The NHS is a microcosm of the British economy

 The NHS is a microcosm of the British economy

Mistakes in how the government has managed the NHS parallel the mistakes in managing the economy. Trying to hold down the government budget is constantly approached by making easy choices rather than the right choices. The same is true in the NHS where the capital budget is raided to cover operating deficits. Both are recipes for long term decline.

All governments would like to see a higher growth rate in the economy. The current one wants to increase incentives with tax cuts but need to pay for those giveaways with spending cuts. But, faced with those spending challenges, they often take the easy road to keep the budget in some sort of balance by cutting the very capital projects that might improve growth in the long term. 

The parallel with the NHS is interesting. Growth in spending seems relentless. That growth can be constrained only by improving productivity. But the choices made to keep the budget under some semblance of control hurt productivity, making tomorrow's problems worse. In this way the NHS is like a microcosm of the whole economy, at least in the ways both have been managed in the last decade or two.

The economy

The link is explained by the factors known to affect productivity in the economy and the NHS.

As Sunak explained in his spring statement while he was still chancellor (my highlighting)

"Over the last fifty years, innovation drove around half the UK’s productivity growth.

…our lower rate of innovation explains almost all our productivity gap with the United States.

Right now, we know that the amount businesses spend on R&D as a percentage of GDP is less than half the OECD average.

…

Weak private sector investment is a longstanding cause of our productivity gap internationally:

Capital investment by UK businesses is considerably lower than the OECD average of 14%.

And it accounts for fully half our productivity gap with France and Germany."

His analysis is mainstream economics. But it is worth asking what governments have actually done about either innovation or capital spending over the last decade or two because the same factors matter not just in the private sector but in the parts of the economy controlled by the government.

This chart on total government spending appeared recently in the FT: 

The point is that, when faced with alternative ways to control total government spending, Osbourne chose the easy path of cutting capital spending, not current spending. And that spending on national infrastructure is the sort of thing that leads to long term improvement in productivity (and there is a direct influence on the economics of private capital spending because the future returns on that will be higher if the national infrastructure is better).

But, politically, capital is easier to cut. Who notices the long term impact of projects that might not finish for years and might only show big benefits in decades? Everyone can see this year's budget deficit. The temptation is to take the easy option even though it is the worse option for productivity and growth in the long term. Yes, all politicians, if asked, would claim they want higher productivity and growth: but they are very reluctant to face worse headlines tomorrow about the budget deficit.

Given that UK productivity growth tanked during the Osbourne austerity period, you might think this lesson had been learned. But that is not what the mood music emerging from Whitehall suggests where, in response to the catastrophic reception of the Kwarteng mini-budget, departments are being asked to make sharp cuts with capital spending at the top of the list.

The NHS

How governments have managed the NHS is a microcosm of this same problem. And it has been catastrophic for the long term health of the system.

If tomorrow's NHS is to be less of a financial burden on future governments, it needs to be much more productive (however that is defined: quality and throughput both matter in healthcare). The same factors–innovation and capital–have big influences on future NHS productivity. But how has the budget been allocated in the last decade or two? 

We can compare the NHS to other health systems in how it allocates money to the things that should matter to future productivity. The easiest to measure is capital spending. And, mirroring the problem with spending in the economy as a whole, the big picture looks to be a catastrophe of poor short term choices (for a more detailed analysis see my longer rant here). In an analysis in 2019, the Health Foundation produced this chart:

And said:

"Capital spending is a critical input in health care, with new technology able to transform services and improve workforce productivity. 

The DHSC has proposed a more technology–and data–driven NHS. New technology and IT could improve patient services and increase productivity, but both currently make up a small proportion of capital spending."

 

So, not only does the NHS get starved of capital spending in general but the mix is very light on the things that would typically have the biggest impact on productivity.

The result of this is that the capital employed per worker (an interesting measure of the stock of things that partly determine productivity) is half that of most comparable systems. 

And, according to the National Audit Office, even when the NHS gets allocated a capital budget, it frequently either underspends it or pilfers it in year to cover operating deficits. This is a perfect illustration of the political choice to take an easy path rather than the right one. And one that has, in effect, killed the hope that NHS productivity could improve enough to lower the financial burden on long term government spending. And this has been the chosen path for two decades. It is little wonder that the productivity of the NHS is falling and that the system is creaking under the strain. 

Some conservative commentators are now arguing that the government can no longer afford to keep spending more, as they need to do to stop the wheels from coming off the bus. But those commentators ignore a major  reason for the current need for more spending: the neglect of any attempt to spend the money on the long term things that would make the NHS much more productive and reduce the pressure to spend more to avoid imminent catastrophe. 

And the opposition don't help pull the debate back to solid ground by claiming everything is about staff shortages. There are two problems with this. One is that investment in better equipment and facilities could improve productivity so much the need for more staff could be reduced. The other is that the biggest reason staffing is a problem is not recruitment, it is retention and a large part of that is caused by the poor working environment some of which is caused by the lack of capital per worker. And the constant churn of staff, especially when experienced staff are replaced by cheaper but less capable staff, undermines team productivity and quality, exacerbating the need for yet more staff in some sort of anti-productivity death spiral.

So what?

And this brings us back to why the NHS is a microcosm of the economy as a whole. In order to attempt a rescue of government finances ravaged by the Kwarteng mini-budget, the key proposals to recover the government deficit currently being discussed are to cut things that are easy to cut quickly. Like capital spending. So, instead of spending on the long term things that enhance future productivity, they are likely to cut them further and in ways that damage the very growth they seek. They should have learned from the Osbourne era that that does not work. The easy path then–capital austerity–hurt the national growth rate and made it harder to fund the sorts of spending the government cannot cut if they don't want to lose their core voters (are they going to cut pensions when the most conservative block of voters are pensioners? I don't think so).

As Martin Wolf said in a recent column in the FT (my highlights):

The UK’s longer-term economic performance must indeed improve if the desires of its people for a better life are to be realised. If the government wants to do something useful about this, it might dust off the report of the London School of Economics’ Growth Commission of 2017. Better incentives are indeed a part of the answer, but only a part. This is why systematic tax reform would be desirable. There must also be difficult deregulation, notably of land use. The state must supply first-class public goods, in the understanding that these are a social benefit, not a cost. There must be fiscal and monetary stability. There must be far higher investment in physical and human capital, both public and private.

Neither the economy nor the NHS will be better tomorrow if the investment in the long term is cut. The persistent habit of picking easy cuts rather than the right cuts is a recipe for long term catastrophe (and possibly short term catastrophe too). 

Spending the money well (especially not neglecting long term investment) is the solution to the growth and productivity problem in the NHS and the wider economy. Spending it badly by making easy choices now is not.

PS that cartoon is modified from an original by the late great B Kliban. See some of his other quirky cartoons here: https://www.gocomics.com/kliban

What the hell is happening with hospital prescribing?

[Update: I need to issue an important caveat about the analysis in this post. When published, I had just been made aware of new and very detailed data sources about hospital prescribing, monthly sources with detailed analysis of volume and indicative price. The analysis was based on those sources and was consistent with a longstanding NHS Digital annual report on the total cost of hospital prescribing. But when the analysis attracted some attention, it was pointed out that the indicative pricing data was highly unreliable because of commercially sensitive discounts that were missed in the public data (including the NHS Digital totals that had been available for about a decade). Some new sources (though they are very, very hard to find, have the (apparently) correct total spend but not the detailed monthly detail on individual drugs).

So any total spend numbers in this analysis may be large overestimates, though volume and price trends are probably correct.

But the situation is a complete clusterfuck as the NHS has been publishing badly incorrect data on total spend for more than a decade. And we still do not have any reliable way to analyse where the hospital drug budget is going or test its value for money. But it is important to be aware of the possible errors when reading the conclusions. Though many are still valid. Which is why I am leaving this analysis here in the hope that our ability to analyse an important chunk of NHS spending will improve in the future.]

According to the data we have, hospital prescribing is one of the fastest growing areas of NHS spend. Until recently, the only public data we had was the total spend. In the last three years new sources on what is happening with much more detail have become available. In the last year this has included data about spend. So we can start to understand some details about what is happening. This is a preliminary analysis.

It is not, though, a thorough analysis. It can't be, as the availability of data is poor and quality of data is partly suspect. Some have questioned whether the financial data is reliable. I can't judge that, but, even if it is not accurate, the overall story is worrying as a major shift in NHS spending has happened without much scrutiny or deliberation.

My hope is that a quick and dirty analysis for this new data can kick off a debate and incentivise further work. It is clearly an area of NHS activity that deserves far more attention.

Primary care prescribing is a well-scrutinized area of NHS spending. It is controlled by GPs and costs the NHS about the same as all the payments made for all GP activity. Prescribing has cost the NHS about £9bn/yr for most of the last decade. And we know a great deal about it as the monthly data about all the prescriptions issued by GPs has been publicly available since 2010. So I can tell how many doses of 40mg simvastatin were prescribed by my GP in january 2011 and how much that cost the NHS.

We don't know the same for what hospitals do. Until recently, all we had was the total spend as published by NHS Digital here: https://digital.nhs.uk/data-and-information/publications/statistical/prescribing-costs-in-hospitals-and-the-community/2019-2020 . This dataset (which also contains the total spend in primary care) looks like this:

The GP prescribing spend is uncontroversial; the hospital spend total has been questioned when I have mentioned it on social media by some but the growth rate has not. If the NHS digital numbers can be trusted, this is a huge shift in NHS spending that has gone without much, if any, scrutiny. A simple projection of the 2019/20 total at the average growth rate suggests that the 2022/23 total will be about £17.5bn whis is both four times bigger than it was in 2010/11 and about the same as the total spend on both GPs and the drugs they prescribe. Or close to 10% of all NHS spend in England.

A large budget growing at 15% a year in an NHS where the overall budget is barely growing should be a significant concern for the system. Some might, rightly, ask what NHSE have cut to enable this rapidly increasing spend (note that all the numbers above are before the pandemic hit and before the government promised lots of extra money for NHS reform).

Historically there has been little analysis of this total because the data was provided to NHSE by IQVIA whose contract limited the detail available (possibly because IQVIA collected it to sell it on to pharma firms to help their efforts to market their products to hospitals).

Ben Goldacre and Brian Mackenna argued forcefully in the BMJ in 2020 that there were few excuses for not getting better information from hospitals and major benefits for doing so.

It is worth quoting some of their arguments (any emphasis is mine).

"...there is little publicly accessible data on what is prescribed and dispensed in each hospital. This effectively blocks work to identify variation and signals indicative of suboptimal care."

"...there are no technical barriers: data is currently extracted, aggregated, and normalised into one national dataset through at least two systems. Access to this data, however, is limited by a complex network of commercial contracts, apparent resistance to transparency at some NHS trusts, and historical reluctance to make change at a policy level.."

"Restricted access presents multiple problems. Firstly, it prevents analytic work by teams with the skills and creativity needed to generate actionable insights for diverse groups of users. A recent survey reported data access as a key barrier preventing early career NHS pharmacists using data to inform practice"

"Secondly, closed working models also create barriers to verification, critical review, and collaborative improvement of analytic work."

"Thirdly, restrictions around data sharing impede innovative approaches to improving quality, safety, and cost effectiveness using medicines data. Independent researchers working on primary care prescribing data have identified whole new categories of cost savings, novel informatics methods, and research on the reasons for slow and rapid uptake of evidence in clinical practice. Hospitals are where new treatments are most likely to be used and where costs are growing fastest; they are therefore where this kind of collaborative analysis is most needed, but it is currently prevented by data access barriers."

"Lastly, data access barriers prevent public and independent external scrutiny of hospital activity. Although publicly accessible data can be uncomfortable for organisations and requires thoughtful handling, thoughtful public scrutiny on public services can help build better quality, safer, and more cost effective care."

This article appeared to have an effect on the leadership who released a monthly datasource which starts in 2019. The new source contains volume data about every item used in hospitals and has recently been supplemented by information on the price paid for those items. The volume data is accessible here and the more recent data with indicative prices is here. Thanks to the team at openprescribing.net for pointing out these recent releases when I complained about the lack of good data on hospital prescribing.

What are the issues with the new data source?

There are several issues with the new hospital prescribing data source. Perhaps the biggest is that few organizations with the capacity to analyze it have had any time to do so. Even the team at opneprescibing.net who have done such a good job with primary care data.

Another big issue is that there is no coherent metadata to classify the drugs (primary care drugs can be grouped in a hierarchical classification based on the BNF which groups similar drugs for similar conditions together). This makes analysis harder. Another issue is that the prices are, again unlike the primary care data, "indicative" rather than actual (more on this later). 

We can overcome some of the problems of not having a classification by looking at the generic names of the drugs which often contain big clues about the type of drug. Also, we can look the specific drugs up in formularies to work out what they are for. But there are about 12k unique names in the list of prescribed items and about 3k different names if you strip out the different formulations of the same drug (these are crude estimates based on some simple text parsing as, franky, who has the time to manually classify 12k bloody text strings). Luckily, many of the important classes of drugs (with large volumes or costs) are easy to identify. Modern biologic drugs for treating haemophillia, for example, all end in "cog"; monoclonal antibodies (a very expensive class of biologics used in cancer and some immune diseases) all end in "mab". So a quick and dirty classification is possible that highlights some of the key trends.

Applying this simple classification also reveals some detailed issues with the data. Those "cog" drugs, for example, show some data issues. Normally the monthly spend on the groups is £5-10m but between march and august 2021 that leapt to between £200m and £800m per month but fell back to ~£10m in later months. See this chart:

The apparent spend on turoctocog alone was over £500m in june 2021, more than a third of the total hospital spend on all drugs. I can think of no good explanation for this (if anyone knows one, please tell me) so I'm assuming it is a data error (maybe someone confused pounds and pence on data entry?). I have excluded the whole class from totals later in this blog (this makes little difference outside those months).

Some might argue that this invalidates the whole dataset. I prefer the idea that a lack of transparency and external analysis makes big data errors harder to find or correct. 

Another issue is that the new dataset only has estimated costs for about 1 year. But I've taken the unit costs from the period with prices and applied them to the volume data so I can estimate total costs from the whole 3 year period (usefully, this agrees with the last total from the NHSD estimate of annual spend).

What can we tell from a quick analysis of this new data source?

As a first rapid check on the consistency of the spending totals, we can check that the NHS financial year 2019/20 is close to the one given in the NHS Digital annual series (19/20 is the last total in that series). Luckily it does:

The growth rate of annual spend is about 20%/year. This is higher than the ~14%/yr in the years from 2010 to 2020 in the NHSD annual series. The rate of growth suggests that hospital drugs are taking up a larger and larger share of NHS spending since the overall budget which has grown at less than 4% over this period. An annual growth rate of 15% doubles the total in less than 5 years. Crudely, hospital drugs now consume about 10% of total NHS spend compared to about 4% in 2010. That's a big, rapid shift that shows no signs of slowing down. 

It is worth noting that even if the estimated prices here are wrong (because they might omit specific discounts negotiated by hospitals) that growth rate is still a worry. Also the estimated prices for drugs like Humira (adalimumab, used in autoimmune diseases like rheumatoid arthritis) is already about 10% of the price in the USA, so the totals are not vastly exaggerating the spend by using US prices.

There are about 3k different substances in the list with about 12k distinct formulations. But these can be grouped into broad categories that make it easier to see the key patterns.

The split of spending across broad drug categories is shown below. Note that, if I showed the annual spend in FY 2021/22, the total would be wildly distorted by the data error for haemophillia drugs (which added ~£2bn to that year when the typical annual rate of spend is <£100m).

These categories are probably imperfect as I have to group drugs by name and manually but it is probably not too far out as there are not many big cost drugs and they can be checked by hand.

There are only about 39 drugs with spend above £100m a year. These are shown below:

The list is dominated by modern biologics (all monoclonal antibodies) which are used in autoimmune diseases and cancer, small molecule anticancer drugs and the new category of cystic fibrosis treatments.

How have those new categories grown over time? This is shown below:

Over just that 3 year period the annual rate of growth for anti-cancer small molecular drugs was ~20%/yr and biologics grew at ~13%/yr with the everything else group at about 6%/yr. The rapid growth rates of biologics (many of which are anticancer therapies) and anti cancer drugs is very notable. We can't tell this for sure with this small time period, but it is likely that these are a major contributor to the rapid growth of the headline spend shown in the NHS Digital annual totals since 2010. 

The data also contains information about which hospitals used the drugs. Without a lot of extra analysis, I can't be confident that practice in use of these drugs is consistent. It seems likely, though, that it practices varies widely as the top spender in april spent over £50m but there were 63 hospital trusts (out of nearly 200) that spent <£1m.

It seems likely to me that, if we could manipulate and analyze this data as well as primary care data, we could spot large variations in practice and drive some more convergence around what constitutes good value for money.

So what?

The first lesson here should be that it is important for the NHS to know where its budget is being spent and what it is being spent on. This budget has had very little public scrutiny.

In an area of spend with such rapid growth it is vital that we know the money is being spent well. Hospital spend on drugs seems to have grown from perhaps 3-4% of the total NHS budget in 2010 to more than 10% in 2022. Even if you argue that the indicative spend above is misleading as hospital pharmacy teams negotiate big discounts over the indicative price, the rate of growth in spend is extremely worrying. At this growth rate, even if the total is overstated by 30% because of discounts, it will reach the totals quoted above within 2 years. And without adequate analysis or control it will keep growing at the same rate consuming more and more of the NHS budget without any confirmation that we are getting the vastly improved outcomes we would expect.

On the topic of discounts, some hospital pharmacists told me they were, in fact, saving the NHS large amounts by negotiating big discounts and should be credited for the several billions of savings from those. But that misses the point that the total spend is rising rapidly, despite their claimed savings. Besides, they could claim that the NHS is saving £5bn/yr on Humira (adalimumab, the biggest drug in the hospital budget) because the NHS pays only 10% of the US price. But these numbers are about as meaningful as the "savings" during a DFS sofa sale.

Another comment from insiders was that this vast growth in spend is policy. "We have to use those expensive new drugs because NICE says so." Or because whatever the cancer drugs fund (or whatever it is called now) says. But NICE doesn't say to give new drugs to every patient. Hospitals still have to judge whether the incremental improvement in QALYs is worth it beyond providing false hope to sick patients. And this is hard to judge without the ability to combine drug usage data with outcomes and to benchmark practice across multiple hospitals which historic versions of this data have made almost impossible and even the recent releases don't make easy. And many of the new cancer drugs are not major breakthroughs that cure cancer, but incremental improvements that add just a year or two to "progression free survival". 

Since 2010 the NHS budget has grown by perhaps 3% a year. The hospital drug budget has grown by about 14% a year and that rate appears to be increasing. What else did the NHS stop doing to free up that money? Much of the money comes from the specialized commissioning budget, but that is legendarily the most out of control in the whole NHS so it isn't clear that anyone knows. 

Where are the big improvements in cancer outcomes? How many QALYs has an increase in the annual budget of >£10bn/yr since 2010 bought the NHS? 

To put this in perspective, it costs the NHS about £9bn a year to run GP practices and they dispense about £9bn a year of drugs. The hospital drug budget is estimated to be bigger than both combined in 2022. Adding about 15% more to the GP budget (roughly the cost of the long stated target to add 6k more GPs) would cost about maybe £1.5bn. Many estimates suggest this would improve the quality and outcomes of care in the NHS by a large margin (probably decreasing mortality by notable amounts according to an old estimate). That is less money than the annual increase in the hospital drug budget.

To put this another way, we have no idea whether the NHS could have improved the health of the whole english population by a much larger amount had it chosen to spend this money on something else. The lack of attention to this huge budget and the lack of detail about what it has bought the NHS in outcomes is a huge problem that deserves far more attention. 

Conclusion

The rapidly increasing NHS spend on expensive hospital drugs seems to have gone almost unnoticed even though it must be displacing other–potentially more useful–areas of activity. NHS leaders have recently, for example, called for a clamp-down on GP overprescribing despite this being a tiny problem in comparison and one that is getting smaller every year not least because of the well curated detailed, public data about primary care prescribing. 

The NHS needs to pay more attention to hospital prescribing. It should be spending serious effort in several areas:

• Fix the obvious errors in the data

• Spend the effort to create a coherent hierarchical classification of the drugs to facilitate coherent analysis

• Map the spend and volume data to clinical outcomes to make it easier to judge the benefits

• Start including reliable data on the actual (not indicative) spend (which might require radical approaches to commercial confidentiality)

If it doesn't do this the risk is that this spend will continue to consume an increasing proportion of the NHS budget with no assurance that it is improving outcomes. Never mind improving outcomes more effectively than spending the same budget elsewhere.

Good Strategy, Bad Strategy, yet more NHS strategy

I wrote a blog in 2015 about how badly what the NHS calls "strategy" stacks up against what any reasonable definition of strategy would suggest. It is time to revisit that as absolutely nothing has changed for the better.

I started the previous blog by referencing Richard Rumelt's great book Good Strategy, Bad Strategy which says this:

“Unfortunately, good strategy is the exception, not the rule. And the problem is growing. More and more organizational leaders say they have a strategy, but they do not. Instead, they espouse what I call bad strategy. Bad strategy tends to skip over pesky details such as problems. It ignores the power of choice and focus, trying instead to accommodate a multitude of conflicting demands and interests. Like a quarterback whose only advice to teammates is “Let’s win,” bad strategy covers up its failure to guide by embracing the language of broad goals, ambition, vision, and values. Each of these elements is, of course, an important part of human life. But, by themselves, they are not substitutes for the hard work of strategy.”

And defines the core of good strategy thusly:

“The kernel of a strategy contains three elements: 1. A diagnosis that defines or explains the nature of the challenge. A good diagnosis simplifies the often overwhelming complexity of reality by identifying certain aspects of the situation as critical. 2. A guiding policy for dealing with the challenge. This is an overall approach chosen to cope with or overcome the obstacles identified in the diagnosis. 3. A set of coherent actions that are designed to carry out the guiding policy. These are steps that are coordinated with one another to work together in accomplishing the guiding policy.”

How can we compare NHS strategy to these criteria? 

Not well is a good summary. Epic fail might be more accurate. Malcolm Tucker would, more colorfully, go straight to clusterfuck or omnishambles. Both the NHS plan and recent documents like the 2022/23 NHS mandate are guilty of "Let's win" as a statement of strategy. His sentence "...bad strategy covers up its failure to guide by embracing the language of broad goals, ambition, vision, and values." could be a review of either document. 

On his more detailed definition of what good strategy looks like, NHS guidance fails on all three criteria. The NHS has studiously avoided diagnosing "what the problem is" for the system as a whole and has, for much of the last decade at least, explicitly promulgated strategy that is contradicted by strong evidence that already exists (concrete examples later).

The tenor of specific mandates has avoided stating any clear policy for meeting whatever challenges there are (which is much easier when you don't have a diagnosis). In fact a good description of the latest mandate is that "everything is a priority". But, to paraphrase Syndrome in the greatest Pixar movie, the Incredibles, "If everything is a priority, nothing is".

And as for aligning actions to the goals of strategy or the stated intentions of the strategy, the NHS has won the World Incoherence championship at least 12 years in a row (more specific examples later).

But let's go through Rumelt's three parts of good strategy and assess the NHS against them.

What is the biggest barrier to improvement? What is the diagnosis?

The NHS has big problems. Some of the symptoms of those problems are very visible: 

• Long and worsening waits for elective treatment

• Apocalyptic waits for emergency treatment

• Overloaded GPs with a workforce rapidly losing faith in the system

• Repeated cover-ups of scandals about care quality in hospitals

Insiders and experts might add others to this list, but these are the big symptoms that are most obvious.

But many of these have been obvious for most of the last decade. 

Some, like GP overload, have even been the subject of significant plans. We've been trying to increase GP numbers since Jeremy Hunt was SoS but Extra trainees don't appear to be arriving fast enough to compensate for the losses in experienced GPs. 

We have also had plans to tackle A&E waits. But the one common feature of all of them is they ignore known diagnoses of the causes of waits. Keith Willet spent a lot of the decade promoting "channel shift" (which in practice meant a lot of efforts to divert patients away from major A&Es) despite repeated analysis suggesting that the divertible "minor" patients were not the cause of the problem (see this analysis from Monitor) and, even if we could make diversion work (we apparently can't) this would not influence the apocalyptic current performance.. And, worse, NHSE have proposed changing the published metrics for A&E departments in ways that obscure their performance rather than help fix it (see my analysis of the proposals).

And these are just the tip of the iceberg. The NHS has had an ambition for decades to shift care away from hospitals into the community. If anything, hospitals now have a stronger hold on the budget than they used to (see some of the analysis on this in the FT article here). The idea of putting more effort into prevention has been stated for years. Yet the budget has repeatedly been an easy target for cuts. 

As the NHS has struggled to recover from covid, there have been repeated initiatives trying to treat the symptoms. Reduce ambulance handover delays! Reduce long waits in A&E! Reverse the climbing elective waiting list! What characterizes these more than anything else is the complete lack of any overarching diagnosis explaining what the problem is. Strategy is literally the same as a football manager whose strategy and tactical advice consists entirely of "win the next match".

What these fragmented attempts to treat symptoms have in common is the lack of any clear diagnosis of the underlying problem causing the symptoms or preventing improvement from happening. If a patient presents to a doctor with "headaches" they could just have a headache or a hangover. But, sometimes, they have meningitis, a brain tumor or a concussion. Treating the symptom works for some of those but not others depending on the actual diagnosis. If the doctor treats the symptom without trying to get a better diagnosis, many patients will be fine but some will suffer harm. The NHS seems to perpetually focus on trying to treat the symptoms and completely ignorant of the risks of an incorrect diagnosis.

But this leap to treating the symptom without getting a better diagnosis is exactly how NHS plans have tried to deal with the big symptoms for more than a decade.

What is the guiding policy?

In the absence of a convincing diagnosis of where the big problems are, policy is–obviously–somewhat untethered to reality. This is a problem. A big problem.

It would be unfair of me to say that the early 2019 NHS Long Term Plan has no analysis or no ambitious goals. But it is stymied by a lack of focus, many critical omissions and a naive belief that structural and financial changes can achieve actual improvement. And many of the ambitious actions proposed there have not resulted in actual changes in the real NHS.

The plan, for example, promised 5,000 more GPs. We don't even have more GPs. It has a section on improving leadership and recognises a shortage in the pipeline of potential leaders. But says nothing about management or the chronic lack of management capacity, despite this being a major cause of the deficit in the leadership pipeline. And it promises more cuts in the name of "efficiency" that are likely to reduce the number of managers. 

Unusually, it recognises a long term failure to invest in capital as a problem. But promises changes that didn't materialize in the spending reviews or budgets between 2017 and 2021. And, though there was a big commitment in 2022 to invest more in capital, a lot of that is earmarked for "new" hospitals or community diagnostics (a good idea, BTW), the core budget for improvements in existing units is little changed and there is nothing in the proposed changes to the capital regimen to prevent the repeated capital underspends or transfers to revenue that have shrunk the capital budget for most of the last decade. Two developments since the start of the 2022/23 financial year suggest backsliding on capital commitments. New rules to constrain FTs are being proposed so the center can avoid an arbitrary treasury rule about total spend (a rule which is a major reason for previous problems in investing enough capital). And the center is already trying to claw back some of the budgets promised just a few months ago.

So, overall, the strategy lacks good diagnosis and any focus on a handful of big problems.

What is the plan?

The 2022/23 mandate is probably even worse. Here are the focus areas from the appendix:

1. More Nurses

2. More GP appointments

3. 40 new hospitals

4. Improved post pandemic performance in A&E and elective waits

5. Supporting leveling up and health inequalities

6. Better access to community and primary care

7. Mental health improvement

8. More technology

9. Better outcomes in 6 areas prioritized in long term plan

10. Better outcomes for long term conditions

11. Better maternity outcomes

12. Better support for workforce

13. Financial balance

All shall have prizes! What I struggle to see is what has been left out. Everything seems to be a priority. Focus is like something the authors needed to look up in a dictionary but couldn't find because they lost their reading glasses. 

What is most disturbing is the absence of any idea that the NHS is a system where the parts interact. This has multiple implications. For example, there is no fixing ambulance performance or A&E performance without tackling exit block from hospital beds. That might suggest a focus on that before demanding improvement in A&E and ambulances. There is no sign of that focus. Also, to actually achieve improvements, the interactions between different components of the NHS need to be considered. For example, improved performance might require more capital spending and more support staff to increase front line productivity. Getting that mix right implies a different analysis of the problem (which is completely absent) and a different mix of spend in the budget. There is no sign of that either. If anything, the stated goals assume we can have more of everything without having to reallocate any money: so, more nurses, more hospitals, more technology, more GP appointments…

Hence my complaint that the apparent logic of the priority list is not achieving anything but pleasing every possible group by telling them that they are a priority (I said this on Twitter and got some pushback claiming the plans are developed by people with good, not cynical motivations). But words are cheap, action is expensive and a homeopathic level of focus is not any more effective in strategy than it is in medicine. Everything Everywhere All At Once is the best movie of the millennium so far, but it is not an effective plan that will focus NHS effort on solving the big problems.

So we seem to have an NHS strategy that misses all three of Rumelt's essential elements of a good strategy.

It might be even worse than that. Let's look at some possible analyses of specific known issues and how the NHS has handled them.

The perpetual mismatch between known problems and the actions required to tackle them

The absence of a clear diagnosis of the biggest problems and the homeopathic level of focus in plans have consequences. One of the most serious is a repeated failure to match action to the goals. Here are some specific examples.

The NHS has long recognised the goal of doing more in the community and more prevention rather than treatment. But neither have seen much action. This analysis from the Kings Fund at the start of 2018 suggests the goal has failed to move the needle on action:

"Our recent work on general practice and district nursing has shown that the policy narrative about the need to transfer care from hospital to community health services is not being accompanied by a similar transfer of resource."

And the Health Foundation, reviewing the prospect for the new Office of Health Improvement and Disparities (the successor to Public Health England) reported:

"The public health grant has been cut by 24% on a real-terms per capita basis since 2015/16."

And the Kings Fund analysis of the 2021 spending review argues: 

"the [public health] grant will be maintained in real terms over the next three years – a decision described as ‘unfathomable’ by public health leaders, who have played a crucial role in the response to and recovery from the Covid-19 pandemic. On a like-for-like basis the public health grant has already been cut by 24 per cent in real terms per person since 2015/16. And it is hard to see how public health services (and the people who deliver and use them) will not come under more intense pressure over the next three years."

So the NHS thinks–as it has for decades–that improving public health is a priority. Except when it comes to allocating money, when it is Cinderella, stuck in the basement with a dirty second hand dress.

What about emergency care? That has become a very visible sign of NHS failure with perhaps 8% of attenders at A&E waiting 12hr for discharge or admission. This alongside very long ambulance waits. This is a priority, isn't it?

Here we have a different kind of problem. It isn't the allocation of money or at least not the total amount spent. It is a persistent set of policies that fail to identify the root cause of long waits in A&E (which are, in turn, the root cause of ambulance waits). 

And it isn't a new or primarily covid-related issue: things have been declining since Lansley's unwise decisions to threaten to abolish the target and then to relax it:

Note the immediate decline in performance coinciding with Lansley relaxation (presumably to make it easier to meet, spoiler, it didn't) in this Strategy Unit chart. Things have kept declining ever since.

The causes of long waits are, at least in principle, well known. I was writing on the topic in 2013,  writing about them in 2016 and again  in 2017. Monitor did an excellent review of the evidence in 2015.

The Monitor report contains a handy picture of what their analysis showed at least for the parts of the decline that could be explained:

Note that things inside A&E department itself explain nothing. Nor do the numbers of discharged patients or total attendance. Pay attention to these observations, there will be a quiz at the end.

Monitor remarked:

"Our view is that the available evidence for the half of the decline that can be explained is strong enough to underpin policy, and that the findings of the analysis point to particular policy interventions that are likely to help prevent the decline from occurring again."

Policy, however, has rolled on apparently oblivious to this analysis. Two major things have dominated it. 

One is the idea that the problem can be tackled by "channel shift" (which means diverting patients to other services). According to Monitor's analysis (and many by me and other experts) this would make no difference at all. 

The second is that we need to measure A&E performance in a different way. The 4hr target is so last decade, according to proposals first put forward in 2019. The logic behind these alternative metrics is shockingly dodgy. A better explanation for them is that they are designed to minimize the opportunity for bad news when performance is published every month. These proposals have still not been implemented (thank fuck) but they have been piloted in 14 trusts. I wonder why the results from the pilots have not been published?

So we have a major area of the NHS where performance has been declining for a decade to a level where instead of getting most patients through A&E in 4hr, England struggles to get 90% through in 12hr. And Those long waits are, most likely, killing patients as a recent analysis  in the Emergency Medicine Journal suggests.

But, while policy and NHSE plans are keen to say this is a priority, the policy ignores credible diagnoses and directs attention to other actions. One of which can't work if the diagnosis is correct, the other of which can only hide the problem, not fix it.

Without diagnosis, focus and coherent action there is no hope for improvement

All strategy is futile if it isn't based on a good diagnosis of the barriers to achieving the goals. And, even if there is a diagnosis, a lack of focus on the top problems will dilute the efforts to nothing can be achieved anywhere. On top of that, if you don't match the plan with action, your goals will remain beyond the horizon if not beyond the heat death of the universe.

Since NHSE strategy and policy seems to have striven to make all three of those errors at the same time, I'm not full of hope. 

We have clear examples where the diagnosis is wrong (A&E policy). The prioritization seems to be based on the idea that, if one priority is good, two would be better and 13 would be amazing (the 2022/23 mandate).The mandate priorities have single handedly reintroduced the idea that homeopathic dilution is effective into the NHS. And, even when there is a priority, clearly stated, the plan takes money away instead of adequately funding the priority area (capital spend and public health spend).

NHS Strategy is–to paraphrase Douglas Adams–a shit show, a clusterfuck of incoherent ideas, the entire set of pejorative descriptions from every major thesaurus in the galaxy.

So what?

Many documents and statements about strategy by NHSE seem to be based on the principle that if they declare that every major area of NHS activity is a priority, this will make everyone happy and motivated to achieve improvement in their domain. Or, if we tell everyone that they are doing a good job (with claims like "we have treated a record number of patients, well done") this will motivate them to improve performance. The trouble with this attitude is that, when the problems are large and manifest to all the staff, telling them things are OK and could get better just demotivates everyone by strongly signaling that the leadership either hasn't reached their clue quota on knowing what the problems are or hasn't any intention of doing anything significant about those problems. When you are in a shit storm, prescribing more anti-constipation meds is rarely the right approach. When the car has four flat tyres, praising the driver for how far they have managed to travel already is an unwise approach.

We may be very close to the point where more boosterism from NHSE will precipitate a complete collapse of the NHS. Everyone knows they are sinking into a sewage filled quagmire. In those circumstances, boosterist statements signal the opposite of their apparent intent. Not "things will soon get better" but, rather, "we are so clueless about the problem that all hope is lost". The exodus of staff from GP land, for example, is already apparent. And may rapidly get worse. What they–and many other staff groups need–is not more boosterism but a clear headed, well argued statement that the center understands what the problem is and will focus on fixing it. They don't need fake promises that miracle cures will fix everything next year: they need hope that the underlying causes of the problems are now recognised and that (perhaps after several years of effort) things will be better. There is no prospect of hope when boosterism squeezes out all realistic analysis of just how bad things are and how hard they will be to fix. 

Far better to do the analysis of what the root causes of the apocalyptic state of the system actually are. Then openly admit them alongside a clear commitment to focus the NHS on tackling the big ones instead of pretending to tackle them all. Focus and honesty might create enough hope that things can be fixed that the impending apocalypse might be avoided. More "strategy" based on boosterism and with all the focus of a clumsy child's first photograph might turn the current apocalypse into armageddon in the near future.