The Maynard Doctrine - In The Land Of Blah, the Policy Zombies thrive!

Health economist nonpareil Professor Alan Maynard looks into the Steve Field and Mark Britnell interventions, in search of susbstance.

This past week has demonstrated that madness is rampant in health policy debates. There is clearly a need to be concerned about the condition of some noisy health policy wonks.

The Guardian (May 14th) reports Professor Steve Field, the chair of the Whitehall ‘listening’ game as saying that the reforms are “unworkable” and competition is intolerable.

What does the dear man mean?

“Unworkable” compared to the current NHS, which is mired in restrictive practices? If there is to be no competition, how can these restrictive practices be undermined?

It is pathetic if Comrade Steve and his tribe beat up the reforms, leave them a castrated wreck and offer no alternative evidence-based solution to the productivity and funding crises facing the NHS. If that is his “solution”, then surely the Tower rather than the Lords should be his reward!

If such imprecision was evident in this physician’s diagnoses of patients (which I am sure it is not) he would be reported to the General Medical Council and found unfit to practice. As it is, he is wallowing around in a sea of policy turmoil where the sharks are nipping each others’ parts and the production of clouds of hot air may be a prudent defence mechanism when you are unsure of the evidence base.

The ill-defined use of words (or blah), sprinkled with ambiguity is the hallmark of current politics and seemingly, some medical practitioners in Whitehall Village.

Funding farrago
Mark Britnell wittering on in the Health Service Journal on Friday the 13th: unlucky day for some, dear boy! Lovely lad is Mark: full of energy, but liable to have bouts of daft ideas.

Change the finance of the NHS and use insurance, Mark? Come on, dear boy! You may be a “Global” KPMG director, but this “globe” is balls.

Getting a grip on feeble purchase
In all healthcare markets, regardless of whether they are public or private, purchasers are pretty useless! Call the purchaser a commissioner if you like and re-disorganise it through Health Authorities (Health Boards in Scotland), Primary Care Groups and Primary Care Trusts (c/o my favourite ex-Trotskyite, Alan Milburn) or GP Fundholders of circa the 1990s and what have you got?

Feeble purchasers. Just like you have got in private insurers and social insurers in the Bismarkian systems!

The use of the word “insurance” is a fraud, unless we define it as an accumulation of funds to meet future outlays - as with privately-insured pensions. In healthcare, whether you are BUPA or a social insurance fund in Germany, financial management means ensuring income equals expenditure each year. Such a ‘pay-as-you-go’ system means the young and healthy fund the care of the ill each year, and hope that when it is their turn to have care, the healthy will fund them in the style to which they are accustomed!

Proposals to alter funding is an old Policy Zombie, as defined in 1993 by Robert Evans and colleagues: a notion that is paraded at regular intervals; knocked down as silly; but returns to entertain and convince dullard politicians that there is an easy solution to an ill-defined problem.

Wherever you look, in public and private systems, the main problems are the same: inefficiency in the supply of healthcare as evidenced by unexplained variations in clinical activity, poor outcome measurement and perverse incentives rewarding the waste of society’s scarce resources.

Would that there was some magic wand, public or private to mitigate these sad facts!

Why not to use insurance funding
Private insurance usually gives you expenditure inflation, inefficiency and inequality; often in bigger doses than the current NHS! Thatcher subsidised private insurance for the elderly i.e. the taxpayer subsidised relatively rich elderly folk to buy the usual highly-restricted policy benefits of the insurers. This device was inefficient, inequitable (why subsidise the rich, elderly to buy a limited package of insurance?) and increased expenditure, since tax subsidies reduces the income of the Treasury!

In the USA, the insurers drive up costs by being passive price-and-quality-takers, rather than aggressive price-and-quality-makers. Consequently, they spend twice as much per head as we Brits, with tens of millions uninsured due to high costs. This expensive, inefficient and inequitable outcome is what Obamacare is now seeking to resolve. Most of the US healthcare Establishment is fighting Obamacare rather forcefully.

This system also demonstrates the difficulties that arise with fragmented funding rather than the NHS monopsony (or sole funder). With fragmentation, the scope to transfer restrictions in one area of funding to another is evident (e.g. squeeze public funding and private funding increases), thereby inflating consumer and employer costs and the use of society’s resources by the health sector.

The problem (as Mark knows so well) is that providers are dominant in all healthcare markets and purchasers are feeble. He puts it this problem as it being essential to disrupt “value chains and the patterns of supply”. Correct, sunshine - even if the blah is unnecessary! Funding reform proposals are silly diversion in the present situation of flat or negative funding and the need for productivity changes.

Whacking the value chains needs radical changes in supply-side incentives (which must be evidence-based), which purchasers have clearly failed to do worldwide in both public and private agencies. This needs to be led by clinicians, inspired by flaming Bunsen burners adhered to their backsides!

Hopefully, Mark will recover soon from this nasty bout of policy haze, and further treatment from the policy evidence base will not be needed.

In the meantime, some further food for thought and evidence:
1) Are “electives” to be redefined? For example: most hernias are asymptomatic Why not treat them only when they are emergencies? How many randomised controlled trials are there of leaving hernias until they are emergencies, compared to treating them within 18 weeks when a-symptomatic? Is such a policy switch likely to be cost effective?
2) By how much does a geriatrician or geriatric nurse reduce length of stay / readmissions / complications etc when an integral part of a surgical team? Some evidence from St Thomas’ seems to indicate nice benefits, but are they worth the cost?

Have a nice day, dear readers. But beware wonks and zombies thriving in the re-disorganisation jungle! Always ask them “where is the evidence?”