Robert Ede: The Government’s latest NHS review dodges key questions on management

24 Jun

Robert Ede is Head of Health and Social Care at Policy Exchange

An independent report into leadership across health and social care, led by Sir Gordon Messenger, has been published. The Review was first announced by Sajid Javid, the Health Secretary, on the eve of last year’s Conservative Party Conference as the Government identified that leadership was a crucial part of “make every penny of taxpayer’s money count” in public services delivery.

Reviews of NHS management are nothing new; Javid’s political hero Margaret Thatcher commissioned supermarket executive Roy Griffiths in 1983 to undertake a Review which led to significant power shifts, including the introduction of general management into the NHS. Many others have been tasked with following Griffith’s footsteps. In the past seven years alone, we have had four similar investigations into leadership conducted by Lord Rose, Sir Ron Kerr, Tom Kark QC and Sir Robert Francis.

This matters because NHS management is in the spotlight. Planned spending for the Department of Health and Social Care in England reached £190.3bn in the past financial year. There has been an ongoing debate in the media about both the level of spending as A&E performance tumbles, people struggle to access GP appointments, and waiting times lengthen.

The public believes that how spending is controlled could be improved: ‘money is wasted in the NHS’ was the fourth most popular reason for the historic low levels of satisfaction with the NHS in the latest British Social Attitudes Survey. In offering suggestions, a blizzard of different commentators suggest that the NHS is either over managed or under-managed, over centralised, or too disparate, too politicised, or not politicised enough.

The document is a good read. Independent reviews on NHS leadership are often voluminous; this is just 10,000 words and can be digested in an afternoon. The brevity is matched by the modest number of recommendations – just seven – all of which have been accepted in full by the Government.

Targeted interventions at entry and mid-level management. Positive action rather than tokenism on equality, diversity, and inclusion. Consistent, accredited training. A standard appraisal system. A new talent management function in the regions. More effective recruitment of non-executive directors. Incentivising talented managers to take the most difficult roles.All sensible. Little to fundamentally disagree with. Does that mean a solid output, or an opportunity missed?

When first appointed alongside Dame Linda Pollard, Chair of Leeds Teaching Hospital in October 2021, Sir Gordon was tasked with assessing the state of leadership across not just the NHS but also social care, and in particular understanding mechanisms to address variation in quality across the country. A seven week wait ensued before the terms of reference were published. Re-reviewing the ten domains and comparing them to the final product is instructive.

The final report make few explicit observations about leadership in primary and social care. The terms of reference suggested that the Review would explore the ‘systems for intervention’ in providers and Integrated Care Systems. Yet the role of inspection and national oversight only receives a short paragraph, and no specific recommendations. Proposals to drive up efficiency were also trailed in the launch, but whilst efforts to standardise training may lead to improvement, as solutions they feel modest when you are setting punchy 5% efficiency savings targets for Trusts to deliver.

Bigger questions are left hanging. The Review says that constant demands from above, including from Ministers, created an instinct to look upwards to “furnish the needs of the hierarchy”. An interesting finding – but with the centre’s role not formally included within the scope of the Review we are left with no solutions.

This feels odd. The Health and Care Act signals a major change in how the NHS is run. Dependent on who you speak to in healthcare policy you’ll get a mix of optimism and pessimism about integrated care systems – the new sub-regional structures with have replaced the Clinical Commissioning Groups under the Lansley reforms of 2012.

Policy Exchange tend to be on a pessimistic side. But where there does appear to be consensus is on the need for an open and legitimate debate around the role of the centre. Questions that keep coming up include:
– Is the current size and respective roles of both NHS England and DHSC justified as we move to a new phase in the pandemic?
– What should be the role and function of the NHS England Regional Teams?
– Does the existing structure and operational independence model allow for a true health-creating agenda across Whitehall?
– Can Ministers find the right balance between achieving good oversight and accountability whilst creating an environment of innovation and professional autonomy?

Policy Exchange think we should lean into, not walk away from these awkward questions. Our recent research on specialised services ruffled feathers when we pointed to the significant growth in both NHS England and DHSC during the past two years.

When NHS Digital and NHSx are formally subsumed, NHS England will have a workforce greater than 20,000 – easily the most complex arm’s length body in the country. We wanted to highlight this, but our argument was never to call for a cull of management across the NHS. Indeed, managers make up a lower proportion of the workforce than most other sectors and in previous research we recommended that the Government expand skilled manager roles with data analytical expertise in trusts with the biggest backlogs.

Management is worth its weight in gold when managing a dynamic and growing planning care waiting list of 6.5 million. The bureaucracy is not too big, but it is in the wrong place.

When it comes to the Messenger Review, Sir Gordon and Dame Linda Pollard offer no assessment of the total numerical and skills mix required to manage the NHS and social care sectors. Indeed, there is almost a complete absence of any quantitative analysis or statistics to underpin the findings.

Ministers also receive no direct advice from Sir Gordon on how to tackle the tensions between accountability and management, apart from being encouraged to spread the limits on the freedom for local leaders to try things “without fear of failure”. Perhaps this is a failure of those commissioning the review rather than Sir Gordon. Policy Exchange has been one of the few organisations to defend the additional Ministerial powers set out in the Health and Care Act– which we believe are proportionate and justifiable.

The timing of the launch is significant given the media headwinds about bureaucracy and waste. This is not just an agenda of the Conservative-leaning press. Since his appointment as Shadow Health and Social Care Secretary, Wes Streeting has chosen to criticise spending on both management and consultants, and recently told the audience at an Institute for Government event that “producer interest has to take second fiddle.”

The Review was an opportunity to offer an assessment on these debates and set out a clear vision for NHS leadership and management as we move towards system working – in the same way that the Griffiths’ Review made the weather for the introduction of the internal market.

This chance has not been taken. Further work is likely – with both Skipton House and the Department working on a future operating model. But you are left feeling that if an independent review couldn’t create the space for something radical, then NHS England is unlikely to yield anything better.

The post Robert Ede: The Government’s latest NHS review dodges key questions on management first appeared on Conservative Home.

A YouGov poll, a ConHome survey – and next Tory leader questions

9 Jun

Here are the results of a Next Tory Leader poll published by YouGov placed side to side with those from this site’s survey member panel in January.

Don’t know: YouGov 23 per cent.  ConHome n/a.

Ben Wallace: YouGov 12 per cent.  ConHome n/a.

Liz Truss: YouGov 11 per cent. ConHome 20 per cent.

Jeremy Hunt: YouGov: 10 per cent.  ConHome 9 per cent.

Penny Mordaunt: YouGov: 8 per cent. ConHome 13 per cent.

Rishi Sunak: YouGov: 7 per cent. ConHome 18 per cent.

Michael Gove: YouGov: 7 per cent. 4 per cent.

Priti Patel:  YouGov: 6 per cent. ConHome: 1 per cent

Tom Tugendhat: YouGov: 5 per cent. ConHome: 7 per cent.

Nadhim Zahawi: YouGov: 5 per cent. ConHome: 4 per cent.

  • We neither provided a don’t know category nor the same list as YouGov: additionally, we had Kemi Badenoch, Steve Baker, Graham Brady, Mark Harper, Sajid Javid, Dominic Raab and Anne-Marie Trevelyan.  We didn’t offer Ben Wallace – currently top of our Cabinet League Table.
  • Water has passed under and indeed over the bridge since January: Truss no longer tops our table, for example.  Sunak’s Spring Statement wasn’t well received and the non-dom controversy has taken place.  Patel has announced the Rwanda illegal immigration policy.
  • The provision of a don’t know category by YouGov highlights what our survey suggested.  Truss tops both polls, but with only a fifth of the vote in our survey, what Ben Walker of the New Statesman writes about YouGov’s poll also applies to ours: “when you collate the views of Tory party members, you find no one stands out”.
  • Note too the similarity of the long tail – indeed, the YouGov poll results for individuals are arguably a form of long tail from the don’t knows.  Our Mordaunt score was double YouGov’s, but at 13 per cent in the latter she wasn’t lighting many fires.  Essentially, both surveys have a mass of people in not dissimilar individual figures.
  • YouGov also produced a poll of 506 Tory members on Monday which asked:” “do you think it was right or wrong for Conservative MPs to submit letters of no confidence in Boris Johnson to the 1922 committee?
  • We asked the panel whether the view that Conservative MPs should remove him as Tory leader was closer to theirs than that they shouldn’t.  We got over a thousand replies.  I think it’s fair to say that the two questions are roughly comparable.
  • YouGov said the MPs were wrong to do so by 53 per cent to 42 per cent.  The panel said that they would be right to remove him by 55 per cent to 41 per cent: almost a mirror  image.
  • Incidentally, the return to the survey from the panel last month for the same question was: 41 per cent and 53 per cent – almost exactly the same result as YouGov’s poll this week.
  • YouGov is a proper opinion poll and ours is a self-selecting survey – albeit one that got Johnson’s eve-of-ballot return to within a single point, which helps to explain why it gets picked up by other media.
  • But you will see that the two are in the same broad territory even allowing for six months’ or so difference: big blocks within the party for and against Johnson staying as leader; no decisive view on who any replacement should be.
  • If you want to join the panel, please send a copy of your membership certificate or other evidence of membership to news@conservativehome.com and you will be added.  It’s not hard to do and each addition helps to make the survey more representative.

 

The post A YouGov poll, a ConHome survey – and next Tory leader questions first appeared on Conservative Home.

Peter Franklin: Five tests for the next Prime Minister

6 Jun

Peter Franklin is an Associate Editor of UnHerd.

The Jubilee was wonderful, but it’s time to start planning for the succession. No, not our next monarch, for whom arrangements are in hand, but the more pressing matter of our next Prime Minister.

We can’t assume that today’s vote of no confidence means the end of Boris Johnson,  but clearly the party must be prepared for a leadership contest. Furthermore, in the absence of an heir apparent, there’ll be no foregone conclusion to the race, let alone a coronation.

Since the implosion of Rishi Sunak, there’s been no heir apparent. So if Johnson does go before the next general election, there’s no guarantee of a speedy leadership contest, let alone a coronation.

Furthermore, it would be the third time since 2010 that the party has chosen a new Prime Minister for the country — so, if it comes to it, we’d better be sure what we’re doing. The voters are in an unforgiving mood right now — and certainly won’t forgive us if we pick a dud. So whether or not you want to bin Boris, it’s important that we give his replacement some serious thought.

But how? Right now, the field of possible candidates is wide open. With no clear front runner, there are — according to the bookies — at least ten candidates in with a significant chance. Jeremy Hunt, Liz Truss, Tom Tugendhat, Penny Mordaunt, Ben Wallace, Rishi Sunak, Nadhim Zahawi, Sajid Javid, Michael Gove, Dominic Raab: I wouldn’t bet my house against any of them.

Choosing on the basis of personality isn’t much help. Most of those mentioned above do have one, but not the stand-out charisma that Johnson brought the fight in 2019. Ideological criteria won’t be of much use either; I’d expect every candidate to toss some red meat to the right of the party while also signalling their acceptability to Red Wall voters in the North and to Liberal Democrat leaners in the South.

Instead of a test of personality or ideology, what we need is a test of seriousness. Each candidate should be asked a series of questions that require properly thought-out answers, not sound bites. After all, if it’s just bluster and balderdash that we want, we’ve already got the master-of-the-art in situ. There’s no point in swapping him for someone else unless the substitute can offer substance in place of stardust.

There are hundreds of questions that could be asked, but here are five to get the ball rolling:

How will you reform the Downing Street operation?

Though the detritus of Partygate forms the most recent layer, the mess at the heart of government has accumulated over decades — not just the tenure of the current inhabitant. Unless a new broom can put this house in order, then how can we trust him or her to make a difference in the wider world?

My advice would be to get government out of Downing Street altogether — and establish a professional operation elsewhere in Whitehall. But I’d love to know if the leadership candidates have other plans. Any or all ideas for cutting through the chaos are worth listening to.

On the other hand, a preference for the dysfunctional status quo would instantly mark out a candidate as undeserving of further consideration. But at least that would save time.

What is a woman?

Yes, I know I said no ideological tests. However, this question is about observable reality not ideology. If a candidate can’t reply with the words “adult human female”, then I want to know why.

I’m prepared to respect — if not agree with — candidates who can set-out a logically coherent alternative view on this issue. But, again, there’s time to be saved here if a would-be-leader of the Conservative Party has nothing but nonsense or evasion to offer.

Will you maintain the UK’s support for Ukraine?

The greatest irony of Brexit is that when “European values” truly came under attack, the leader who stood shoulder-to-shoulder with Volodymyr Zelensky wasn’t Emmanuel Macron or Olaf Scholz, but Boris Johnson.

If the latter is forced out, then the most urgent question for the world is whether a new PM would maintain, strengthen or weaken British support for Ukraine. Looking at the current field of possible candidates, there’s scope for all three outcomes — and that could have an impact not just on the UK’s position, but that of the West as a whole.

Foreign policy issues rarely make much impact on Tory leadership contests, but this one should be an exception. Beyond the warm words and empty platitudes which the French and Germans indulge in, each of the leadership candidates would need to tell us exactly where they stand on the most important European conflict since the Second World War.

What explains Britain’s terrible record on productivity?

I fear that any debate on economic policy would degenerate into an auction of tax cut promises. Then again, spending promises might predominate instead — especially on measures to tackle the cost of living crisis.

Either way, we need to remember that tax cuts and spending sprees ultimately have to be paid for — and, for that, we need economic growth. So in the event of a leadership contest, what I’d really want to hear from the candidates is an explanation for why UK growth has been so slow for so long.

In particular, I’d like them to explain why Britain’s productivity collapsed after the financial meltdown of 2008 — and why it’s never properly recovered. Of course, it may be that they have no thoughts on this matter at all, in which case we’ll know we have an economic illiterate on our hands.

Are your proposals for solving the housing crisis substantially different from what’s been tried so far?

Any Conservative leadership contest is about the future of the Conservative Party — but without a solution to the housing crisis we don’t have one.

You only have to look at party support by age group to see what’s heading our way if we fail to make the dream of home ownership a reality for Generation Rent. This problem has been staring us in the face for more than a decade, and yet successive Tory governments have stuck to counter-productive policies that have pushed house price inflation higher and higher.

Reform does not guarantee success, but we can either give change a chance or continue down the same road to oblivion. It would be good to know which of these options each candidate prefers.

Steve Barclay: My fellow Conservatives face a choice. Look outwards, and follow Johnson. Or look inwards – and tear ourselves apart.

6 Jun

Steve Barclay is Chancellor of the Duchy of Lancaster, Minister for the Cabinet Office and Chief of Staff at Ten Downing Street.

Over the weekend, the whole country came together to celebrate Her Majesty the Queen’s 7

years of selfless service.

I very much enjoyed the special events put on to celebrate this remarkable occasion, and I know that my parliamentary colleagues – and readers of ConservativeHome – were participating in celebrations in communities across the country.

As we return to Westminster today, the Conservative parliamentary party faces a choice: we can focus on delivering the policies needed to meet the challenges faced by those communities – and of people across the whole United Kingdom.

Or we can choose to waste time and energy looking backwards and inwards, talking to ourselves about ourselves.

In my view, politics is always about the future – because the people who elect us are focused on the challenges and opportunities ahead, not the debates of yesterday.

That is why the next general election will be decided on who offers the best vision for the future of the United Kingdom, not on prior mistakes or successes.

Our remarkable vaccine rollout – the fastest in Europe – and our unprecedented economic support during Covid helped save lives and livelihoods. But that won’t form the basic choice in front of voters next time.

Equally, nor will the mistakes – for example, the contents of the Sue Gray report.

We have lost half of this Parliament to Covid. That is not the fault of the Prime Minister or of Conservative MPs – and our constituents understand that. But it will be our fault entirely if we choose to waste the remaining half of the parliament on distractions over leadership.

The country faces many pressing challenges right now – so we must focus on what matters to the livelihoods of constituents rather than the obsessions of those on social media. My colleagues understand from their constituency work and surgeries just how much the cost of living situation is impacting hardworking people. Pressure on energy bills and food prices is causing real stress and anxiety across the country – and this will continue into the winter.

It is crucial that we show people we are delivering on the change they voted for in 2019.

If we continually divert our direction as a Conservative Party – and by extension the government and the country – into a protracted leadership debate, we will be sending out the opposite message.

Our Prime Minister, Boris Johnson, has shown in his leadership on Ukraine, in getting Brexit done, in protecting jobs from the pandemic and resisting the repeated calls for a lockdown in the summer, that he is the right person to make the bold calls needed to respond to the economic challenge we now face. He is dedicated to unlocking talent across the UK and levelling up, and to delivering on our promises to the people who elected us. That is at the heart of the Cabinet’s agenda.

Rishi Sunak is fast tracking reforms to enable our pension funds and insurance firms to unlock billions in capital for investment in places that have felt ignored in the past. These are the big-ticket changes Brexit offers to communities like my own, who voted strongly to leave.

Priti Patel is ahead of our target to recruit 20,000 police offices to make our streets safer, and Sajid Javid is rolling out community diagnostic centres around the country to help clear the Covid backlogs.

Grant Shapps has set out reforms to help rail commuters who have to pay higher fares due to out-of-date trade union working practices. Jacob Rees-Mogg is reducing the size of Whitehall, ensuring we deliver more efficiently for everyone.

In all this, we are saying to people: we will support you. To get the skills you need. To get the investment your area needs. To ensure your local streets are safer and your health is supported.

And later this week, the Prime Minister will set out plans to expand home ownership to Generation Rent – building on our core Conservative belief that people aspire to own their own homes.

He and I are instinctive tax cutters: we know the tax burden as a result of Covid  is high and we know this would be the most benefit to the majority of our constituents. Money left in people’s pockets helps them plan and grows the economy.

The Parliamentary majority we hold is incredibly rare. To waste time now on continued internal factionalisaton would be indefensible to many of our party members – given how hard they worked to secure that majority.

I first stood for Parliament in 1997, when John Major had been hamstrung with a single figure majority. We then endured 13 years of Blair and Brown with no majority, before the frustrating constraints of coalition. We must not squander the enormous opportunity we have with our majority now – to make real Conservative change and deliver across the country.

The Queen’s Speech set out the government’s top priorities for the year ahead: growing the economy to address the cost of living, making our streets safer, funding the NHS to clear Covid backlogs, and providing the leadership needed in challenging times.

The problems we face aren’t easy to solve. Democracies around the world are all currently facing similar challenges. But under Boris Johnson’s leadership, our plan for jobs shows how we are navigated through these global challenges. To disrupt that progress now would be inexcusable to many who lent their vote to us for the first time at the last general election, and who want to see our Prime Minister deliver the changes promised for their communities.

Our Cabinet League Table. Wallace top again, Patel up, Johnson down – and Sunak in the red

25 Apr
  • This is Ben Wallace’s third table-topping month (with 85 points his rating has barely moved), and a pattern is beginning to form below him – as Liz Truss, Nadhim Zahawi and Anne-Marie Trevelyan come in variously at second, third and fourth (with scores in the mid to low sixties).  Both the first of those and now the second are being written up as potential leadership candidates.
  • Priti Patel was bottom of the table last month on -17 points, having languished at the lower end of it for some time – not least because of the small boats issue.  The Government now has a policy to deal with it, and her rating consequently jumps to 31 points, near the middle of the table.
  • Boris Johnson was in the same zone last month, having been in negative ratings for the previous three, and is now back down again – third from bottom.  Ukraine will have pushed him up last month; partygate will have pulled him down this. But the driver of his low scores is that the Government is too left-wing, at least in the view of many activists.
  • Rishi Sunak plunged last month to third from bottom in the wake of the Spring Statement (on plus eight points).  He drops to last place this month, coming in at minus five points, in the wake of the furore about his wife’s tax affairs and former non-dom status.  It is perhaps surprising that his fall isn’t larger; it may even be that the worst is behind him – in this table at least.

Andrew Haldenby and Nick Bosanquet: Doctors can’t provide face-to-face appointments for all patients. Nor should they.

14 Apr

If it didn’t know it already, the Government is under real pressure on the NHS. Last week’s annual public satisfaction survey showed a remarkable change in public attitudes and hinted at the way forward. In terms of the research, four points:

First, satisfaction in the Service has collapsed.

Overall satisfaction with the NHS fell to 36 per cent – an unprecedented 17 percentage point decrease on 2020. This is the lowest level of satisfaction recorded since 1997. More people (41 per cent) were dissatisfied with the NHS than satisfied.

This fall in satisfaction was seen across all ages, income groups, sexes and supporters of different political parties.

It encompassed every part of the Service – hospitals, general practice and dentistry. Satisfaction with GP services fell by the greatest amount: by 30 percentage points, from 68 per cent satisfied to 38 per cent. This is the lowest level recorded since the survey began in 1983.

Second – the cause was the long waits for consultation or treatment resulting from the pandemic.

The main reason people gave for being dissatisfied with the NHS overall was waiting times for GP and hospital appointments (65 per cent of respondents).

Third – the proportion of people wanting higher tax rises to fund the NHS is falling.

There was a statistically significant fall in the proportion of people that believe that extra funding should come from a separate tax for the NHS – from a high of 35 per cent in 2017 to 26 per cent in 2021.

This is consistent with the British Social Attitudes survey (see graph). From 2010, public support for higher taxes and spending rose, reaching a peak in 2017. Since then, support has declined.

Very likely, the trend in support for higher taxation and spending is now in decline, mirroring the trend between 2002 and 2010. In other words, it will remain in decline for the next two general elections.

Fourth and last – while voters want a massive change in NHS performance, they do not want a wholesale redesign of the service. Around 90 per cent of voters believe that the NHS should “definitely” or “probably” be free at the point of use, be available for everyone and be primarily funded through taxes.

Where does this leave health policy? Three points.

First, some have argued that the NHS should be replaced by a compulsory insurance model on the Swiss or German model. While those systems have advantages in terms of patient choice, they are not going to pass the test of public opinion. Voters want the existing system, working better.

Second, it would be a brave politician who introduced a further NHS-specific tax in this Parliament or the next. The NHS has received very large spending increases since 2018. As in previous cycles, voters now want a period in which the Service lives within its means, and gets full value for its resources.

The Government recently justified the increase in National Insurance Contributions in terms of the extra activity that the money would generate, especially extra diagnostic tests. Ministers are right to link resources and outputs. But they should be much clearer about the specific impacts of their spending increases.

The NHS used to give more attention to the comparative costs of services in different locations than it does now. It should regain the habit.

Ministers would then be able to identify the most productive methods used by NHS teams – and use that information to reassure the public.

Third, the Secretary of State needs to address public dissatisfaction with general practitioners without further degrading their professional competence.

GPs and their teams are the essential foundation of an affordable NHS. They have already achieved major increases in productivity in recent years, doubling numbers of consultations for relatively little extra cost.

But their numbers are limited and they cannot provide face-to-face appointments to all patients. Nor should they. Their professional duty is to prioritise those with the most medical need, not the loudest voices. A practice covering 10,000 patients will be responsible for a key group of 2,000 people with serious long term health problems.

Last year, the Government allowed the debate on general practice to become a political row, which will only have undermined the profession further.

Rather, Ministers and profession together should collect evidence on the difficult choices facing GPs, and communicate those to the public.

Who is actually demanding face-to-face appointments and why? People with injuries should be heading for urgent care centres or A&E, not for the GP. How many of the complainers are frequent attenders with known conditions? Blackpool has set up a special service of health coaches for frequent attenders.

For the future, any changes in GP programmes should be assessed by NICE, rather than be the subject of instant reactions by Ministers.

Matthew Taylor: The Health Secretary must have faith that local NHS leaders can steer reform

5 Apr

Matthew Taylor is Chief Executive of the NHS Confederation

The Secretary of State for Health and Social Care Sajid Javid recently delivered an important speech on healthcare reform, setting out his vision for the future of England’s NHS. Some had expected a raft of new policy announcements, with an academy school style NHS revolution even being punted.

Instead, although the speech was labelled lacklustre by some, the Health Secretary largely reinforced the existing reform agenda set out in the Government’s Health and Care Bill and the integration white paper, building on the NHS Long Term Plan.

The last decade has seen healthcare leaders trying to work around the fragmentary nature of the 2012 Health and Social Care Act, and they are in strong agreement that the current direction of travel towards integration between health and care services is the right one.

There is now consensus across health and care that the biggest challenges facing the health and care sector – the elective care waiting list backlog, a changing demographic and ageing population and significant health inequalities – can only be addressed by bringing together local organisations as partners and planning collaboratively.

To do this effectively health and care organisations are set to partner locally in two ways. Firstly, through ‘place-based partnerships’ that will integrate local authorities and primary, secondary, community and voluntary providers of health and care. On top of that, they will do so through ‘provider collaboratives’ that will see integration between organisations offering similar or complementary services.

The Health Secretary has acknowledged both are fundamental to the Government’s reform agenda. He has also said he wants to see more of these partnerships for reform “so that teams and organisations with a track record of solving long-standing service issues can share learning across systems to bring improvements.”

Yet, despite the positive rhetoric on local empowerment, there remains a fundamental contradiction which concerns NHS leaders greatly. Some key aspects of the Health and Care Bill that, as they stand, will centralise, not devolve, decision making powers. The new powers being proposed by the Government run counter to its devolution agenda for the health service and will instead allow the Health Secretary to intervene at any stage of a proposal made by local health and care leaders to reconfigure services.

These powers of intervention will not only be possible for major changes like closing an A&E department, but, under the measures contained within the Bill, the Health Secretary will be able to reverse even minor alterations to services including boundary changes.

Decisions about local services can be politically sensitive. However, such decisions should usually be taken at a local level given they are often necessary to make improvements in care quality and the best use of NHS resources. In future, such decisions could be undermined at the intervention of the Secretary of State.

Local politicians, campaigning groups and members of the public alike are aware of this. They will know that referring local decisions directly to the Health Secretary and his department could scupper contentious plans, even before they have been properly consulted on locally. The process of open local consultation is an integral aspect of the existing decision-making process and allowing it to be bypassed may well prevent brave and necessary choices from being made.

Compromise, however, is still possible. On behalf of NHS leaders, the NHS Confederation has pressed for checks and balances to be applied to the new powers the Government seeks over local services. These would include a requirement for the Secretary of State to demonstrate that any intervention on a local service decision is to maximise patient safety, and that clinicians, Local Health Overview and Scrutiny Committees, and any relevant local NHS or partner organisations affected by the decision are fully consulted.

We have a golden opportunity to get the Health and Care Bill right if the NHS is to deliver top class services and value for money for patients. The Health Secretary himself recently invited us to listen to the “innovators already doing incredible things within the system”.

As the clock ticks on the passing of the Health and Care Bill, NHS leaders would urge the Government to cede some ground on these new powers. After all, history has frequently shown us that local NHS decisions are best left to the knowledge and expertise of those who are closest to their local communities.

Our Cabinet League Table. Sunak plunges to third from bottom.

4 Apr
  • Last September, I reported that Dominic Raab had plummeted third from top in July to fourth from bottom in our Cabinet League Table.  Today, he is back to sixth from top, having worked his way out of the relegation zone.
  • I write this to offer comfort to enthusiasts for Rishi Sunak, who was eleventh last month, but now finds himself plunged to third from bottom, in the wake of a Spring Statement with which the majority of our panel is dissatisfied.
  • Having managed the table for a long time, I know that what goes down can come up again – and vice-versa.  Our respondents are very knowing, and many use the table as a form of running commentary rather than a means of permanent judgement.
  • At the top, the changes are very marginal, with Steve Barclay’s fall of nine points from 64 to 55, and drop from second to fifth, being the largest movement in the top ten – and it’s not a very large one in the great scheme of events.
  • At the bottom, Priti Patel falls into negative ratings after a month’s bad headlines over Ukrainian refugees.  The Home Office is so permanently troubled that it’s hard to see her moving up towards the comfort of mid-table in the near future.
  • Meanwhile, Boris Johnson is out of negative ratings, where he had been for three months running, and into the middle of the table.  This is at once an impressive recovery from where he was and a lacklustre rating given his position as Prime Minister.
  • Johnson will undoubtedly have gained from his handling of the Ukraine, which received an overwhelming thumbs up from our panel.  Ninety-three per cent took a positive view of it and 58 per cent a negative one of Sunak’s Spring Statement.

Steve Moore: The government should be proud, not scared, of the UK’s market for cannabis products

21 Mar

Steve Moore is the co-founder of the Centre for Medicinal Cannabis and Volteface. He is a former Chief Executive of the Big Society Network.

On Monday 11 June, 2018 Charlotte Caldwell and her 14-year-old son Billy landed at Heathrow’s Terminal 5 from Toronto. Caldwell had spent the previous weekend having Billy treated at Sick Kids, the nearest equivalent Canada has to Great Ormond Street Hospital. Billy, who suffers from status epilepsy, was assessed by Canada’s leading paediatric neurologist and prescribed a cannabis-based medical product that was the subject of an active clinical trial.

But upon arriving at Heathrow this medicine was confiscated by UK Border Control as a breach of the Misuse of Drugs Act. Over the next week, Caldwell took to the media to demand the medicine’s return. Then Home Secretary Sajid Javid only relented to this the following Friday evening, when Billy was rushed to the ICU at Chelsea and Westminster Hospital. The confiscated medicine was given to his treating consultant the next morning.

Following this, Javid instructed the Chief Medical Officer, Dame Sally Davies, to urgently review the therapeutic effects of cannabis. Her report ended 50 years of campaigns to legalise medicinal use of the plant. The new law legalising medicinal use took effect from 1 November, 2018.

Medicinal marijuana has long been widely available in the US. However, a new innovation that has emerged in the past decade could transform access to cannabis products and pose a huge challenge for regulators. Since the late 1990’s, a Harvard-educated former anti-war activist Fred Gardner has been researching cannabidiol, a non-intoxicating cannabis compound more commonly known as CBD. His studies in rodents and cell cultures have suggested it could provide relief from seizures, pain, anxiety and inflammation. Botanists and clinicians increasingly took his work seriously from 2011. Gradually, a whole new industry emerged from the cultural underground of the United States into mainstream ubiquity across the world.

It was a development that confounded regulators everywhere, including, until recently, the UK. Now, next to the US, we are the second largest market  for CBD products. In February 2020, the UK Food Standards Agency became the first regulator in the world to commit to securing safety approval of CBD products. The initial tranche of approvals will emerge in the next year effectively de-risking the product category for institutional investors.

While Gardiner was pursuing his studies, a British scientist, Dr Geoffrey Guy, undertook his own research and engaged intensively with the UK medical and political establishment. Guy’s energetic advocacy and campaigning led directly to the Chief Inspector of Drugs at the Home Office issuing him the licences required to create GW Pharmaceuticals, after a long period of negotiations. It is the world’s largest legal cannabis cultivator and was acquired by Jazz Pharmaceuticals in 2021 for $7.6 billion. 

Although largely unacknowledged, the UK has had a huge and positive influence on the fast growing global cannabinoid market. We have facilitated the creation of the most successful medical cannabis company in history and now lead the world by being the first to regulate the most popular CBD product.

However, none of this success was designed in Whitehall. This was highlighted by George Freeman, Theresa Villiers and Iain Duncan Smith in last year’s independent Task Group on Innovation and Regulatory Reform report. This near-billion pound industry exists as a product of the Geoffrey Guys and Charlotte Caldwells of this world and successive governments reluctantly consenting to their efforts. Any public policy deliberations about cannabis in the UK remain hazardous, as Sir Professor Robin Murray’s seminal South London studies into potential psychotic symptoms of use still shrouds almost every conversation.

Germany, amongst other countries, is now considering how to follow Canada in legalising and regulating cannabis for adult recreational use. But this is still not anywhere close to being the case in the UK. Both main parties have a commitment to reducing public consumption of temptation goods that is wholly incompatible with any attempts to create a commercial market for pot in the UK.

The global cannabis market that now exists is in the medicinal and nutraceutical space. Britain has the potential to become the world leader in product research and innovation, building on our strategic prowess in life sciences. Achieving this will require a combination of adroit, cross-departmental public policy husbandry, smarter regulation and intelligent private-public investment. Stewardship, not containment, must be the watchword.

The Centre for Medicinal Cannabis have announced today that Professor Christopher Hodges will chair an industry wide review of regulation and public policy relating to the UK’s legal cannabis industry. Hodges, who is becoming an increasingly influential thinker inside Whitehall regarding new approaches to regulation, will publish his report in May. Upon its receipt Ministers like George Freeman will have the first detailed blueprint setting out how the UK can fast-track its way to become the global leader in cannabinoid innovation.

Rhetoric from Ministers on a smaller state and curbing woke absurdities is welcome. When will policies match?

20 Feb

PJ O’Rourke, the American satirist who died this week, reflected that there are four ways to spend money:

“If you spend your own money on yourself, you are concerned about both value for money and quality. If you spend your own money on someone else, you are concerned about value for money, but less about whether it is suitable. This is why children get socks for Christmas. If you spend other people’s money on yourself, you are still concerned to get good stuff, but the price no longer matters. And if you spend other people’s money on other people…that’s the Government.”

Next year the state is due to spend £4.18p for each £10 that we earn. We can do what we like with the other £5.82. The Government’s current plans have the state share of spending going up a notch to 41.9 per cent of GDP the following year. Yet a week ago, Steve Barclay MP,  the Chancellor of the Duchy of Lancaster and Chief of Staff at No 10 Downing Street, wrote that “it is a priority to restore a smaller state.”

Oliver Dowden, the Conservative Party Chairman, gave a speech this week to the Heritage Foundation, denouncing woke ideology as a “dangerous form of decadence”:

“This ideology is now everywhere. It’s in our universities but also, in our schools. In government bodies…”

Perceptive readers will have spotted the flaw. It is under a Conservative Government that we are seeing our liberty diminished by the state spending more of our money, while our freedom of expression is eroded by the imposition of groupthink.

So while statements from Ministers endorsing Conservative principles are a welcome start, the clamour is growing for the reality to match such aspirations.  Let us consider, for instance, an NHS Quango called Health Education England. The Mail on Sunday reports:

“Andrew Scarborough, 36, who is mixed race, fears the obsession of his employer NHS Health Education England (HEE) with politically correct causes such as ‘white privilege’ and ‘toxic positivity’ distracts workers from doing their jobs. The project support administrator – who is still being asked to work from home along with his colleagues, despite the Government urging people to return to their desks – said he found it increasingly difficult to carry out his duties due to the barrage of woke emails and bulletins received almost daily from his bosses. When he queried the quango’s ‘political’ messaging, he claims he was reprimanded and called a racist. He decided to speak out when HEE, which gets £4 billion of taxpayer cash each year to support NHS training and skills development, invited staff to a virtual ‘white privilege’ course to address ‘unconscious bias’ and ‘white fragility’.”

£4 billion? Surely the journalist must have made a mistake and this ludicrous and obscure outfit gets £4 million? But no. Though the latest HEE annual report does have plenty of impenetrable jargon. But the figure for the money it gets from us is pretty clear. £4.3 billion. It has 2,432 staff. 15 of them are paid to be full time trade union officials. The Chief Executive was reported to be on £225,000 a year. The Chief Operating Officer did even better on £235,000. The Director of Corporate Accountability and Engagement earned £150,000. The Director of Innovation and Transformation got by on £135,000.

But what do they all do? That’s when it gets a bit fuzzy:

“Our vision is to help improve the quality of life and health and care services for the people of England by ensuring the workforce of today and tomorrow has the right skills, values and behaviours, in the right numbers, at the right time and in the right place.”

The money goes on training. But is it of practical benefit? An initial medical degree takes four years. But the medical schools get most of the funds for that from tuition fees and from the Office of Students. (The OfS distributes £1.4 billion a year to help with “high cost” courses.) The HEE swings into action for the later stage. An apprenticeship for trainee doctors and nurses to be embedded with experienced professionals in hospitals is, of course, of great importance. Some of that £4.3 billion goes to hospitals willing to take the time to show the ropes to these keen new recruits.

But how much goes on taking doctors and nurses, young and old, away from the wards and off to hotels for conferences on “toxic positivity”?

Even when the funding is for something worthwhile there are concerns about the lack of accountability. A report from the Reform think tank highlighted a lack of transparency. But it also suggests a wide variation in the spending per placements. There have been complaints that NHS Trusts have not been clear about what training they provide for the money.

Probably the HEE should be abolished. The training funds could be devolved to the NHS Trusts to make an offer to student doctors and nurses; perhaps that if they worked once fully qualified for a number of years their cost would be written off but otherwise would need to be reimbursed. Or the medical student could be issued with a voucher to provide a reward for hospitals offering an internship. Some kind of internal market of that kind would surely be an improvement on the current arrangements. It would also offer a financial constraint on all the extraneous woke absurdities.

Perhaps the HEE should continue, but be scaled back so that its only spending was of practical benefit to patient care.

But it is obvious that the £4.3 billion of our money currently being spent by the HEE is not justified. It represents over a third of the planned £12 billion increase in National Insurance. Sajid Javid, the Health Secretary, is fond of repeating the mantra that “every penny spent on the NHS must be spent wisely and in the very best interests of taxpayers.” Now he and his colleagues need to do some work on giving these claims credibility.