What would a government seeking to improve the NHS to win the next General Election have done (and not done) in 2023?

Today I’m taking you to a difficult place. For some of you it will be a new place but let’s go there anyway.

It’s a kind of role play in which you must pretend to be the Secretary of State for Health and Social Care in a government that has about 18 months to go before an election. You know from polling that one of main issues that will determine the outcome of that election will be long NHS waiting times. You also know that your boss, the Prime Minister, has pledged that, within a year, waiting list times will be in decline. (You may even have assured him that this would happen before he made the pledge). So you look at what you can do over the next two years to improve the way in which the NHS delivers services to reduce long waits. This really is your top priority.

You have an imperfect delivery organisation – let’s call it NHSE – but it’s what you have. And you remember when you were first elected to Parliament in 2010 that you voted, repeatedly, for the operational independence of this new organisation. (and as you drift off into your troubled sleep each night you think “WHY, WHY did I do that!?”). But there it is. Now, with less than 2 years to go before the election, that is the delivery organisation for which you voted and which you now have.

In the spring of 2023 you look at it and think “it’s become really bloated during Covid” and decide it would look much better if it were smaller (WHY, WHY did nobody say “But we need this organisation to work really well over the next two years. Don’t distract it”.)

So, in the late spring of 2023 you suggest that this organisation – your only means of delivering your government’s top health priority over the next 18 months – should also focus on applying for each other’s jobs. After all, what could possibly go wrong? It will all be completed in a couple of months, and you will earn the political kudos of the money saved by axing 9000 NHS managers.

If you read the HSJ you might have been a bit worried to see that on 18 May 2023 it reports that as the NHSE removes these 9000 posts, some staff will not know their fate until March 2024. Meaning that for most of the period leading up to the election you will have disrupted the ability of the delivery organisation (the one you voted to create) to work solely on the key election issue of reducing waiting lists.

This is what makes politics so interesting because we assume that senior politicians act in their own best political interests. But in reality they don’t. A short-term government can’t even think 18 months ahead and cannot resist the opportunity of a one-day headline for “cutting 9000 NHS managers”.

Let’s now move our role play forward in time. The waiting times have kept on going up. Whenever there are rumours of a Cabinet reshuffle, your name is near the top of the removal list. (That’s just so unfair – ed.)

Roll forward again to the beginning of the winter before the election. We are now just 6 weeks away from the time that the PM (your boss) has promised that waiting lists will come down.

The Treasury has declined to give you the extra £1bn you asked for the rest of the year. So, you must do something.

As the HSJ reported on 08/11/2023

“The NHS’s work to bring down the 7 million elective waiting list is being curtailed, after the Treasury refused to fund most of a £1bn NHS deficit driven by strikes”.

The NHS is being asked to revise their “trajectories” downwards (by the person who needs to ask them to revise them upwards) for trying to meet the government’s flagship target to reduce 65-week waiters by March.

Separately the “elective recovery fund” activity targets – intended to encourage waiting list reduction – will be lowered by 2% for every system unlocking an additional £360 million.

As a senior politician, planning to win a general election on the back of NHS improvements in waiting times, this all begins to look rather odd.

To reduce waiting times, you are effectively in the hands of 300 or so NHS trusts’ CEOs and a few thousand primary care networks. In the year 2023/4 you really need them all to have a good year-long run at planning to increase productivity.

But you already blew that year for planning. You already changed the way in which the electoral recovery fund works – in July.

Now imagine the plight of a CEO of one of these delivery organisations. How do you respond?

The wiser ones amongst you will have factored in these changing priorities. In April 2023 you will have known, given your recent experience, that it is daft to plan on the basis that incentives will remain the same for a whole 12 months.

So, being canny, you will have waited for the July reset. And been grateful to plan with some certainty for a 9-month year. Let’s pretend you are good at your job and over the next few months ramp up the amount of work taking place and plan for a further ramp up over the winter and into next spring.

However, in November (8 months into the year) you discover that despite trying your hardest for a few months (and you had hoped for the rest of the year) you now must cut back.

This puzzles you because you know there are people out there waiting in pain and distress, and being told not to help deal with that is odd.

Alternatively, following the July reset, some CEOs decided it was just much too hard to ramp up to hit the elective targets. And in November they have been proved right. It would have been foolish to have taken the July reset seriously and made all that effort.

Luckily for them the national delivery organisation that is meant to be managing all of this is still busy applying for its own jobs.

I’ve presented this as a role play because those of my readers not involved in politics will think that all too often in the NHS, politicians oversee the NHS. And many of you will see that as a problem.

But I hope this story illustrates the problems that arise when politicians really aren’t in charge – because they can’t plan 24 months ahead. Even to attain something that they say they want. (and that is very important to millions of people).

And, if you’re still imagining yourself as Secretary of State (unlike Steve Barclay), never mind. By next spring, when you are on the back benches, there will be tax cuts in the budget..