The Friday Blog: Back to the Policy Future Part 3
It has been one of those weeks when it has been difficult to imagine anything else being squeezed into it. At ABHI Towers we were probably not that grateful the organisers of London Tech Week and the NHS ConfedExpo ran their events simultaneously, but we divided ourselves accordingly. Less worried were our friends in Austrade or the Australian Trade and Investment Commission to give them their full title, who brought a delegation of companies to attend both, and I was fortunate to be able to join them. In London, we were in the amazing surroundings of Australia House on the Strand. If you have not already been, and you do get the opportunity, I would highly recommend accepting the invite. The building was opened in 1918 and uses materials sourced from Australia, something which caused shipping problems during the Great War, but its interior is ornate enough for it to have been used as the setting of Gringotts Wizarding Bank in Harry Potter and the Philosopher's Stone. I am not particularly a Harry Potter fan, but I was excited to find out via one of the podcasts that I subscribe to, that the Australian cricket team had visited a few days previously. The Baggy Greens are in town for the final of the World Test Championship against South Africa. The fixture may have passed you by, but if you are that way inclined and are in striking distance of NW London, you might have the rare chance to walk into a big game at the home of cricket for the back end.
That was not the only reason I was pleased to be there, in his opening remarks the High Commissioner, Stephen Smith (no, not that one) talked about the like-mindedness of our two countries and how that would be a great facilitator of collaboration, pointing to an uptick in trade since the signing of an FTA in 2021. I was able to say how struck I have always been by how many UK companies tell me that Australia is one of their top priority markets, despite the distance and relatively small size. It took me a little while to understand why. I have always said that the Irish are masters at leveraging their diaspora, and are really clever at marketing themselves. In case you never noticed, we are all Irish on St Patrick’s Day, admittedly some of us buy into it more than others, and, personally, I have become very adept at splitting the G. Admittedly, we are not, or never will be as popular as the Irish, but we have a kind of equivalent in the people that receive, either here, or de facto, their professional medical training from the UK. Walk into any hospital ward or operating theatre in Manchester and I will wager you will find Aussies in most of them. Walk into any hospital ward or operating theatre in Melbourne and I will wager you will find Brits in most of them. Clinical practice is very similar, and technology developed in either of our countries fits nicely into the other.
Those unpatriotic Aussies that did not stay in town for the cricket, continued the tour of events in historic British public buildings in Manchester. The venue for their reception with Greater Manchester Chamber of Commerce was the impressive Elliot House. Built in 1878, it has variously served as a register office, the home of the Manchester Education Board, and a temporary library. It is one of those wonderfully solid, red brick constructions that makes me know I am in the North West. What made Accrington famous and all that. It is situated on Deansgate, which, I think, is Manchester’s main thoroughfare. I say think, because that is the thing about Manchester, I am never sure where the city centre actually is. Birmingham has the Bull Ring, Leeds the City Square, but what about Manchester? Albert Square? The Arndale? Piccadilly Gardens? Deansgate? Answers on a postcard #GMPlanningDepartment.
The ConfedExpo was quite an experience. I did not think the train moved particularly quickly. But it must have done to cause a breach in the time / space continuum, because when I got off it, I was, in policy terms, back in 2000. Foundation Trust freedoms, National Service Frameworks and PFI are all back. It was as if the conference, and perhaps also the wider NHS, was trying to pretend that the period since 2010 had never happened. The journo who facilitated Sir Jim Mackey’s session made the point that many of the same people who were around in 2000 are back, something that everyone had noted and was the talk of many dinner tables in and around the city on Wednesday evening. It was absolutely rammed too. Some 9,000 delegates and it felt like it trying to access some of the bigger meeting spaces.
Kicking off proceedings was the admirable Lord Victor Adebowale, who started in sombre tone, apologising to those who would not be here next year because they would not have a job in the NHS. As he was speaking, redundancy letters were pinging into mailboxes. He said that the service was facing its toughest environment for 40 years and highlighted three themes. The fact that we were unlikely to get close to the election hanging commitment to return RTT to constitutional standards, that financial pressures were increasing, and that public satisfaction was at its lowest ever level. There had clearly been a memo circulated about the rule of three, just about everyone I saw present was keen to emphasise that they were going to tell us three things. The utter master of this was NHSE Chair Penny Dash. In her address committing to absolute alignment between her organisation and the DHSC, each of her three things had three themes contained within them. Her headlines were redesigning the system, quality at the core of everything, and changes to the operating model of the NHS. The first of these would be about the development of a neighbourhood health system, more care delivered closer to home rather than in hospitals – a three shifter for you. Outpatients would need to be overhauled, there being 130 million appointments a year and half of the seven million on waiting lists for more than the magic 18 weeks are waiting for a trip to the shed. The operating model bit is all about redesigning the centre, the future of ICBs and collaborative working between all organisations who touched on health and its wider determinants.
Presenters on the main stage were all very coy about what we might expect from the 10 Year Health Plan, but we got as close as anyone will to an insight when we heard from Sally Warren, another New Labour disciple brought in last July as DG overseeing publication. She started by making the apparent, but perhaps not necessarily always entirely obvious to the person on the Clapham Omnibus point, that the plan was a 10 year one and would take 10 years to deliver. Not one, not three, but 10. It will also be published as a government White Paper, not actual guidance. In lay terms this means that it will be about 1/10 the size of the subsequent documentation. We should not expect to see disease specific recommendations in the plan itself (but see below), as the plan will be about preparing the system to deliver the three shifts and tackle workforce issues rather than getting into the fine detail of treating cancer, managing diabetes or making sure we have enough fat jabs to go around. The spirit of the plan will be to set out the cultural changes required, and we might expect to see a number of other shifts. From a state to a patient-controlled NHS, from a centralised to a devolved system, from a service delivered in buildings to one delivered remotely, from an inequitable service to an equitable one, and from a single entity delivering services to a partnership model.
Dash then dashed backed with her next three things. Tech, tech and tech. Well, actually, she also mentioned new payment mechanisms for digital and a big role for ICBs, not that I would bet on that ultimately happening, but the main focus will be on operations and quality. Same as it ever was. Next up was Big Jim himself, stressing that the NHS had done relatively well in the Spending Review (join us on Monday to see how true that is) and that the 10 Year Health Plan will be all about Neighbourhood Health and Quality – outcomes rather than inputs. Of course, the way it was going he needed his three things, lest he get a telling off from propaganda control. The main man set out a reset of how the various elements of the service work together and a move away from an over controlled centralised system. He talked about creating the conditions for success, suggesting that National Service Frameworks would return, and that funding allocations would support localism. Finally, he talked about rebasing the ambitions of the NHS. Mackey, like many at the conference, is clearly happier with a Labour government, and spoke fondly of the freedoms that existed in the early days of Foundation Trusts and how these would return to drive localism. He, and others, including Confed boss Matthew Taylor, also said that there would be room for private investment to support capital expenditure, alongside protecting capital allocations and preventing the dreaded transfers to revenue. PFI was, after all, how the last Labour government regenerated the NHS estate in the early noughties. Indeed, at one point, it was the only game in town, before suddenly becoming something you could not talk about in polite company. It always struck me that the problem was not the principle, but the fact that the NHS negotiated some very bad deals, tying itself into some, frankly, silly contracts, and paying so much that the debts have been sold on multiple times. Someone has got a great deal, just not you and I dear taxpayer.
Yesterday afternoon, after some uncertainty about whether he would actually turn up, Young Wes appeared on the main stage. He started by pointing out that we should not be focussing on the 3% uplift announced in the Spending Review, but the fact that the total budget is very substantial, and next year will top £205 billion. He too stressed the need to move away from a highly centralised state bureaucracy, and identified not three, but five themes (he is the boss after all) that would drive a new operating model. Firstly, there would be real clarity of purpose, with a smaller centre driving excellence and leveraging the procurement power of the NHS. Next, there would be consequences of performance, inequities would not be tolerated and that Foundation Trust freedoms would be reinvigorated and reinvented. (Cue fist pumps from Sir J). He said that leadership matters, pay for leaders would be tied to performance, and the focus of Trusts would be on outcomes and not merely driving activity, and Mayors would be involved the development of neighbourhood health services. He said also that he knew that money talks, more best practice tariffs would be introduced to remove outdated behaviours, and financial incentives would be used to drive public health. Finally, he said that the patient must be King. Unusually for these things, he spent a considerable amount of time taking questions from the floor and, generally I thought, did a pretty good job and appeared to have the backing of the room. We still do not know for sure when we will see his Plan, I heard “coming weeks” a few times, but we will see how much of the apparent goodwill remains when the redundancies kick in, and the focus on delivery heats up.
Comments at the conference also suggested that the Confed and NHS Providers may well be heading to a (re) merger, the latter have peeled off from the former in 2011 to reflect internal market tensions. As we move to a more integrated system, it would make perfect sense for the two organisations to come together. I did think about that during Taylor’s speech. It was not one of the CEO of a membership organisation, and I am not sure how well received it would be. If you fancy a flutter, have one on the former New Labour man being in the Lords with a portfolio in pretty short order.
To another weekend, rugby fans will be gripped to see if recent underachievers Bath and Leinster can win their respective championships, and Sunday is, apparently, Father’s Day. Not sure about that, the only thing in my diary at the moment is a tip run.
