative peer Baroness Harding should be the one to re-introduce it, but far from the weirdest thing in the NHS these days.

Echoing HEE chair Sir David Behan’s previous comments to HSJ, Baroness Harding further said the NHS had been “asking the wrong question” by looking to plan the number of professionals for particular specialties: “it is a huge mistake to think you can divorce the most important asset you have from operational and financial performance and we have been making that mistake nationally as well as locally”.

Mmmmmm. That’s raising expectations of the workforce plan nicely, if and when they actually deign to publish it. My instinct is that it will be more Dido’s Lament than anything too solutions-based.

Capital letters: the blind leading the blind

We are equally unsighted when it comes to how the Treasury Munchkins will permit the system to allocate vital capital funding (lots of which has been transferred to revenue budgets to assist with the three-cup trick that the NHS is not financially sub-aqua). The consequent capital and maintenance backlog is going to cost about £10 billion, as the Naylor Review of NHS estates showed.

We know from HSJ’s February analysis that even for the homeopathic sum released, demand hugely outstripped supply. Conservative backbenchers asking the minister for capital for their local NHS during Labour’s Urgent Question on the missing mandate is a sign of our times.

Like workforce, capital and maintenance is a crucial area. Like workforce, the strategy (if it exists) is late: delayed until the Autumn Statement, at the earliest.

But Social Care

The government’s Green Paper on social care has made Godot look like a paradigm of punctuality. In the latest Westminster political embarrassment, health minister Stephen Hammond (answering Labour’s Urgent Question on the fugitive mandate) could only tell the Commons that it would appear “soon”.

In a glorious piece of side-eye, the Commons Library drily informs us that the Green paper will be published “at the earliest opportunity”.

The Library’s briefing notes that “in the March 2017 Budget, the Conservative Government said that it would publish a Green Paper on social care, in order to allow a public consultation to be held. This followed the decision in July 2015 to postpone the introduction of a cap on lifetime social care charges and a more generous means-test that had been proposed by the Dilnot Commission and accepted in principle by the then Coalition Government.

“During the subsequent 2017 General Election campaign, the Conservative Party made a manifesto commitment to introduce the Green Paper and made a number of pledges regarding how individuals pay for social care.

“The publication of the Green Paper has been delayed several times: it was originally due to published in “summer 2017”. The latest position is that it will be published “at the earliest opportunity”, although the Health and Social Care Secretary had previously said in January 2019 that he “certainly intend for that [publication] to happen before April [2019]”.


So here we are: no mandate, no workforce plan, no capital/maintenance plan and no social care plan.

I don’t know if this is some Dadaist attempt to reimagine health policymaking as jazz: getting a bunch of people together to fight over a tune. Perhaps at some stage, our political masters will come to understand that the joys of improvisation are overrated.

End of a century

This all has an uncomfortably fin de siècle vibe to it, doesn’t it?

There is a certain symmetry that this column is also the end of a century: this is the 100th consecutive weekly instalment of “Cowper’s Cut”, and the last that will appear in HSJ.

I want to thank HSJ’s editor Alastair McLellan for giving me this opportunity to write a weekly column. I’ve always been proud of writing for HSJ: it’s one of the best publications. It’s been delightful to have a regular role, first in 2013 as the Comment editor, and for the last two years as a columnist. I had no idea whether I could do a weekly column, and it turned out that I could. So thank you to Alastair, and thank you to all HSJ’s journalists for making a consistently excellent product.

I’d like to thanks HSJ’s readers, too. As you’re trying to navigate the rapids of austerity and uncertainty, there aren’t always a lot of thanks. But all the smart people working in and around and alongside the NHS know perfectly well that frontline staff and managers are both vital to equitable and high-quality care. Your work matters. Thank you for it.

I’m not disappearing: various other regular writing projects for HSJ will keep me off the streets (well, some of the time). Change can be a very good thing. As health policy guru Taylor Swift so nearly wrote, “commentators gonna commentate”. I look forward to seeing you all around, online and in the real world. Good luck, and take care.