The Maynard Doctrine: Boomerang health policy: what goes around, comes around

Professor Alan Maynard OBE admires the Buddhist nature of NHS reform. The wheel turns and civilisations rise; the wheel turns, and civilisations fall …

Health policymakers continue to rediscover ancient and well-researched problems, and to repeat the redisorganisational mistakes of yesteryear.

In part, this is due to a failure to distinguish between organisational structures; processes of care (or outputs); and patient outcomes - i.e. the rather important question, ‘did we make the patient better’?

For decades, silly old politicians have acted as if redisorganisation of structure and processes always and everywhere improved patients’ health. Sadly, this has not been the case.

Expensive spasms of musical chairs as organisations waxed and waned have done little to improve patient care and efficiency. However, they have been successful in increasing staff anxiety and managerial caution - and have cost taxpayers hundreds of millions in redundancy and early pension costs.

Plus ca change …
Clearly, given the parlous nature of the UK economy and government debt, there is a risk that after the imminent general election, the mistakes of yesteryear will be repeated even more extremely in 2010-11.

All the political parties are offering us health manifestoes which tend to praise public health in a manner similar to Virginia Bottomley’s ‘Health of the Nation’ over fifteen years ago and the well-intentioned but evidence-free burblings of subsequent Secretaries of State.

Politics and evidence: uneasy bedfellows
A fundamental issue with these policies is that we are unsure what interventions are cost-effective. Even when we are sure, politics prevents progress.

’Progress in alcohol policy is inhibited by politicians preferring alcohol-induced mayhem rather than confronting powerful industry lobbies which threaten their electoral prosperity’.

An obvious example of this is alcohol policy where, as the Parliamentary Select Committee on Health emphasised in January and even the Chief Medical Officer at the Department of Health supports strongly, there is a need to have a minimum price of 50 pence per unit plus other interventions to curb the damage wrote by this delightful product.

Progress in alcohol policy is inhibited by politicians preferring alcohol-induced mayhem rather than confronting powerful industry lobbies which threaten their electoral prosperity.

Politics similarly prevents emulation of New York and policies in other US cities aimed at reducing childhood obesity by taxing sugary drinks and fast foods. Again, politicians quake, threaten to refer the issue to a committee for consideration in the best ‘Yes Minister’ tradition; meanwhile praying that their kids will not get diabetes and worse!

Given the perversity of politics it may need a Tory government to stand up to industry and mitigate, through the tax system, the adverse effects of poor diet on the British population. However, any such policy change will require a “Damascus event”!

The Tories, like Labour, are unlikely to exhibit any sense in the regulation of the illicit drug market. The recent scare over a product which is legal but has been associated with the deaths of two young men has led to the usual panic and calls for it to be designated as a Class A drug.

It is possible that these unfortunate men were polydrug users, and that the cocktail of material they were using caused their deaths. The actual product is of uncertain chemistry - but legal. The risk is that it will be designated Class A and this will create yet another illegal market.

Once a Class A always a Class A, and guaranteed income for ‘poor’ street dealers seeking nice new BMWs and undermining of often already highly-deprived communities! The Dangerous Drugs Act is so efficient at redistributing income to criminals, and ruining the lives of vulnerable folk!

What other nonsense can we expect from our leaders?

Last week The Times newspaper resurrected a familiar policy zombie: user charges! An ignoramus called Jamie White noted demand for GPs was too high because the cost to punters was zero. The “solution” was to charge i.e. to disadvantage the poor, elderly ill.

It would be much more honest if this laddie just said ‘let’s use charges to reduce government costs, screw the poor ill and induce delays in the treatment of patients so that when they finally turn up in the NHS, they will be near to death and die quickly and cheaply!’

No doubt we will hear lots more about user charges after the election when these goals may be prioritised!

The Whitehall consensus on “quality, safety and productivity” is a matter of concern. What is productivity? For the Department of Stealth, it seems to mean the relationship between inputs and outputs. For any sane person productivity means the relationship between inputs and outcomes for patients.

The “religious” who determine policy in Whitehall assume that an increase in outputs means automatically an increase in outcomes. But where is the evidence, comrades?

Outcomes, not outputs
There is a risk that the drive to increase productivity will produce more outputs that have little benefit to patients i.e. do not improve their outcomes.

This obvious risk seems to be lost in a welter of spin and blah from policymakers acting like lemmings anxious to fall over the cliff in their ignorance of obvious and basic issues.

Whenever you hear this word “productivity”, ask yourself: does the plonker who is using the term understand this fundamental distinction?  If he or she does not comprehend this distinction, biff him / her on the nose!

As we stagger towards the election, the level of re-circulated policy nonsense will increase. Zombie policies discredited many times over the years will be resurrected to appeal to the ill-informed and zealots.

Enjoy the fun, and try to stay sane!