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The Maynard Doctrine – A pause for thought

Health economist Professor Alan Maynard offers some reflections on the current state of transition in the NHS.

Some items to ponder in the bath, or whilst Eastenders or Match of the Day are on TV, or wherever you think about the enigmas and quaint old NHS fashions that continuously entertain us.


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1) If you were the NHS Commissioning Board, how would you contract with primary care providers to enhance productivity and patient care and reduce system costs?

2) Why aren’t patient reported outcome measures (PROMs) part of the GP quality outcomes framework (QOF)? Why wouldn’t GPs not want to be confused by patient quality of life outcome data?

3) We have known for well over a decade that admission to hospital at the weekend is more likely to be fatal. This has again been confirmed by Freemantle et al (authors include Sir Bruce Keogh of the NHS-NCB) in the Journal of the Royal Society of Medicine, Feb, 2012.

This being the case, why haven’t public and private hospitals sought to mitigate this risk more energetically? Is it the cost, or is it a lack of awareness of potential benefit?

4) Why aren’t the Royal Colleges of Medicine better performance-managed by themselves and by the Government who gives them subsidies via their charitable status?

5) Why are there no national undergraduate exams for medical students? This is a long-standing puzzle.

Each medieval and more modern medical school sets its own exams and responds to GMC vague curriculum advice differently - e.g. Oxford gives one-and-a-half hours of health economics in Year Five to folk whose career management will expend millions of taxpayers’ money.

Is it time for a national exam system for would-be medics, like in the USA? Is it time to train those who will prioritise our access to care, how to manage and use economics?

6) NHS England Hospital Episode Statistics (HES) and equivalent systems in Scotland, Wales and Ulster detail referral, postcode, treatment details and outcomes (deaths and discharges i.e. horizontal and vertical discharges!) for all patients.

This being the case:
i) why isn’t private provider data not compulsorily collected and integrated with NHS-HES data to give comprehensive comparative information - to give integrated information about all NHS and private consultant activity?

ii) why are clinical and non-clinical managers so reluctant to use such data to manage their workforces and increase productivity? Ashley in the British Journal Prev. Soc.Med (1972, 26, 135-47) advocated its use 40 years ago! Managers are not dim; so how can they be motivated to address these issues more energetically?

iii) shouldn’t revalidation by the GMC be dependent on transparency and comparative data on activity, complications and outcomes for GPs and hospital doctors?

7) The Department of Health and Social Security published a consultative document called Priorities in Health and Social Care in 1976. In this venerable tome, the case for “integrated care” was emphasised and money was allocated to “joint finance” to facilitate this development.

Why has there been so little progress in nearly 40 years? Is it because “what’s regular ain’t daft” and hospitals are best? Where is the evidence that “integrated care” is cost-effective? Why aren’t apparent successes (e.g. Torbay) not replicated NHS-wide?

8) When labour costs consume 70% of the NHS budget, why is workforce planning so naïve and evidence-free? Do you agree with the Centre for Workforce Intelligence estimates that we face a potential “surplus” of 6,000 consultants? Why are the activity rates of female consultants across all specialties lower than for males? (See Bloor et al, Journal of the Royal Society of Medicine, 2008) Where is it cost-effective to substitute nurses for doctors?

9) Why are UK managers, politicians, journalists and lobby folk so ignorant of the workings of overseas healthcare systems?

Obvious examples of Things We Should Discuss include:
the high levels of regulation of the mixed public-private system of providers in the Netherlands;
the fact that 47 per cent of US healthcare is funded by taxpayers (see Fuchs, NEJM, March 15th, 2012);
and universally, the problems in all public and private and mixed healthcare systems are that commissioners / purchasers / insurers are price-and-quality-takers rather than price-and-quality-makers and unwarranted clinical practice variations are ubiquitous.

Why don't we talk about this?

10) Now the NHS Bill has stumbled through Parliament and become the NHS Act, where is Plan B for those of us who will have to manage this messy document into patient care and service delivery?

Some narrowly-focused and sometimes bonkers “leftie” ideologues have moaned, groaned and petitioned exhaustively, as if only they can “save” the NHS with negativity alone. Both they and those quietly anxious to preserve the NHS have said all too little about how to maintain income protection for all citizens with healthcare funded by taxation and free at the point of delivery.

Why is there such myopia? Where is plan B?

11) The policy zombie nonpareil of user charges in healthcare is due a return visit. Whenever fiscal constraints tighten, some bright young (or not-so-young) things advocate the extension of user charges in the NHS, such as patients paying for GP visits and hospital “hotel” services.

Three Canadian economists of a collectivist preference argued “In the present structure of healthcare delivery, most proposals for “patient participation in health care financing” reduce to misguided or cynical efforts to tax the ill and/or drive up the total cost of health care while shifting some of the burden out of government benefits” (Stoddart, Barer and Evans)

Beware those proposing user charges to augment NHS income! Unless of course you want to tax the ill and shift costs from government to patients; like some we could name! (More on this in a forthcoming editorial in the British Journal of General Practice, April, 2012)

12) Given austerity, should private health insurance be subsidised “to shift the burden” of funding the NHS from government? The National government of John Howard in Austral tried this (see Hall and Maynard, BMJ, 2005).

Private insurers are price-and-quality-takers, just like the NHS. Private insurers are as poor at managing clinical practice variations and waste as the NHS (see the US experience).

Secondly, why should a government subsidise taxpayers who are relatively affluent, as the Aussies do, to purchase private insurance? This is inequitable and expensive: as insurance premiums rise, the tax take declines.

There is no evidence that private providers are better than public providers at delivering cost-effective healthcare. Furthermore, they lack transparency in terms of activity and outcomes (see 6 above and the Office of Fair Trading report, December 2012)

As you ponder these all too familiar issues in your bath or in front of Match of the Day, do not let the water go cold or support Man United! Both may be bad for your health!

If you have answers as to why the NHS and the private sector (insurers and providers) are so slow to improve, do tweet me! (@ProfAlanMaynard)