The Maynard Doctrine: How is Sir Galahad doing? A termly report

Health economist Professor Alan Maynard runs the rule over the Stevens regime

Who would want Simon Steven’s job? One can only admire the fortitude of Sir Galahad (better known as SS). He is mired in the bog that is Whitehall, with the natives running riot, practising planned parsimony voted for by no sensible citizen.

Sir G quests quietly and determinedly for the Holy Grails: leverage to facilitate financial solvency; avoidance of crises; and radical reform of NHS attitudes and practices.

Sir Galahad’s gospel, the Five-Year Forward View (FYFV), involves major challenges for managers. As he wrestles with managers distressed by mounting deficits and fears for their employment, he has to be eternally vigilant and encourage and kick the hard-pressed and despairing.

Let’s review and rate Sir G’s performance - and the case for resilience and fortitude in the face of political and managerial dullards, who may not fully share his zeal.

Funding
The FYFV gave the government advanced notice of NHS funding needs by precipitating discussion of resources before the election and before the Spending Review. This pre-emptive strike ensued that NHS funding was in the public eye and, consequently, in the election manifestos.

Nice one, Sir G!

The £30 billion funding gap for the 2015-20 period in the FYFP was a spectacular figure - and a guesstimate, at best. The division of the £30 billion into £8 billion from public finance and £22 billion from employing Sooty’s magic wand to produce 'productivity gains' was bold.

Did he get the division of the £30 billion right, let alone its level? Perhaps you were too parsimonious with regard to the amount from taxation, Sir G?

With the putative £22 billion of 'efficiency savings', there are some nice problems. The action in 2015 to activate innovate solutions to funding has created dozens of Vanguard schemes and investment in evaluation.

Let’s imagine that half of these schemes are demonstrably efficient, and the remainder are dross which get abandoned.

Several problems remain.

Firstly, to what extent are these schemes generalisable to the wider NHS, and how will change be sold to managers not in Vanguard projects?

Secondly, implementation of these projects - let alone adoption by non-Vanguard managers - will take time. Realistically, these investments are likely to bear fruit too late to contribute great savings. Conclusion: keep trying, Sir G, and hopefully the Gods will shine on you!

Socialist incomes policy was The Nicholson Challenge
What, then, can Sir G do to get his £22 billion? The “Nicholson challenge” to save £20 billion in 2010-15 rested largely on socialist incomes policy i.e. wage freezes for the public sector. This success profoundly distorted the wages of NHS employees. For instance, it led to the rapid growth of agency workers, both doctors and nurses, getting much higher pay outside NHS.

This distortion of the labour markets cost over a billion pounds last year, and continues to create current deficits.

Consequently, the clowns in the Department of Health, headed up by our favourite pantomime dame, Tiddly-Brain Hunt, decided to cap agency spend.

This repletion of socialist controls requires either breach of the cap to ensure safe staffing, or adherence to the cap and the potential slaughter of patients. Over 25 per cent of trusts are already seeking agreement to ignore the agency staffing cap.

If our favourite Dame Hunt had balls, he would tax UK-trained agency nurses and doctors to pay back the public funding of their training. He would also forbid all NHS organisations from allowing agency free-loaders to reduce income tax by setting up companies and paying tax at a lower rate.

Hopefully, Sir, Galahad can be persuaded to mention such vigorous market solutions to the command-and-control Panto Dame?

The financial outcome from the Right Honourable Chancer of the Exchequer was a £2 billion “bung” before the 2015 election to garner some votes, and the pledged £8 billion for the 2016-20 period.

Sadly this £10 billion is unlikely to be enough to fund the rising tide of patients’ with expensive multiple morbidities and the avarice and advocacy of corporate suppliers of allegedly innovative technologies, plying the media with treatments of sometimes limited cost-effectiveness.

A farewell to financial balance
Sir G has another nice problem: that of end-of-year deficits. Providers estimate a £1 billion deficit. Some over-funded CCGs (i.e. unable to spend their budgets; curiously often in deprived areas) may reduce the limited capacity of commissioners to mitigate the immediate doom-laden financial position.

Sadly, Government-induced hysteria about deficits is causing the usual daft proposals for user charges and ‘privatisation’ among ill-informed commentators in national media.

Dear Sir G: it is time to educate the public that households have one wallet, and extracting additional funding from them by methods other than taxation are neither efficient nor equitable. Do get on with this and stop dilly-dallying!

Increasing demand
a) 24/7 staffing
In a determined attempt to worsen the financial position, Dame Hunt is adding to expenditure pressures with the Conservative manifesto pledge of 24/7 staffing and the chaos that is social care

Freemantle et al (BMJ 2015) have shown that hospital mortality rates are higher at the weekend and on public holidays compared to ‘normal’ Wednesdays. One of the co-authors of the Freemantle paper is Professor Bruce Keogh, medical director at NHS England. The authors of this study emphasise that there is a statistical relationship of higher mortality at weekends, but causation is unclear.

The Government’s solution is more staff and related capacity at weekends. Meacock et al (Health Economics 2015) have shown that to increase capacity at weekends would cost over £1 billion, and is demonstrably not cost-effective.

Obviously, such reservations are irrelevant now the right hon. Cameroon and the right hon.Chancer of the Exchequer have nailed their political colours to the mast of 24/7. To fund their largesse, they need to raise expenditure above FYFV levels.
Do they plan to do so? No. They prefer to squeeze budgets and pray.

The former action manifests itself in the junior doctors’ pay dispute. This is proving a marvellously efficient way of disillusioning the medical profession further. It would be funny, if it was not so Donald Trump-like and stupid.

Sir G, please persuade your political colleagues of the need to cuddle the professions, rather than treat them as easy targets for cheap publicity. Current levels of alienation are dangerous for patients and the future of the NHS.

Sir Galahad’s financial success is significant, but modest. Current deficits are likely to absorb much of the growth money allocated by a parsimonious government.  Continued bruising encounters with the representatives of 37 per cent of the voters (25 per cent of the population) are unavoidable and will dent his armour, but keep at it lad!

b) Social care
The Coalition government savaged local authority budgets. They imposed cuts of nearly 25 per cent in funding. However, not content with that, they abolished existing attempts to equalise financial funding across the country. The resultant differential cuts in funding harmed those authorities that were disadvantaged (e.g. Liverpool and Newcastle) more than the affluent shires.

Conservatives and Liberal Democrats clearly dislike the deprived, and act to ensure that their deprivation is increased. Their actions cut the capacity to care for disadvantaged children and elderly in ways that are reminiscent of the Elizabethan Poor Laws.

These cuts leave recovered NHS patients (in the unfortunate phrase) ‘bed-blocking’ hospitals due lack of funding capacity for community care.

In the run-up to the 2015 general election, and in order to garner votes, the Coalition introduced the Better Care Fund (BCF). This top-sliced NHS budgets and gave the funds to local authorities for improved social care. This was nice window dressing, but was inadequate to meet rising demand for social care.

Furthermore, enforced local government parsimony continues to threaten the financial viability of private nursing homes.

With private providers threatened by bankruptcy, the Conservative Government has continued the BCF, and allowed local authorities to raise council taxes by 2 per cent to fund social care.

The latter is discretionary; so those authorities with higher financial bases will get a better tax yield if this option is taken up. In those authorities where council values are lower (such as the frozen North), the Government will be able to screw the poorer authorities even more.

Sir Galahad must be grinding his teeth. He has publically requesting increased social care funding, and dare not comment on the success of recent governments in disadvantaging the poor and needy.

c) Prevention
The Government has cut the budget of Public Health England by £200 million The FYFV emphasises prevention, and Sir Galahad has proposed taxing the sales of sugary beverages in NHS hospitals. The Government mumbles about a sugar tax and alcohol controls, but fails to translate its PR into action.

Why?

Because Nestle, Coke, Mars and other purveyors of lardy products that lead many to diabetes, heart attacks and strokes need their profits to fund their shareholders - and a conservative Conservative Government, which prefers voluntary agreements and a Responsibility Deal that manifestly don’t work.  Nanny-state interference of citizen’s freedom to bankrupt the NHS and die prematurely must be avoided, to protect profits and shareholdings.

Sir Galahad’s FYFP advocated increased investment in prevention. Sadly, he is ignored by corporate merchants of junk foods.

Conclusion
Sir Galahad battles on against the dark forces of austerity, myopia and ignorance. You are doing OK, lad, despite the daftness of your Lords and Masters.  Good luck mate, and keep at it!

President Clinton’s advisors’ approach to managing government and electoral success was to emphasise “it’s the economy, stupid”. As with the USA, so it is with the NHS.

Sir Galahad needs to force through changes in behaviours and providers structure but he also needs more money now.

Time for increased taxation, before the economy declines.