As Big Dog nears his final trip to the vet, briefings break out over the NHS Elective Recovery Plan

The plan forms a handy battleground for Conservative leadership ambitions but gives little detail on how aspirations to cut waiting lists will be met, Andy Cowper writes
Photo: Christopher Furlong/Pool via REUTERS/Alamy Stock Photo

By Andy Cowper

23 Feb 2022

 

It is a truth universally acknowledged that if it’s a month with a vowel in the name, the Daily Mail will be doing one of its “public sector leaders who earn more than the prime minister SHOCK!” pieces.

Along came NHS England chief executive Amanda Pritchard’s turn, as the Mail spotted that she had got the full salary for her job. (For context: her predecessor, Lord Simon Stevens of Birmingham, volunteered for a 10% pay cut on taking the role. This is rather easier to do if your previous job was running US health insurance giant UnitedHealth, meaning you have quite a few dollars in the bank.)

Good on Pritchard, frankly. She displayed her mettle and earned her corn by winning a battle with the Treasury over the NHS elective recovery plan. Not many people win fights with the Treasury. CSW readers will have spotted that the NHS backlog rose over 6.1 million (and will keep rising), and probably noticed a “war of the briefings” in the national newspapers.

Of Big Dogs and Briefingate

The political context of this battle is pertinent. The anti-Midas touch of the Boris Johnson administration crystallised over the scandal around disgraced Randox lobbyist and former MP Owen Paterson; and was then amplified and magnified by the still-ongoing Partygate scandals. Johnson’s self-promotion as the “Big Dog” of the government has been terminally punctured, leaving him looking more King Charles spaniel than husky.

Now that the (ahem) Big Dog is nearing his final trip to the vet, the puppies all start to wonder which of them comes next. And it is in terms of leadership ambitions that we must read the media briefings from the PM For The Time Being, the chancellor Rishi Sunak and the health but social care secretary (and ex-chancellor) Sajid "The Saj" Javid.

Briefingate kicked off with a story briefed by Mr Johnson to his real boss he Telegraph that those mean, nasty Treasury folks weren’t letting him have the money for the NHS elective/electoral recovery plan.

Boo, nasty mean Treasury people! Boo!

The Treasury was briefing back to The Times that the “incredibly well-funded NHS” would have to deliver on targets.

Would The Saj be left out of these skirmishes? Of course he wouldn’t! He made sure that The Times had a story about the Treasury blocking the Elective Recovery Plan. It’s even sillier than usual, including as it does a quote from one source that “the NHS are the ones who didn’t want to announce any targets”.

So, about those targets …

OK: what did the Elective/Electoral Recovery Plan say? First and foremost, it is very much Not A Plan. The document has “ambitions, guidance, and best practice”. So creating 30% more elective capacity over pre-pandemic levels by 2024-5 is an “aim”.

Other aims include to “make progressive improvements on long waits, with a goal to eliminate waits of over one year by March 2025, and waits of over two years by July 2022”.

The words “ambition”, “aim” and “goal” all allow for a lot of wriggle-room, obviously.

There are re-statements of the cancer plan targets, of course. Likewise, there are commitments that by March 2025 there will be no 52-week waits.

The document hopes that by July 2022, no patient will wait longer than two years for elective care; that by April 2023, no patient will wait over 18 months; and that by March 2024, the waiting list will be falling and no patient will wait longer than 65 weeks.

Waiting lists are to be prioritised by age, deprivation and ethnicity. That’s sensible.

The plan also dilutes the existing (but un-hit) diagnostics target: presently, 99% of patients needing a diagnostic test should get it within six weeks. The ERP says that by March 2025, the NHS will deliver this for 95% of patients.

It’s not long until we get to caveat time: “these ambitions ... of course depend on returning to and maintaining low levels of Covid-19, enabling the NHS to restore normalised operating conditions and reduce high levels of staff absence”.

Ahem. At the time of writing, there are 11,000 Covid patients in hospital currently, and just over 300 in critical care beds, on ventilators. The Omicron wave is going out, but it’s very much not yet all over.

Health Service Journal’s coverage suggests that the elimination of 52-week waiters by March 2024 (before the next general election) was a bone of contention between the government and NHS England. Agreement that the relevant March 2024 target should be a falling waiting list represents a good win for NHS England’s chief exec.

To state the obvious: ongoing demand from Covid-19 and associated infection controls makes it hard to quantify how big the waiting list is yet to become. Likewise, our lack of clarity about how much once-anticipated demand has simply disappeared because of deaths. So an activity-based target makes sense.

Nothing on workforce

Workforce issues are not seriously addressed, in any way. That seems unsustainable, to put it mildly. The ERP requires an expansion of NHS capacity: to expand NHS capacity is going to require more staff.

There is still no workforce plan; nor any sign of a budget for Health Education England for the next financial year, which is less than six weeks away.

The most important passage on workforce states: “Any solutions for tackling the Covid-19 elective backlog cannot rely on making the same staff ... work ever harder. To succeed, we have to grow and support our workforce, so they can deliver excellent care.”

Pritchard is clearly no mean counter-puncher in negotiations. Good for her. Indeed, she made clear in her latest message to the service that she intends to build on this win by pushing for a workforce strategy: “We cannot build the recovery on our staff working at ever increasing levels of intensity ... a long term plan for the workforce is essential, and I’ll continue to work hard and make the case for that plan to deliver and get the backing it needs, for staff and patients alike”.

"The Saj", of course, already told the Health Select Committee recently that he wants a workforce plan: “there’s some Health Education England work working on a framework for workforce ... back in July last year, I commissioned what I call this framework ... just recently, I commissioned the NHS to develop a long-term workforce strategy, which hasn’t been done before ... the merger between HEE and NHS England should hopefully make this more joined-up”.

So that’s nice. But there’s nothing in terms of a commitment about when this workforce plan will actually arrive, though. 

One final thought about the ERP: if this really is the version after the Treasury put their adorable little feet down and insisted on more targets, then it’d be comedy gold to see the previous version.

They think it’s all over…

This week the PM announced early ending of the remaining Covid-19 restrictions this week, including the mandate to self-isolate once diagnosed as infected. Free mass testing will also end from 1 April.

The proposed basis for this was the reduction in infections and hospitalisations. And where were the scientists to back this widely-trailled move? 

After weeks of remaining catherdrally silent, chief medical officer Prof Sir Chris Whitty and chief scientific adviser Sir Patrick Vallance emerged to stand beside the PM as he urged the public to be “considerate” to others if they test positive for Covid after restrictions end – assuming they can pay for the test, of course. 

In contrast to the PM’s buillsh tone, Whitty and Vallance sounded notes of caution, referring to high case rates and “significant problems” which could be caused by new variants. Their muted messages revealed the deeply unscientific nature of this announcement.

Just before parliamentary recess, the PM told the commons “we have to clear our Covid backlogs”. Yet here he was, ending restrictions a month early, at a time when there are over 11,000 in hospital for Covid and 300 in mechanical ventilator beds. 

A small positive note was the decision to retain the Office for National Statistics weekly Covid19 infection sampling survey – albeit scaled down. This survey is regarded as the “gold standard” because it has tracked the same households since June 2020: as such, it is not subject to variations in numbers of people self-testing. 

All of this matters to the NHS’s prospects. Because as the Ipsos MORI opinion polling work for Health Foundation pointed out, people have started paying attention to the state of the NHS: and they have started to expect that it will deteriorate further. 

Electorally, not only will this have consequences for the government, it is already having them: new polling for Redfield and Wilton found Labour in the lead across all principal public policy areas for the first time in a very long time. 

Andy Cowper is editor of Health Policy Insight

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