The Maynard Doctrine - The NHS regulatory hogwash

Health economist Professor Alan Maynard asks what regulation is actually delivering

Public and private sector regulatory schizophrenia
There are two remarkable aspects of regulation.

Firstly, regulations are costly and usually created to protect and benefit the public, i.e. they usually involve significant costs and benefits. Those favouring their abolition generally assume deregulation is virtually costless in the absence of evidence.

Not so! Thus, for example, the regulation of dangerous liquid acids was eased in 2015 and this facilitated attacks on moped users, especially in London. The usual slow legislative response is now seeking to restore regulation, to protect the public

Secondly, the Government’s own regulation industry is uneven. It is forever advocating the deregulation of the private sector and the inflation of the regulation of the public sector. The implied prejudice is that private capitalists are wise and trustworthy, and public managers are stupid rogues.

Thus the government has sold off the Post Office, denationalises banks, the Land Registry and other agencies such as the Parole Board with little regard to evidence of cost-effectiveness. Privatisation policy is as ever faith-based and often to the benefit of private sector scavengers such as Bell Pottinger and other public relations and consultancy parasites.

However, when it comes to regulation of the public sector, government loves to legislate and pile one 'reform' quickly on top of preceding ones. Usually this frenzied activity is informed by the Minister panicking when faced by a Daily Mail-induced “crisis”, with the following the usual Whitehall bureaucratic process, defy summarised as The Politician's Syllogism:

“Something must be done”

“This is something”

“Therefore this must be done”

(Lynn and Jay, 'Yes, Minister', Volume 2, 1987)

Consideration of the costs and benefits of for instance, the Lansley reforms of the NHS in 2012 were superficial. Where this and other policies are informed by Departmental impact statements, they are usually limited by data constraints with no follow-up of the magnitude of Government folly arising from such leaps in the dark

Stumbling through the dark: the case of the NHS
The NHS is blessed with hyper-regulation. The current Secretary of State, Jeremy Hunt, moves from one wheeze to the next regardless of the opportunity costs to long suffering NHS managers.

His latest wheeze is the reduction of medication errors. Whilst there have been wide variations in prescribing by GPs for 70 years, its causes are unclear. Prescriptions carry no diagnostic information whereby Mr Hunt could investigate inappropriateness of pharmaceutical provision to patients. In the absence of such evidence, Mr Hunt is 'wheezing' in the dark

Sad Mr Hunt likes to be seen to be doing something i.e. creating the illusion of purposeful activity.

“Politicians like activity, it is their substitute for achievement” ('Yes, Minister', again)

In particular he is addicted to creating “quality initiatives” with little regard to the costs of his often well-meant but illusory achievements

Twenty years ago, the American Institute of Medicine launched a report entitled “Crossing The Quality Chasm”. (National Academies Press, 2001). It created a policy focus on the pursuit of activity that was “safe, effective, patient centred, timely, efficient and equitable “.

This discovery of the quality issue and the international bandwagon effect it created undoubtedly influences those seeking truth in Richmond House, Whitehall, and the lair of Mr Hunt. Subsequently, during his period of office, Mr Hunt has used the “quality issue” as his primary instrument of disguising the effects of funding parsimony and workforce market-wrecking i.e. austerity and the creation of a threadbare NHS.

The authors of a recent article in the Journal of the American Medical Association (Schuster, Onorato and Meltzer, JAMA, 2017.11525) have discovered that two decades of well-intentioned pursuit of 'quality' in health care has imposed high costs on American patients.

These costs could have funded patient care, rather than being used to fund a plethora of policies of unknown cost-effectiveness. Hopefully, despite Mr Hunt’s reading difficulties, he can take on board this valuable lesson from elementary economics and a learned American medical journal. There are no free lunches.

So following the Americans and Economics 101‘s concept of opportunity cost, it is time to focus on what is given up by quality initiatives (i.e. cost) and what is gained (i.e. benefits to patients, insurers and taxpayers). After decades of mere advocacy of policies of uncertain effectiveness and unknown cost, it is time for science rather than blinkered optimism.

Where to start? Every week NHS England or the Department of Stealth announces another set of regulatory initiatives At the national level, there is also a plethora of untested regulatory initiatives to enhance (allegedly) the quality of care for patients e.g. the Care Quality Commission continually revamps some aspect of its work as it strives to do more with less government funding.

The caring professions are the target of unevaluated revalidation. For example, what are the costs and benefits of revalidation of nurses, doctors and professions allied to medicine?

At a more fundamental level, is the purchaser-provider split an inefficient job creation programme or something that benefits patients cost effectively? (BMJ debate 2016).

Indulge yourself with a casual starter review of such organisations as CCGs and hospitals by reading their Board minutes. What nonsense you will find there! A non-random small sample reveals hundreds of pages of 'reporting', with length varying from 200 to 600 pages in the few I inspected. I suspect many board members read little of this torrent of data, and maintain a state of ignorant acquiescence of NHS England and Department of Health dictates.

What a costly waste of management time. Ticking government boxes diverts managers from resolving local problems.

It is pertinent to recall Parkinson’s argument that “leaders” like to increase the size of their empires, recruiting subordinates not rivals, and secondly increasing numbers of managers increase work for each other. As Simon Jenkins recently noted (Guardian, September 15th), managers spend whole days in meetings “and return home with no one any the wiser”.

Of course this would never happen in the NHS or Hunt’s Department of Health where after sacking hundreds at a cost of nearly £40 million, he is now eagerly recruiting hundreds of new staff with no sense of the history of his daft wheezes!

Is it time to cost all the inputs into Board papers and meetings at local and national levels, and publicise the consequent expenditure in hours consumed and time costed? Bureaucracy is essential, but has a crazy government fixated with unnecessary and unwelcome austerity and un-evidenced 'quality initiatives' gone berserk? I fear so.

Conclusions
The pursuit of quality improvements in the NHS is essential, and must be based on evidence. Prognostications based on evidence-free wheezes conjured up by ill-informed politicians and their acolytes are inefficient and unethical.

Let us remind ourselves always of two vital rules for policy wheezes created by intellectually bankrupt politicians and others in charge of the dear old NHS:

1) Every decision has an opportunity cost. Loud advocacy of the illusory benefits of quality initiatives and regulatory wheezes by the Department of Health and NHS England must be challenged with evidence of the benefits achieved for patients and the costs imposed on society. Mindless dreaming of the former and ignoring the latter reduces patient welfare, is unethical and should be rewarded by ridicule and dismissal.

2) In Whitehall, NHS England, CCGs and hospitals, decision-making should be imbued with “scepticaemia”. This has been defined as “An uncommon generalised disorder of low infectivity. Medical school education is likely to confer lifelong immunity” (Skrabanek and McCormick, Facts and Fallacies in Medicine, Tarragon Press, 1987)

With scepticaemia and consideration of opportunity cost, the functioning of the NHS could be improved to the benefit of patients.