Andy Cowper: Learning the lessons from Covid-19

At a time of taxing politics – and politicising taxes – a government review of NHS management mustn’t get in the way of learning from the pandemic
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By Andy Cowper

18 Oct 2021

The political party conference season is over for another year. As the Westminster government moves to return to business as unusual with the loping run-up to the Spending Review, we have seen some of the political battleground mapped.

Civil servants can start planning how to negotiate the various minefields ahead.

Let’s start with what we learned from the Conservatives: there is still no meaningful definition of the Government’s signature policy of ‘levelling up’, despite the attempts of Michael Gove and the smart Neil O’Brien.

At one level, leaving the meaning of ‘levelling up’ vague allows the government to claim that almost anything it does is levelling up (so raising or cutting taxes could both be branded as ‘levelling up’). On the down side, if you don't have any actual goals targets, then proving you’ve delivered on it becomes harder. Post-hoc rationalisation will only get you so far, as we are starting to see in so many sectors of the economy with ‘taking back control’ through Brexit.

And the economy? Brand-conscious Chancellor Rishi Sunak gave a delightfully incoherent speech to the party faithful, claiming: "I believe that mindless ideology is dangerous. I’m a pragmatist. I care about what works, not about the purity of any dogma.

“I believe in fiscal responsibility. Just borrowing more money and stacking up bills for future generations to pay, is not just economically irresponsible. It’s immoral. Because it’s not the state’s money. It’s your money."

Ahem. His second set of points there quite literally *is* ideology. It *is* dogma. It's just traditional economically dry Tory ideology and dogma that Sunak likes, and thinks is sellable.

The chancellor’s self-praise for backing Brexit was curious, given his subsequent comments that you cannot make progress if you’re pitting people against each other.  In terms of coherence, this was matched by his praise for austerity: “I’m grateful, and we should all be grateful to my predecessors and their 10 years of sound Conservative management of our economy. They believed in fiscal responsibility. I believe in fiscal responsibility”.

Tax and social care

It’s going to be an interesting Spending Review for sure, as the Institute for Fiscal Studies pointed out in their ‘Green Budget’. Well-informed sources indicate that the prime minister has agreed with the chancellor to rein in his spending tendencies for now, with a view to being able to cut taxes before the next election.

This plan may prove over-optimistic. As IFS director Paul Johnson pointed out, it’s likely that the new health and social care levy will be swallowed whole by the need to clear the NHS backlog. So “to fix the crisis in social care once and for all”, as the PM promised, will require more or higher taxes.

Towards delivery

Delivery of social care is evidently focusing minds, as this story briefed to The Guardian about Sajid Javid’s ‘radical plans to merge social care and the NHS’ showed. It suggests that a new white paper will propose the creation of a new national care service under which health and social care would be delivered by the same organisation”.

As so often with new policies that the Johnson administration briefs out, you get the sense that a kite is being flown. But why, and to what effect?

The article inevitably fails to propose the questions to which ‘a unified delivery organisation’ is the answer. Richard Humphries (formerly of the Kings Fund; one of a few people who understand social care and its interaction with the NHS very well) pointed out that David Cameron “ordered” the integration of health and social care back in 2012, and that went nowhere. So Richard’s probably right to be philosophically phlegmatic about this.

Reviewing NHS management (again)

On the eve of health and social care secretary Sajid Javid’s speech to party conference, an obligatory briefing to the Telegraph revealed that “General Sir Gordon Messenger, a former vice chief of defence staff, will be charged with driving up the quality of management and ensuring “every penny” of taxpayers’ money is “well spent”.”

The Telegraph story goes on to reveal that a senior government source added that the review had been launched to ensure that the health service did not squander the major cash injection announced by Mr Johnson last month to overhaul social care and clear NHS backlogs. The government is determined that every pound of investment is well spent so that everyone gets the care that they deserve”.

So what’s the Messenger Review about, then? Basic politics: it’s anticipatory blame-shifting. This government knows enough to realise that the NHS and social care are about to walk into a very difficult winter indeed. Even if the weather isn’t too bad.

This review of NHS and social care management is the classic deflection tactic of getting your excuses in first about the coming crises. It’s a political prophylactic.

We’re going to see a lot hard questions about deteriorating NHS performance. To these, ministers’ and MPs’ replies will begin with ‘well, of course the Messenger review is looking at all aspects of how the NHS and social care are using this extra money (yes, the money that doesn't start until next April), so we shouldn't anticipate its conclusions, but I want to reassure you that nothing will be off the table’.

Externally-led reviews (the bigger, the better) are the politician’s deflector shield of choice when it’s hugely apparent that things are about to get seriously bad. Event X happens: “Our wide-ranging review will be dealing with the causes of Event X”.

How much will the review amount to in practical terms? Well, let’s remember that in the dim and distant political past of last month, on the BBC1 Andrew Marr Show, Javid promised us a review of ‘nonsense’ NHS targets.

Learning from Covid19

The joint report of the Commons select committees on Health And Social Care and Science And Technology on ‘Coronavirus: lessons learned to date’ is a bracing read.

It is even-handed, giving credit where it is due, to the vaccines procurement and initial roll-out and the development of treatments such as Dexamethasone. But it is damning on various aspects of the response, concluding that:

  • The delays in establishing an adequate test, trace and isolate system hampered efforts to understand and contain the outbreak, and it failed in its stated purpose to avoid lockdowns;
  • The initial decision to delay a comprehensive lockdown – despite practice elsewhere in the world – reflected a fatalism about the spread of Covid-19 that should have been robustly challenged at the time;
  • Social care was not given sufficient priority in the early stages of the pandemic;
  • The experience of the Covid-19 pandemic underlines the need for an urgent and long-term strategy to tackle health inequalities; and 
  • The UK’s preparedness for a pandemic had been widely acclaimed in advance, but performed less well than many other countries in practice.

The report is illuminating on NHS capacity issues, noting that then-NHS England chief executive Sir Simon Stevens praised the flexibility of NHS staff, saying “people, under the most difficult circumstances, have all pitched in with incredible esprit de corps while recognising, frankly, that people across the health service are tired, stressed and frustrated”.

Likewise, it is damning about the performance of Test And Trace: “The failure of the test and trace system to rise to meet even the most predictable of demands in Autumn 2020, especially given many weeks to prepare, suggests that lessons that were learnable during the pandemic were not applied. An urgent priority for the government must be to satisfy itself that there is now a dependable organisation for Covid testing that can both anticipate and meet future demands.

“In the autumn of 2020, Test and Trace made a series of submissions for a budget to allow it the operational resources it assessed were required during the year ahead. The sums of money were vast. The budget of the operation was established at £37bn  … for such an unprecedented request, a big justification was mounted, most notably that investing at that level would avoid the need for future lockdowns. New outbreaks would in future be rapidly detected and eliminated, so allowing most of the country to resume much of normal life”.

Yet we were back in a third lockdown by early January 2021. Not for nothing do the committees recommend that “those responsible for future test and trace programmes should establish a culture and processes to learn rapidly from errors and to act to prevent them being repeated”.

The joint report also notes that “the NHS responded quickly and strongly to the demands of the pandemic, but compared to other health systems it ‘runs hot’—with little spare capacity built in to cope with sudden and unexpected surges of demand such as in a pandemic”.

It recommends that “the experience of the demands placed on the NHS during the Covid-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS… comprehensive analysis should be carried out to assess the safety of running the NHS with the limited latent capacity that it currently has, particularly in intensive care units, critical care units and high dependency units”.

That sounds expensive. Will it happen? We shall see.

Andy Cowper is the editor of Health Policy Insight

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