Cowper’s Cut: Will the 10-year NHS plan give us magical realism or socialist realism?

‘Tis the season to be jolly, allegedly. And as we trundle towards Christmas and 2019, the political Gods are favouring us with a Valhalla’s worth of reasons to make a wry smile play around the corners of our well chiselled features.

The state of NHS performance, unfortunately, is no laughing matter. It is not yet particularly cold, nor is there yet much flu. Yet.

And as waiting times expert Rob Findlay wrote for HSJ earlier this week, ambitions to hold the waiting list steady for 2018-19 are doomed.

The health thinktanks also noticed this. Two notable stats from the Nuffield Trust coverage: attendances in major accident and emergency departments (Type 1) surpassed 1.3 million in November 2018, which is 2 per cent higher than the same month last year; and emergency admissions via A&E have been increasing year on year, reaching over 403,000 in November 2018 (7 per cent higher than in November 2017).

The waiting time collapse is having real impact: the independent sector has seen self pay revenue rise by 9 per cent to reach £1.1bn in 2017. LaingBuisson, authoritative analysts of the UK private sector, conclude that “dissatisfaction with the NHS is now the primary driver of self pay demand… rising NHS waiting lists together with CCG demand management initiatives have become the biggest influences for patients seeking self pay diagnosis and treatment”.

The LaingBuisson work also notes that “despite improved price transparency since the Competition and Markets Authority report on the private healthcare market in 2014, there are stark differences in the fees for ‘fixed price surgery’. The price of a total knee replacement varies from £9,559 to £15,202, while the price of cataract surgery for one eye varies from £1,650 to £3,353”.

‘It’s be published before Christmas’. OK. Which Christmas?

What, then, of the long-term plan for the NHS – the 10-Year Forward View?

Ho ho ho. Despite the assurances of Skipton House’s Sun King (and serial top chief executive of the NHS Commissioning Board for the past five years) Simon Stevens and Appless Matt ’Ancock, multiple sources now confirm that the government almost certainly will not publish the 10YFV in 2018.

The experienced and informed Paul Waugh of HuffPo cited “serious concerns that the plan would be tarnished by the Brexit row and would not get the ‘big bang’ positive coverage May and Tory strategists had hoped for”.

Oh dear. Oh very dear.

It is clearly tragic if a 10-year strategy won’t bring the government some good headlines, as the Conservative And (ahem) Unionist Party continues its 30 year long internal uncivil war over Europe merrily untrammelled by concerns about the national interest.

The bonfire of the sanities that is Brexit has, as I’ve been pointing out in these columns for the past two years, been consuming all the oxygen in British politics.

Indeed I correctly predicted that the 10YFV would not be published in 2018.

It is now clear from my colleague Dave West and many other sources that the combined might of NHS Engroovement-Improveland will be meeting NHS chief executives next Wednesday and Thursday to brief out the 19-20 clinical commissioning group allocations, and as much detail as they can of what Year One of the 10-Year Forward View will contain. I look forward to hearing from my contacts at those sessions.

The guidance before the policy: The cart before the horse

This is perfect, isn’t it? The current incumbent set of empty suits that aspires to pass for a government can’t set a date for releasing the NHS 10-Year Forward View, because of Brexit.

So the NHS just ploughs on as if the government had released it.

Subversion, subtle and effective

This recalls to mind my observation about the Five Year Forward View being a subtle subversion and graphic reworking by Simon Stevens of the Lansley reforms. 

It was a subtle subversion – and it was an effective subversion, too. Other than in organisational name, it becomes clearer by the week that the choice and competition driven NHS of dear old Lord Lansley’s detailed and daft imagination came to pass only in terms of the reduction of bureaucracy by replacing 150 statutory commissioning bodies with 218 odd statutory commissioning bodies with different names.

Oh, and by creating NHS Engroovement-Improveland: the biggest quango in the history of the NHS.

So what the hell is going on here?

And do the politicians even notice that Simon Stevens is in effect trolling them with anhydrously dry wit?

Towards a 10-Year Forward View

Perhaps we are living in a time when any long-term NHS plan is fated to run behind the reality of a baked in financial deficit. Which makes this perfect timing for dear old legacy Monitor to double the incentive for trusts to agree tougher control totals, by offering £2 for every £1 of improvement.

No, me neither. Despite having pointed and giggled at the wild success of control totals last week. Yes, I’m so influential.

Two obvious options for the 10YFV would be to operate in very different genres of realism.

The first option is magical realism. Fans of the fiction of Allende, Borges, Marquez and Rushdie might welcome this, but I suspect it is unlikely to help.

The second option is socialist realism, and particularly the cult of Stakhanov – a man who apparently achieved impossible productivity targets. Ahem. Looking at the state of the current Labour Party, there is clearly a market for Communist-Trotskyist nostalgia. But it doesn’t seem to be bringing Labour nearer to power, and I doubt it would help the NHS.

And perhaps the point of NHS long-term plans is to help us realise that they are never actually meant to be delivered. They are sacred texts, to be admired for their aesthetic beauty.

Perhaps the NHS planning industry should be best understood as a religious job creation scheme. They are designed to create jobs for theologians. “I think what The Sun King means here is…”

Not to mention jobs for Pharisees: “The 10YFV aligns perfectly with our representative organisation’s view because XYZ, and we welcome it with the following caveats: ABCDEFGHIJ …”

(As I have previously written on a number of occasions, most tensions in the system today are because the legislation and rules are parochial while the forward view is ecumenical. Just call me the NHS Chief Ecumenist.)

Why the briefing?

So, in the absence of “the plan”, why are next week’s briefings and releases happening?

There are a few reasons. The June finding increase meant that the 2019-20 CCG allocations have been increased, and that has to factor into planning.

More to the point, some of the 10YFV has been well trailed: new emphasis on cancer, mental health and primary care have all been made clear. It’s largely an extension of the 2017 Five Year Forward View: Next Steps, and who among us doesn’t love an encore?

There should also be specifics about how 2019-20 will be a pivot year away from the distortions of the control totals regime (which makes legacy-Monitor’s decision to double down on them mentioned above quite the thing).

There is likely to be some messaging about the need for the NHS to hold its performance and nerve as winter continues to bite. Rubbing current government politicians’ and Treasury Munchkins’ noses in the impossibility of regaining performance might promise temporary homeopathic relief, but won’t solve any short term problems.

The service of course knows that it has no real option other than to do the best it can. But who knows: it may make some at the centre feel better to have said it.

There will also probably be similar messaging on Brexit, where the plans for a no deal crash out (which remains the default option at present) now involve serious logistical thinking about ports, roads, freight and air. (And if they have any sense, the army.)

Thinking more broadly, the centre is likely to want to get the system thinking about the Venn diagram overlap between the concerns of the NHS trade associations community and those in some patient voice and external scrutiny organisations.

As the game needs to be raised on mental health, autism, preventive services, the HealthWatches local and national, the MINDs, the Patients Associations and the rest should become increasingly important voices.

There is a problem here, of course: we have not really even begun the difficult conversations about the things that will have to stop or be defunded for the new areas to grow, innovation to flourish and unmet need in “low profile” areas to be met.

All of this is quite an ask, while the NHS frantically tries to make sure that as few people as possible are avoidably harmed as waits lengthen and the workforce crisis goes on and on and on.

I suppose you could say that at least the 10YFV, unlike the unsurprisingly repostponed social care Green Paper, actually exists. Even if we can’t see it. It requires faith, brothers and sisters!

Ipsos MORI chief executive Ben Page noted last week that “as Brexit recedes in public concern (eventually) the NHS is waiting to take its place”. Ben is rarely wrong, and certainly not here. As we then discussed, the NHS would have been the top issue in the long-running Economist/Ipsos MORI Issues Index of British public policy concerns, were it not for Brexit/immigration.

What a merry dance. We must hope that the service is not dancing to its own destruction.