Author Archives: Lyn Whitfield

About Lyn Whitfield

Journalist-Editor-Project Manager

The NHS’ own plan 2.0

Jeremy Hunt on protest poster

Jeremy Hunt on an NHS protest poster (picture: Rohin Francis on Flikr: https://www.flickr.com/photos/rohinfrancis/22277630191/in/photostream)

I’m going to a health conference on Thursday that has been organised by the think-tank Reform. Health secretary Jeremy Hunt is the keynote speaker.

If we find ourselves playing conference bingo, we can expect to hear him say that “we gave the NHS £10 billion” (depends how you count), “that was more than the NHS asked for” (nope, it definitely wasn’t), and “we’re funding the NHS’ own plan” (erm…)

If he has something more substantial to say, then there’s a lot for him to talk about; most of it stemming from the progress or otherwise of ‘the NHS’ own plan’.

The NHS’ own plan

This is the ‘Five Year Forward View’ project, drawn up by NHS England’s chief executive, Simon Stevens, to close a gap between flat NHS funding and rising demand and costs that could reach £30 billion by 2020-21.

It worked on the basis that, if the government put in £8 billion, and social care and public health funding was maintained, and the NHS was able to keep on top of its efficiency agenda, and it used some cash to ‘pump prime’ new ways of doing things… it should be able to find the other £22 billion.

The Forward View only came out in October 2014, but a fair bit of this is already off track (see posts below). The government did announce £8 billion for the NHS in its 2014 budget (and then back-counted another £2 billion, to get to the £10 billion figure).

But as Stevens has told several Parliamentary enquiries now, the money is not going in smoothly (it doesn’t feel like it, but this year is a relative ‘year of plenty’ – there will be virtually no funding increases in the next two years). To make things worse, the acute sector has fallen over a cliff.

The King’s Fund, another think-tank that tracks NHS finances closely, reported in February that hospitals will miss their £580 million deficit target this year, and are likely to overspend by £820-920 million.

Director of policy Richard Murray argued that, at best, this will wipe out the ‘sustainability and transformation fund’ money that would otherwise be available to ‘kick-start’ change. At worst, it could eat up reserves and even push the NHS overall into the red.

Meanwhile, investment in public health by a Conservative government always sounded like a non-starter and, as major news outlets have been pointing out, social care faces a crisis all its own.

In fact, it’s so bad that the King’s Fund’s pre-budget statement reckons that if Chancellor Philip Hammond has any money that he doesn’t need for his Brexit fund, it should go into social care.

STPs: neither sustainable nor transformative?

So, the mood music against which the Forward View has to be taken forward isn’t promising. But what about the plan itself? Ideas for turning the Forward View into reality have been put forward in 44 ‘sustainability and transformation plans’.

These got off to a bad start. NHS England tried to hold them back so its comms teams could vet them for ‘positive messages’, but councils went ahead and published them anyway.

This led to accusations that the plans had been drawn up “in secret” that have proved hard to shake off. Not least because papers and activists have picked over them looking for hospital closures and job losses – and these are easy to find.

Just this week, the BMA put out a blog post arguing that without more money, the plans were not only “doomed” but “a way to dress up cuts to public services.” Saying that plans that have yet to start have already “failed” seems a bit much. But there are reasons to worry about the STPs.

Reorganisation by stealth

For a start, there are signs that NHS managers are doing what comes most naturally, which is to focus on management.

Stevens told his most recent appearance at the Public Accounts Committee that the STP ‘footprints’, which are rapidly acquiring the accoutrements of administrative areas, such as leaders and key performance indicators, would in due course become ‘accountable care organisations.’

In other words, bodies that take responsibility for the health (treatment or long term care) of a local community, and get paid according to the size and health profile of that community (rather than services run or treatments delivered).

Stevens admitted this would end the purchaser/provider split for the first time since the internal market was introduced by the Tories in the 1990s; which is a big thing in health policy circles.

All of this is happening without the centrally-dictated reorganisation that has been repeatedly inflicted on the NHS, most recently by former health secretary Andrew Lansley.

Most people in the NHS would say “and thank goodness for that.” However, the fact that the latest reorganisation of the health service is less visible than most doesn’t mean that managers are not being distracted by it.

Fuelling public anxiety?

Also, the lack of public clarity on what is happening seems to be adding to public concern. Just this weekend, there was a huge march in support of the NHS at which there were many cheers for speakers who claimed that it was being ‘privatised.’

Yet the STP changes are, if anything, moving in the opposite direction (unless the conspiracy theorists are correct, and the ultimate ambition is to create ACOs that can be taken over by US corporations – which is frankly unlikely, given the margins and more likely losses on offer).

Be bolder, people

More substantively, the STPs are big and complex; and yet it’s hard to escape the feeling that they are nothing like bold enough. As I live in the county, take Hampshire’s STP.

It talks about the need to: resolve long-standing issues with care on the Isle of Wight, sort out Portsmouth’s struggling A&E, resolve the very public crisis at Southern Health and Care NHS Trust (which suffered another blow this week when the CQC announced it was going to prosecute), and work out what to do with the small district general hospitals in Winchester and Basingstoke.

Also, about the need to: keep these organisations on top of their efficiency savings agendas, while introducing new, more integrated ways of working underpinned by a big expansion of its existing shared care record / IT platform.

Delivering on any one of these imperatives would be a major achievement in five years, but there is neither time nor money to treat them as sequential issues. And what the STP lacks is a sense of how its different elements can be done at once, to support each other.

Never mind a vision of what a safe, modern service, with a digital front-end and highly trained staff in expensive buildings only where they are really needed, might look like – for the available money.

IT’s just not happening…

Just to stress, Hampshire’s STP is not alone in this. Kingsley Manning, the former chair of NHS Digital, wrote a column for HSJ recently in which he argued that the STPs generally fail to engage properly with productivity, and with how IT might drive that.

Instead, he noted, they tend to tick off analytics, shared care records, and digital services as nice things to have, rather than as programmes that will deliver the kinds of improvement in workforce productivity that have been seen in other service industries.

Mind you, when it comes to IT, it’s not just the STPs that are struggling. Last week, my former employer, digitalhealth.net reported that one of the biggest trusts in the country, University Hospitals of Leicester NHS Foundation Trust, had been unable to get its electronic patient record plans past NHS Improvement.

It wanted to spend around £25 million on a US system called Cerner Millennium and, while that’s a lot, it seems incredible that neither the company, nor the trust’s IT department, nor its general management, could get together a business case for it in an organisation spending £860 million a year, and employing 14,000 people.

(Of course, NHS England might have helped, but it seems to have become hopelessly distracted by trying to get a handful of ‘global digital exemplars’ up to snuff with £100 million that, HSJ reported this week, the Treasury probably wants back).

The NHS’ own plan 2.0

As commentator Roy Lilley noted in his newsletter this week, this kind of thing does not tend to worry the activists and medical staff who joined last weekend’s NHS march. They just want more money for the NHS and for their local services to be ‘saved’.

It would be unreasonable to expect otherwise. But Lilley is right; even if this government was going to find more money for the NHS (and all the pre-budget briefing is that it won’t – although social care might, might just get something) it needs to be spent effectively – and that means differently.

Stevens is working on a big reboot of the Forward View. So, if Hunt is going to do more than play conference bingo on Thursday, he’ll need to say something about what ‘the NHS own plan 2.0’ looks like.

Also, how the NHS’ regulatory structures are going to get behind it and start getting managers to think like, well, managers; and how politicians are going to sell all this to a hostile staff body and a very worried public. What’s the betting?

Liveblogging Open Data Camp, Cardiff

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Coffee, check, bun, check, laptop, check… liveblogging is go…

Last weekend I was part of a team that went to Cardiff to cover the fourth Open Data Camp. Two ‘drawnalists’ (from drawnalism.com) captured the event in pictures, while I helped Adam Tinworth (from one man and his blog) to live-blog the sessions.

Open Data Camp is a two-day event that brings together organisations committed to releasing information as open data and developers that want to use it in products of various kinds (anyone for a ‘Pokemon for Trees’ in Bristol?)

Its fourth iteration had more than 125 delegates on the first day and more than 100 on the second, and they pitched more than 30 sessions to what is an ‘unconference’ (delegates propose sessions, decide what to go to, speak up if they have something to say, and move on if something isn’t working out for them).

So the job… work out what is going on, agree with the organisers what to cover, dash along to a session, accurately capture what is being said or debated, turn that into a coherent report at the same time, be done and dusted by the end of the session or very shortly after that, load the post with drawnalism capture, Tweet, and get off to the next one…

It’s a lot of skill. I noted after the same team covered Open Data Camp 3 in Bristol that my Crown Court reporting experience comes in very handy. In court, I’d listen to one case while writing out enough of another to be able to ‘read’ a story to copy-takers during a break (full stop, new par…).

Now, copy is posted electronically; but you still need to be able to listen out for the points that are going to engage your audience, get them down accurately, capture quotes, shape-up a story on the run, and be ready to help colleagues (once snappers, now drawnalists) with supporting images.

Plus, of course, you need digital dexterity (Tweet and keep on Tweeting). And with just a half hour break, it helps not to need too much by way of lunch, as well!

Still, it’s an engaging challenge; and we got some almost embarrassingly good feedback on the #odcamp hashtag on Twitter. The very, very live-blog is at odcamp.org.uk: and there’s more about Drawnalism and what its artists got up to on drawnalism.com.

Gin and lemon drizzle cake

gin-drizzle-cake

Pistaccio and lemon cake, with gin and lemon drizzle…

So, I woke up on Sunday morning and thought, apropos of nothing all that much: “I wonder if you can make the lemon drizzle on a lemon drizzle cake with gin…” And you can…

[Recipe: cake: 4oz butter and 4oz sugar, creamed, two eggs, beaten in, 40z flour, folded in, plus the zest of one lemon (optional) and 20z blitzed pistaccios: drizzle: juice of the lemon, plus enough water to make up to 100ml liquid, 100ml gin, 100g caster / icing sugar, reduced to a thick syrop and poured over the cake].

 

Briefing against the NHS boss: Maybe time to rethink that, Prime Minister?

Simon Stevens at the PAC; FT picture

The FT’s take on Simon Stevens’ appearance at the public accounts committee; where he made cheeky use of a story in the Daily Mail, which briefed against him in November.

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.

 

#adventrunning 2016

In the run up to Christmas, I’ve been #adventrunning. It’s an exercise streak – it started as ‘run every day of advent’ but this year relaxed the rules a little bit, to allow for other forms of exercise (as long as you did at least 30 minutes per day).

The rule change meant I could count in my pilates mat class and studio session (although, to be fair to myself, my mat class does the full classical mat at this time of year, which can be exhausting – why Joseph Pilates felt it necessary to include so many teaser variations will always be a mystery…)

A streak is interesting. You do get tired, quite quickly, as you don’t get the recovery days that you would following, say, a marathon training programme. On the other hand, the daily discipline is good.

It was particularly good for me this year, as I found myself leaving my job in December; and the running worked off some stressful meetings, got me out of the office and, latterly, out of the house.

Also, the body does adjust. First week, I did three mile runs in the week, with two six milers at the weekend. Second week I was up to four miles in the week (one of them substantially downhill to recover!) Third week, I was back on the four, six, four pattern.

In total, I did just over 80 miles on the #advent running, and I’m now determined to make it to 100 miles by the end of the month. This may or may not be enough to run off the Christmas cake that also got baked, marzipanned and iced over the four weekends… but it should kickstart 2017. Bring on the next challenge!

Donald Trump and the media: the message is being srutinised, what about the medium?

trump-from-wikipedia-for-blog-post

The raw material: Donald Trump in campaign mode, Wikipedia image

Since the election of Donald Trump (and, like many people, I feel upset just typing those words) there has been a lot of debate about the role of journalism in his becoming US president elect.

An early issue up for debate was the behaviour of traditional press and broadcast outlets. Some, of course, were Trump supporters: which, in a way, is fine. You can deplore Fox News (or, in the UK, the Daily Mail) but you can hardly be in any doubt about where it is coming from.

The issue that got brief attention was that ‘impartial’ sources tended to give near-equivalent mentions to the latest accusations (of fraud, racism, misogyny…) against Trump and the endlessly reheated issue of Hillary Clinton’s use of a private email server for state business (not helped by the late intervention of the FBI).

More recently, there has been much discussion of the role of social media and, in particular, Facebook, both in presenting credible and non-credible news stories in the same timeline, making it hard for users to distinguish between them, and in disseminating outright false news.

Facebook is getting the facetime

The Facebook issue is interesting because it is so keen to claim that it is not a news service – just a platform on which news happens to be posted.  Yet, as the Digital Editors Network conference I wrote about below discovered, news is hugely valuable to it.

Pew research in the US says 44% of Americans get their news Facebook, so it keeps them there and in front of its advertisers. Like it or not, this makes it a media player, both for feeding users information that keeps them in their ‘filter bubble’ and for feeding them outright lies.

Quite what Facebook will do about this is interesting. Getting staff in to verify sources, fact check details, and promote credible stories would take it well into traditional journalism territory; with all the costs and potential for political rows and libel cases that come with it.

It’s hard to imagine it wanting to do this – its previous attempts to tackle false news have focused on retaining its ‘we’re just a platform’ defence by letting users report false information.

Even if it did, it might not make much difference unless it also changed the algorithm by which it pushes ‘liked’ information to people; which would disrupt its business model; just as the traditional newspaper model looks less and less sustainable.

New doesn’t mean mainstream

While it’s interesting, though, I wonder if the Facebook row is something of a distraction. Logic dictates that if 44% of Americans are getting their news from Facebook, the majority are still getting news elsewhere. Plus, of course, even Facebook users will have other news sources.

Given the long-term decline in newspaper readership, let’s assume a big bit of ‘elsewhere’ is broadcast output – if not set-piece TV news and current affairs shows, for which audiences are also in decline, then short, radio bulletins. This focuses attention back on the issue of what passes for ‘impartial’.

In the UK, the BBC has been called out for trying to fulfil its remit to be ‘impartial’ by getting two voices to speak on a controversial subject, even when one is representing a minority position, or claiming a fact or non-fact as nothing more than a point of view.

This has been blamed for skewed public perceptions of issues ranging from the MMR vaccine to climate change and Brexit. It’s also an important component of the ‘normalisation’ of figures such as Nigel Farage, who now appears on flagship shows as if his views were part of acceptable, mainstream, discourse.

The impact of constant, short, and ubiquitous bulletins 

This failure is exaggerated when news is boiled down into very short bulletins of the kind that go out around music programmes and so get piped into shops, workplaces, and cars. I doubt broadsheet and academic commentators hear many of these; or regard them as worthy of being called news if they do.

But driving around Leeds during the EU referendum campaign, it was not unusual to hear ‘on the hour’ bulletins that boiled the issues down to “Brexit supporters have claimed leaving the EU will deliver £350m for the NHS; Remain supporters have disputed this… and now the weather.”

The same phenomena can be seen in free newspapers and, of course, social media. A quick glance at Google and Twitter analytics for any given piece of content will suggest that people don’t so much consume news as headlines and summaries via their feeds; and in practice the summaries may be swapped out for a comment or bit of invective.

Unfortunately, the question of how we might address the impact of news being reduced to a headline and 140 characters across so much free to air content makes the question of how to tackle false news on Facebook look easy. Perhaps that’s another reason it doesn’t come up much.

Do the devices matter?

One further issue that I’ve not seen touched on anywhere is whether the devices on which people consume news and comment in themselves affect their perception of it.

There’s an unspoken assumption in most commentary on the media, Trump, and Brexit that it is content, not the vehicle for it, which matters. But two thoughts prompt the idea that the device itself might have an effect.

Firstly, I’ve commuted for a long time. When I first started travelling to work, people read papers on the train, and those papers were an important projection of the kind of people they were (respectable Telegraph readers, Guardianistas).

Over the years, fewer and fewer people have read papers and more and more have taken to using laptops and then smartphones on their journeys. People invest a lot of research and money in choosing their devices, and a lot of time in loading them up with the right kind of apps.

As such, they’ve taken on a chunk of the outward show of ‘this is who I am’ that used to be expressed by a paper. If people are going to invest so much in a device then, intuitively, it seems likely that they are going to place weight on the information they receive over it.

Secondly, in my day job I write about NHS IT, and I recently came across the idea of a ‘digital placebo’ – just delivering advice to people over their phones, or giving them access to a monitoring app, made them feel better.

Why? Again, because they were so invested in their phones that they enjoyed using them and put additional trust in an intervention delivered this way.

The medium and the message

If people are going to invest extra credibility in the news they get via their devices, just because they are getting it via their devices, then efforts to make sure that information is balanced, correct, easy to identify as such, and accessible outside an algorithmic ‘filter bubble’ will be important.

Yet somehow it feels like it won’t be enough. I’m not sure what media outlets can do with the thought. But papers used to put a lot of effort into their print products and design, to project their values and reader aspirations.

That will be hard to replicate in a world in which Apple and Samsung own the media, and much of their content appears on feeds that are outside their design. But somehow it feels as if we are going to have to address the medium as well as the message.

 

 

Reading between the lines, the PM and the Daily Mail have it in for NHS boss Simon Stevens

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The Mail Online, 20 November

There’s an astonishing story in the Daily Mail today. It says Downing Street is “gunning” for Simon Stevens, the chief executive of NHS England.

The paper says Theresa May is furious for “telling MPs that the Prime Minister had exaggerated the amount of extra money promised for the NHS” while appearing at a health select committee hearing.

Specifically, it claims Stevens annoyed the PM by telling the committee she was wrong to say the NHS would get “an extra £10 billion a year between now and 2020-21 – up from the £8 billion promised by former Chancellor George Osborne.”

Also, that he’s seen as stepping out of line by making a bid for more money, ahead of this week’s Autumn Statement on Wednesday.

The story may be true

There doesn’t seem to be any reason to think this story is not true. The paper likes May much more than her predecessor, David Cameron, and she has gone out of her way to support its line on, say, Brexit.

So the remarks as reported are likely to have been made. What’s astonishing is that Stevens didn’t say what the paper/Downing Street claims that he said.

NHS finances are complex, and set out in the blog post directly below this one. The basics, however, are that Stevens drew up a plan in 2014 that said the NHS was facing a gap between funding, demand and costs of £30 billion.

He reckoned it could make £22 billion of efficiency savings, with a lot of change, and a following wind, leaving the government to come up with £8 billion. Osborne duly obliged, claiming in last year’s budget that he was “fully funding” what he was quick to call “the NHS’ own plan.”

Things then get complicated because various ministers have claimed the government is in fact putting in £10 billion; counting an additional £2 billion Osborne had already announced for 2014-15.

The health committee reckons it is actually putting in £4.5 billion, because £3 billion is being transferred from the budget for things like running the Department of Health and public health. And one think tank reckons it should be as little as £800,000, because the Treasury has done some creative accounting on inflation and dating.

The health committee went into all this; and Stevens had to confirm the £10 billion to £8 billion and £8 billion to £4.5 billion figures.  He didn’t make the claim attributed to him today. At most could be accused of being forced to do maths in public.

Certainly, journalists have since asked May to do the same kind of maths, and she’s found that embarrassing. But that’s another issue.

The ‘facts’ are not

Stevens did tell an earlier public accounts committee hearing that the money was not being phased in as he asked, and that public health and social care spending had not held up as his modelling demanded. Which raised eyebrows among mandarins and policy wonks.

But he has absolutely not made a public bid for more money. In fact, he almost certainly wants to avoid any suggestion that there may be a bail-out on the way for the acute sector (hospitals), which overspent by £2.4 billion last year, and have been told to accept swinging ‘control targets’ to avoid a repeat this year.

Any hint of a bail-out would make hospitals and their commissioners less inclined to get into the difficult business of change that is being proposed by the sustainability and transformation plans that are supposed to turn Stevens’ ‘Five Year Forward View’ into local action.

As set out directly below, there are plenty of indications this project is not going well, but Stevens does not want it being derailed from the start. Also, when asked a direct question at the health committee, he said that if there was any money going this autumn it should go into social care, which has a financial crisis all of its own.

Ok, what’s the alternative?

The other reason that the Mail’s story is astonishing is that it’s hard to imagine who May thinks is going to take over from Stevens if he goes. Stevens was a Labour advisor at the turn of the century, but when he was recruited to take over from Sir David Nicholson he was working at United Health in the US.

It’s safe to assume that he took a massive pay cut to come back to England. In doing that, he also took on a job that amounts to trying to persuade the NHS to sort out a financial crisis that Nicholson warned it about in 2008 and that it largely failed to tackle.

Stevens isn’t as well-loved as Nicholson, and he can address conferences like he’s read too many management consultant text books in airport lounges, but he must really believe in the health service to have taken on the challenge.

If May and her advisors think there are loads of candidates willing to step into Stevens’ shoes, they are likely to find they are wrong. Indeed, before this morning’s intervention, the general assumption was that the government would be only too keen to keep Stevens in place.

Trotting out Osborne’s “NHS’ own plan” line gives ministers cover whenever there is a suggestion that the health service might fall over this winter, prove to be financially unsustainable in the long-term, or need to get rid of a lot of ageing, clinically unsafe, but much loved local hospitals.

Indeed, MPs on the health select committee have tended to express a cack-handed kind of sympathy with Stevens; asking if he is being set up as the “fall guy” for when the Forward View fails to deliver, as some unhelpful voices are starting to say it will.

Meantime, Labour moans that Stevens is covering for the Tories’ failure to spend adequately on the NHS, that he really wants to make cuts or that he wants to privatise large chunks of it (and yes, the last two are contradictory).

Worrying… on so many levels

We have to hope that May and her advisors know the facts, and were simplifying for effect in their comments to the Mail. If that’s the case, what are we to make of the story?

One interpretation would be that we have a Prime Minister who is so thin-skinned that she is prepared to lash out at a civil servant for answering Parliamentary questions, if this in turn makes journalists ask her difficult questions. This would not be good.

Another is that Downing Street realises the NHS is in deep trouble, that the government is going to have to find more cash for it or face protests on the streets (or both), and that it’s getting its retaliation in early by setting the press pack against the man in charge.

This would be worse. Any check on the Forward View and its STP process will make it less likely to succeed, when the odds are turning against it anway. And one thing we can be sure of is that the government has no alternative plan; and no capacity thanks to Brexit to develop one.