Andrew Haldenby: To clear the post-pandemic backlog, the NHS will need not yet more spending, but improved productivity

6 Apr

Andrew Haldenby is co-founder of Aiming for Health Success, a new health research body, alongside Professor Nick Bosanquet.

The NHS exits the pandemic with not only a backlog of two million hospital patients, but also the longest waiting times for 30 years.

300,000 people are waiting for hospital treatment for 12 months or more on the latest figures, compared to just 1,500 in January 2020. As a proportion of the waiting list, year-long waits are now at the same level as in 1992. Waiting times are a measure of suffering because many conditions worsen over time. The hospital backlog is a historic threat to patient care and wellbeing.

The NHS has offered varying responses. The NHS Confederation, representing hospitals and other providers, asked the Prime Minister in February to be “honest” and to tell the public to expect year-long waits “for some years”. Against that, I have spoken to hospital leaders who are doing all they can to tackle waiting lists, including running operating theatres until midnight and considering a 24-hour service.

Ministers should be firmly on the side on the side of the latter group. There is no reason for the current situation to become a new normal. Matthew Hancock and colleagues should expect the NHS to eliminate the backlog in full before the next general election.

The solution does not lie in a “bigger” NHS. The Service will not increase hospital bed numbers or workforce for at least the next five years, despite the headline commitments in the 2019 Conservative manifesto.

Of the “40 new hospitals” programme, only three have firm finish dates before 2024. (Even after that, the programme is a series of refurbishments rather than new builds. As the map shows, it does not benefit the whole country, with the great majority of projects taking place in London and the South of England).

Ministers recently announced an increase of 10,000 nurses over the last year, fuelled largely by overseas recruitment. Their problem is that the number of qualified nurses leaving the service is likely to be at least 15,000 a year. International recruitment will continue but finding local recruits will be harder due to the time taken to increase numbers of trainers. As a result, the manifesto target of 50,000 nurses will maintain rather than grow the workforce.

The aim is not “bigger” but “better” i.e. the sharpest focus on a high-productivity NHS of any government in the Service’s history. The current NHS strategy (laid down in the “ten year plan” in 2019) is good but it wasn’t designed to tackle the current backlog. Ministers need that plan to happen much more quickly and key new policies to come in alongside.

The first goal is to generate the extra activity needed to tackle the backlog. Traditional hospitals, even working extra hours, cannot do this. The new 42 NHS regions (“Integrated Care Systems”) need to establish new high-volume centres on the model of the South West London Elective Orthopaedic Centre (SWLEOC). Opened in 2004, it performs around 5,200 procedures a year. As such it is the largest hip and knee replacement centre in the UK and one of the largest in Europe.

Given the need for new capital to start these centres, the NHS should call on all national and global resources. Some of the centres could be joint ventures with experienced providers such as the Cleveland Clinic and Apollo Healthcare in India. Ministers should expect to see plans for an initial group of 10 centres before the end of the summer, with the first patients being treated next year.

The second goal is the shift towards the new model of care that successive governments have described for the last 15 years. The idea is right: a reorientation of the NHS so that hospitals are no longer the centre of gravity of the Service.

Community services will provide much faster diagnostic scans, often working in partnership with private firms. Strengthened GPs, working with consultants, will lead patients’ treatments, reducing the bottleneck of waiting for hospital appointments. GPs can also work with patients to change their lifestyles, in a way that hospitals cannot. The pandemic has highlighted the problem of obesity which is a key risk factor for long term conditions.

Simon Stevens, the excellent chief executive of the NHS, said last week that “prevention and integration are the holy grail”. His commitment to a more productive NHS is not in doubt but he will know that progress has been difficult. As the NAO has shown, the share of the NHS budget going to hospitals has actually increased in recent years. Both he and Ministers should give local NHS leaders the tools, and the support, to move faster.

On staffing, the focus should be community teams. The current recruitment of 20,000 new staff in primary care networks should be just the beginning of a strengthening of local capacity. As well as adding new entry-level staff, the NHS should support experienced leaders. A special grade of NHS Team Leader, with access to digital learning, mentoring and higher pay, would help.

On funding, reducing the number of hospital outpatient appointments by 30 per cent, as the NHS is committed to do, would release £7 billion per year for new services. Ministers should go further and expect hospitals to reduce inpatient and emergency attendees by a third as well, in this Parliament, helping to turn hospitals into hubs for community services.

Ministers will come under intense pressure to increase NHS spending further in the spending review this autumn. They should resist. Health spending has already risen by a third as a share of GDP (10 per cent now compared 6.9 per cent in 1997). Unless this rise is constrained, it is difficult to see how any government can make progress in other areas. That includes education which is at the heart of any effective levelling-up effort.

On social care, successive Governments have become bogged down in the search for a perfect funding system. In the meantime, social care delivers higher quality care than acute hospitals and is providing welcome new options for care in people’s homes, even for those with complex needs. Ministers may not need a grand plan. Simply providing realistic funding for local-authority financed care residents would provide security for operators. The worst approach would be to nationalize social care as a free service under the NHS, leading to higher costs and much worse access.

Last week Sir David Nicholson, the previous head of the NHS, said that waiting times could reach two years by the next election. The Guardian reported that lengthening delays for treatment will be a “major political problem” for Boris Johnson. This need not be the case. After the success of the vaccine programme, tackling the backlog could be the Government’s lasting achievement.

Andrew Haldenby: Cameron was right to bury Labour’s targets regime. Johnson shouldn’t now seek to resurrect it.

20 Jan

Andrew Haldenby is a director of Haldenby Woodford, a public services consultancy.

According to reports, Home Office Ministers want to bring back national crime reduction targets for the police – most likely a 20 per cent reduction in crimes such as burglary, vehicle theft and serious violence. There is a wealth of evidence as to why this remarkably bad idea will make policing worse, not better. There are many things that Ministers can do to improve the police (and public services more generally). But central targets are not among them.

The new targets may be inspired by the “MOPAC 7”. Boris Johnson and Kit Malthouse introduced targets for 20 per cent reductions in seven crimes during the Prime Minister’s time as London Mayor. If so, that is a huge red flag. The MOPAC Seven led to one of the police inspectorate’s most damning reports in recent years.

In 2016, the inspectorate found that the Met’s work on three-quarters of their child protection cases (278 out of 374 examined) either “needed improvement” or “was inadequate”. The Met had neglected work on child protection because of “the attention given to measuring and monitoring the MOPAC 7 crime types”.

The inspectorate rightly judged that this was “unacceptable”: “Irrespective of the mayor’s stated priorities, it is the responsibility of every police force to protect all citizens – particularly children, as they are the most vulnerable and have the most to lose.”

Police officers will tell you that “if it gets measured, it gets done”. Forcing the police to address certain crimes means that others will receive less attention. The police inspectorate noted that the MOPAC 7 list also excluded “serious crimes such as terrorism, murder, sexual offences, kidnapping and firearms offences”.

Another consequence of targets is gaming – that is, manipulation by the police to give the appearance that crime is falling against a target, when the reality is different.

Police officers will give you endless examples when asked. One reminded me that in 2011, in the riots after the death in London of Mark Duggan, one Midlands town was particularly successful in its policing (due to good community relations).

On one night, a small disturbance in one street led to 40 cars being damaged, and 40 crimes were recorded.

In another town, much more serious violence spread across the whole urban area. The police force however recorded only three crimes of public disorder. Targets create incentives for gaming: both Ministers and police forces wish to produce statistics that give the evidence of falling crime.

In 2012, a police inspector gave evidence to the Home Affairs Select Committee setting out the evidence on gaming during the previous high water mark of police targets, during Tony Blair’s first two terms.

He identified “cuffing” (i.e. the under-recording of recorded crimes) and “skewing” (moving resources to target crime areas – like the MOPAC 7). He quoted a police officer who said: “Every borough is playing the game; those that are not are seen as under-performing. Policing has completely lost its way. We only investigate crimes that matter in terms of performance data.”

It is difficult to describe how poisonous the atmosphere around police targets had become by the end of the Labour government. In 2009, the then Metropolitan Police Commissioner, Ian Blair, said that there was “almost no public faith” in falling crime numbers. Sara Thornton, then Thames Valley Chief Constable, said her force would deliver “what the public wants” and added “you do not improve policing by setting lots of targets from the centre”.  The Coalition Government eventually abandoned them, to great relief in police forces and in Whitehall and Westminster.

Given all this, it seems almost incredible that Ministers want to bring targets back. It may be that Ministers are looking for extra performance in return for the 20,000 new officers being recruited. If this is the case, the question has to be asked: if Ministers don’t trust the police to use the extra officers, why did Ministers decide to recruit them in the first place?

The Blair Government showed that it is possible to create a doom loop – extra resources tied to new targets, followed by more resources and more targets, leading to all the problems outlined above. If Conservative Ministers set off down this path, it would be a gift to Keir Starmer’s Labour Party, which would capitalise on police disaffection and public scepticism in the same way that David Cameron did. There is great respect for the Home Secretary at present among officers. This direction would put that at risk.

It has to be recognised that targets have a powerful appeal to every Minister, not just in the Home Office. They appear to embody a seriousness of purpose in a simple, easy-to-communicate form.

But Home Office Ministers already have a strong policing agenda that they can develop. The 2019 manifesto promised much greater action on the prevention of crime– specifically around reducing youth offending, reducing addiction and improving rehabilitation. A sustained programme in these areas will change lives for the better. If they move with energy now, Ministers will have results before the next general election.

Others suggest that Ministers have lost trust in the police, on the grounds that they have taken on too much “woke” culture, as shown by their reticence in the destruction of statues last year.

A police officer responded to this by telling me of his experience in the Black Lives Matter disturbance in London in June. He said that he spent several hours, in warm weather and riot gear, being called a “fascist” by the protestors in front of him. Ironically, he was then injured when an actual fascist hit him in the back later on. “Woke” protesters see the police as safeguards of national institutions, not part of their campaign.

Speaking in Parliament last year, Malthouse rightly said there is no direct link between the number of police officers and the level of crimes (“Throughout our history, we have seen police numbers at a lower level and crime higher, and police numbers at a higher level and crime also high. There is no direct correlation”).

Instead, he pointed to the importance of “motivation” and “leadership” on the part of senior officers. He was right. Targets would cut across that leadership and reduce leaders’ motivation at a stroke. They would drive a wedge between Government and officers and open the door to the Opposition. They are not a good idea.

Andrew Haldenby: The private sector has delivered in this crisis – creating the UK’s outstanding network of test centres

1 Dec

Andrew Haldenby is a director of Haldenby Woodford, a public services consultancy.

A Western European country has done something remarkable in the fight against Coronavirus. It has built a national network of test centres with the first one set up and running within days of the pandemic starting. It has recruited from scratch a workforce equivalent to the five biggest police forces in the country. It has used private sector expertise to deliver genuine quality: 24-hour mobilisation to high risk areas, all-but-perfect safety from infection on 650 national sites, full weekday and weekend service.

The nation is the United Kingdom. We have been so self-critical over NHS Test and Trace that we have failed to recognise an incredible public service achievement.

Running test centres safely and reliably is a real challenge. Any transmission of the virus from staff to visitor, or vice versa, would result in a centre being closed and the opportunity to test people being lost. The Government and companies have together worked up rigorous safety standards. The companies seen as highest quality, such as Sodexo, go further by providing bespoke training to all members of staff.

The scale of the operation, with a total workforce of over 40,000, has required creative management. The best companies have set up dedicated seven-day-a-week recruitment operations to ensure centres are always fully staffed. Many staff have been recruited from the hard-hit hospitality sector, supporting the economy during the pandemic.

Centres are best located in areas of greatest infection, responding to local data that is constantly updated. Often, the Government will call companies in the evening to require a centre to be set up on the following morning, and companies can do it. The firms have also trialled the instant result, antigen tests which will be a game-changer in the fight against the virus.

This success is a blow for critics of private sector delivery of public services. That includes Keir Starmer. (While he has been keen to distinguish himself from his predecessor, in terms of actual policy the Labour leader is just as opposed to private sector delivery as was Jeremy Corbyn.) Centres have performed well partly because of firms’ long experience in running services for hospitals and in running major events around the world.

Some may say that this achievement is a worthy one, but it is the overall performance of Test and Trace that matters, and that performance is poor. That seems to have become the received wisdom but I would challenge it.

In his key lecture on government reform, Michael Gove rightly said: “We need, as a Government, to create the space for the experimental and to acknowledge we won’t always achieve perfection on Day One.” This is the right test for any new public service, especially one set up from scratch in unprecedented circumstances. In fact Test and Trace has got some things right since day one – for example test centres. In others it has learnt and improved. Unlike many firms, it has not had the luxury of refining its services before launching them. It has had to develop them in real time.

It has learnt lessons on contact tracing. To be successful, contact tracing requires the knowledge and co-operation of local communities. Test and Trace was set up as a national organisation but accepted that it should work in tandem with local agencies as long ago as May. The Director of Public Health at Blackburn with Darwen Council recently described to the Health Select Committee described how his team is picking up local people with positive test results whom the national team have not been able to reach. The Blackburn team is reaching 89 per cent of the local group. As Matt Hancock rightly said to the Committee last week, the combination of the national and local effort is working.

(It is worth noting that every major European country has found contact tracing hard. Even Germany, with a much-praised local tracing system, has gone into partial lockdown because its tracers had been overwhelmed. It is difficult to compare the UK to Asian countries, such as South Korea, which have run contact tracing successfully. Those countries were simply years ahead given their experience with the SARS virus in 2003 and the MERS virus in 2015.)

Test and Trace is also addressing a subject that has been little discussed: the fact that at least 50 per cent of people refuse to isolate when they are asked to do so. It has studied the reasons behind these decisions (often a fear of losing income). It has put forward solutions, such as the £500 payment to those isolating, introduced in September.

The big hope here is the instant-result antigen tests. These offer the prospect that people asked to isolate can themselves receive a test with an immediate result. If negative, that will give them immediate release from isolation. As the Prime Minister said last week, this changes the incentives for people. Instead of seeing the Test and Trace system as a potential route to lockdown, it becomes a way back to normal life. Test and Trace distributed 600,000 tests to local authorities eight days ago. It is piloting antigen tests which can be self-administered, further increasing their impact.

The final argument against testing is that it will no longer be needed given the vaccines that are on the way. Certainly the vaccines will affect the need for tests, and future contracts for test centres should be flexible in length and volume, taking advantage of the adaptability of private firms. It would however be a mistake to scrap the infrastructure that has been built.

The length of the immunity from Covid-19 due to a vaccine is not yet known. Even after the vaccines are introduced, society will want to test to ensure the safety of gatherings of people, for example in universities and offices. Most importantly, the UK should not leave itself as exposed as it was at the beginning of 2020, when our testing capacity was found to be wanting. Given the steady rise in global movement of people, we are more at risk from pandemics than in the past. Part of the legacy of this pandemic should be a much greater level of readiness for the next one.

With two new Lighthouse Labs opening in early the New Year, testing capacity will pass one million per day. By any standard that is a remarkable achievement compared to the daily capacity of 10,000 per day in March 2020. Self-administered antigen tests will make blanket lockdowns redundant. All of this is founded on a test centre network which is a model of public-private partnership, and which, in current politics, only a Conservative government could have delivered. It may be time to revise the received wisdom on Test and Trace.