Well, that was lively. NHS England’s chief executive, Simon Stevens, was up in front of the Commons’ public accounts committee yesterday (watch here on Parliamentlive.tv).
As he headed into London, he would no doubt have seen an “exclusive” in the Times, claiming that “aides” to Prime Minister Theresa May had “privately criticised” him for being both “insufficiently enthusiastic” in carrying out his job and unduly “political” in flagging up some of its challenges (story, paywall).
May is starting to get a reputation for this kind of thing; the Times story came just a few days after the very public departure of Sir Ivan Rogers, Britain’s EU ambassador, who was duly briefed against for being insufficiently enthusiastic about leave.
But if there are risks in her government starting to look like the kind of thin-skinned and petty-minded administration that lashes out whenever a public servant presents it with inconvenient facts, her “aides” seem to be unworried by them.
The Times story was hardly accidental. Indeed, it was hardly an “exclusive” as the Daily Mail was given pretty much exactly the same thing back in November.
Instead, it looked like an attempt to use the PAC hearing to re-run a hare that had failed to get running (but which I blogged about at the time).
Doing the math (again)
If the “leaks” were an attempt to bring Stevens to heel, they not only failed, but directed huge amounts of press attention onto fine details of NHS finances that are, in fact, well known; but which are now being presented as new and worrying.
The PAC hearing was part of a short series of hearings on the financial sustainability of the NHS, prompted by a National Audit Office report. The NAO (a financial watchdog that reports to the PAC and gives it unusual clout for a select committee) has been running yearly reports on the financial sustainability of the NHS for some years.
This year, for the third year running, it concluded that the NHS finances were not sustainable. In doing so, it went into exactly how much money the government has promised to give the health service over the next five years.
In what turned out to be his last autumn statement, in 2014, then-Chancellor George Osborne said this was £10 billion. He also claimed this would “fully fund” the NHS’ “own plan” for sorting out its financial woes, the ‘Five Year Forward View’.
This is a plan that Stevens wrote, which says the health service can find £22 billion by 2020-21 from further “efficiency” and bringing in new models of working.
Since then, the NAO – and many other bodies – have shown the £10 billion includes £2 billion that had already been announced for 2014-15 and £3.5 billion shifted from running bits of the Department of Health and public health.
Despite this, May has repeatedly used the £10 billion figure in speeches about the NHS. She did it back in October, and was told off for it by the opposition and by the UK Statistics Authority. And she did it again this week, in her much-heralded speech on mental health, adding that it was “more” than the NHS had asked for, for good measure.
It’s baffling that May continues to use the £10 billion figure, when it’s been disproved so often, and it wasn’t her government that came up with it. But she does, and then her supporters get antsy when experts do the math in public.
The November briefing against Stevens seems to have been prompted by his appearance at the Commons health select committee, which is running its own inquiry into NHS finances, covering more or less exactly the same ground as the PAC (and which I also blogged about).
At the hearing, he was careful to hedge around the question of whether he had, in fact, got what he asked for from the spending review.
However, he did have to agree that the money is not being distributed in the way that the Forward View asked for – most is going in this year; there will be barely any increase next year or the year after, when spending per head of population will, in fact, fall.
And at an earlier PAC hearing, he noted that some of the other assumptions made by the Forward View are not bearing up in real-life.
Most obviously, the plan assumes that if the NHS is to close its funding gap by 2020-21, money will need to be spent on public health – to start cutting demand – and on social care – to help keep the ageing population out of hospital. Yet public health spending is being cut, and social care has a crisis all of its own.
Coming out fighting
So, when Stevens got to Parliament yesterday, he didn’t really say anything new to generate headlines. He just went further than he’s done previously in spelling out what the government has done on NHS funding; and seemed to enjoy himself doing it.
In response to an opening question from PAC chair Meg Hillier, he said it would be “stretching it” to say the NHS had got “more money than it had asked for”.
He contradicted the DH’s permanent secretary, Chris Wormald, when he said an OECD report had shown the UK spends about what most countries spend on health; pointing out that comparable, rich, European countries spend much more per head of population.
He cheekily held up a story from the Daily Mail, the paper that took the bait on the November briefing against him, and said he agreed with it that the NHS “trails the rest of the EU for medics, beds and scanners”; implying that more of all will be needed.
And he had a neat little swipe at the Time story, saying he had been “running a little campaign” to stop cuts on social care and doing so “very enthusiastically, I might add.”
What does the boss think?
It would be very interesting to know what health secretary Jeremy Hunt thinks of all this. He is now England’s longest serving health secretary, after being re-appointed to the job by May in aftermath of the Brexit debacle.
But his career has been associated with that of Osborne, who May publicly dumped as Chancellor in the same reshuffle. There were rumours on the day that he was off as well – he arrived very late at Downing Street without his NHS badge on, and there were reports in the BBC and papers that he had been sacked before he reappeared with it back in place.
It’s not inconceivable, then, that he might welcome Stevens’ digs at a Prime Minister unlikely to feel warmly towards him, and unlikely to promote him; he told the NHS Confederation’s annual conference last year that health would be his last political job.
Also, Hunt has shown remarkable commitment to the NHS, and might see the headlines about a “winter crisis” and hospitals on “black alert” that have been constant since Christmas as evidence of a crisis too good to waste when it comes to putting pressure on Downing Street for more money.
After all, most spending departments rebel against Treasury constraints at some point, and May has hardly shown herself to be an adept at keeping ministers or officials in line.
Never mind the £10 billion, what about the £22 billion?
Still, the bigger question is whether the NHS can use the money it has got – never mind any new cash – effectively to address the long-term pressures on it.
The NAO has cast doubt on this, pointing out that the Forward View is not a strategy and does not come with worked through delivery plans with budgets attached. Local health economies have been asked to draw up ‘sustainability and transformation plans’ to put it into action.
But these are only just being published, and are of variable quality (post). The PAC got to this point late in what turned out to be long hearing, after Twitter had lost interest and the papers had gone off to write their stories.
Its MPs were told, by Jim Mackey, the chief executive of NHS Improvement (the regulator that decides whether trusts can operate), that a consolidated and more detailed plan would be available by March or April.
He also said there would be new ‘key performance indicators’ for the STP footprints to meet, with financial control targets for their commissioners, trusts and other organisations to meet together to follow in a year or so.
The centre needs to get a grip on money and targets, if it is to impress on the NHS that STPs are the only game in town, because hospitals overspent to the tune of £2.4 billion last year, and hospitals are publicly saying they are no longer meeting key targets, such as the four hour see, treat or admit target for A&E.
But even if Stevens and Mackey can get back on top of things, there is, as one MP pointed out, a timing issue. It’s simply not clear how the NHS can get from where it is to where the Forward View says it could be, given the huge shift in finances, structures, mangement thinking, and public support that would be required to get it there.
Yesterday’s politics and right-wing press twitting were fun; that question is deadly serious.