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

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.

 

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

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.

Brexit: getting harder by the day

There is no reason for this post, except that I haven’t written about Brexit, and I had some time this afternoon, and I’m still not feeling better about it…

On the day after the 2015 general election, my partner and I sat in the back garden and worked our way through half a bottle of gin (the most excellent, locally produced, Twisted Nose, as it happens).

It felt like a very bad election to lose. Lots of things have happened since to prove it. The election returned a Conservative government, unchecked even by the Lib Dems, which immediately doubled down on ‘austerity’.

Yet, despite his unexpected majority, and the licence it gave him to pursue policies to appeal to the nasty wing of his party, Prime Minister David Cameron decided he needed to deliver on the EU referendum. The one he had promised to try and appease those inclined towards UKIP.

Appeasement never works, and the campaign was terrible. Cameron tried to argue he had secured significant concessions from the EU before it got going, but these were barely mentioned once it did.

Amazingly, it was reported that “what is the EU” shot to the top of Google’s search terms the day after the vote – so the niceties of whether or not Cameron had secured anything significant with his opt-out from the requirement for ‘ever closer union’ could never have been a deciding factor.

Remain tried to fight on the economic benefits of membership, but was shouted down for ‘scaremongering.’ The Labour Party went missing in action, with its leader, Jeremy Corbyn, putting out half-hearted support messages hedged around with reasonable but untimely concerns about workers rights.

Then, there was the nasty undertow of anti-immigrant rhetoric. Yet, despite all this, I thought the EU referendum was a distraction. An annoying one, inflicted on the country by a weak PM with a PR’s instinct for selling a message over worrying about substance.

I didn’t think we’d leave. And then we did. On 23 June my partner and I were on holiday in Leeds, so we’d voted by post some time earlier.  In the afternoon, we went for a run along the Leeds and Liverpool canal, where we came across a number of Labour canvassers for ‘in’.

Beside a Victorian factory designed to look like an Italian palace, to show how cultured the builder was, they gave us the, in retrospect, less than reassuring message that “people are a lot less hostile” than they had been. I still went to bed thinking there would be a ‘remain’ vote.

At 2.30am, I woke up to find my partner sitting in bed following the declarations on his phone, reporting that “things are not looking good.” At 4.00am, I woke up to find him in the same position, reporting that “it looks like we’re out.” A bit later, we both gave up on sleep as the result was confirmed.

Then we spent the rest of the day in shock (actually, we eventually went to the Turkish baths in Harrogate, because it was the only place we couldn’t obsessively follow the reaction on news sites and social media).

That shock has not really gone away. It’s not just the economics. Ok, the pound has continued to fall, which makes it look as if we’re in for a nasty bout of price inflation as the impact feeds through into food, clothes, oil and other imported goods.

Financial services and manufacturing firms have seen their share prices fall and are indicating that they could leave the UK, if there is a ‘hard Brexit’. The new PM, Theresa May, made a hard Brexit more likely at the Conservative Party conference last week, by indicating that she would trade access to the single market for curbs on the free movement of people.

Her party cheered when ministers indicated those curbs might apply to “foreign” workers, students… and doctors; apparently unconcerned that the quid pro quo may be the re-imposition of visas to visit the continent, never mind work there.

No, even more than the economics, it’s the feeling that the UK, or England and Wales, or the poor bits outside their major cities, is cutting itself off from a wider community of nations. Nations committed to liberal ideas, rights-based legal systems, constitutional democracy and networks of academic endeavour.

Things those of us in ‘the 48%’ were brought up to believe in. There is no doubt that the EU imperfectly realised those ideals. Or that it could be bureaucratic. Or that it could have done more to stand up to the vested interests and global business that inflicted the hardship that the ‘out’ vote is now seen to be reacting against.

Or that the remaining 27 countries have some worryingly right-wing, anti-immigrant fringes. Yet Britain already feels like a smaller, narrower-minded place out of it.

The May government does not help. May reminds me of the Brown Owls who ran town councils in my childhood. Church minded ‘independents who weren’t even Tories because they couldn’t conceive of right thinking people thinking other than they did.

They got things done, but by making complex decisions simple and ordering people about. They even hankered after grammar schools; the inconvenient abolition of which my comprehensive got around by organising its classes into rigid ‘sets’.

Education, travel and hard work were the escape routes; and, unfortunately, they are the things a good chunk of my country has just decided it does not want. Meantime, Labour (and I’m a Labour Party member) has remained missing in action, with Corbyn alternately refighting the 1980s, acquiescing in the Momentum take-over of the party, and buying ex-blankets on Hadrian’s Wall.

And as for the Lib Dems… on the rare occasions they’re seen on in the media, it’s hard not to revive the old Wimbledon call of “come on Tim” [Henman/Farron]. May has now said she will incorporate EU law into English law, so the Tories can abolish the bits they don’t like at their leisure, and then trigger Article 50 by April 2017.

So more or less two years after the May 2015 general election, we will have just two years to leave; and apparently get back to the 1950s. It’s all incredibly depressing. I’m not nearly over the trauma. And we’re all going to need a LOT more gin.