The Maynard Doctrine: Jeremy Hunt’s report card

Health economist Professor Alan Maynard offers an August examination result on Health Secretary Jeremy Hunt’s tenure

Jeremy Hunt has been Secretary Of State For Health since 2012 - over 5 years. In grading his performance, it is essential to examine the policies he has championed and progress he has made.

Before you read this, what grade would you give him?

Hunt’s policies
Times have been difficult for the Secretary Of State For Health, with the nonsense of austerity and the Conservatives desire to shrink the size of the State. Hunt has kept NHS funding growing marginally, but in the face of population growth of half a million and the de-funding of social care budgets, with 30 per cent cuts to local government, the financial situation has been very difficult.

To disguise these difficulties, the Government has showered policymakers and managers with frequent “reforms” and wheezes to baffle the Opposition and create headlines of progress in the quality of patient care.

What issues have employed the skills of Mr Hunt?

Unwarranted variations in clinical practice
For those who can read their history, politicians probably excepted, the literature on unwarranted variations in clinical practice alternates between the issue of the day and something best ignored.

You can read research in the Journal of the Royal Society of Medicine from the 1930s in which excessive tonsillectomy rates in public schools (funded by affluent and deluded parents) produced excess mortality.

Or you can read the American Jack Wennberg who has studied variations since the 1970s and again found unwarranted and excess activity i.e. waste. The evidence is vast and overwhelming.

Remedies for variation
The search for remedies has been numerous and expensive. Evidence of success is less plentiful.

i) Physician incentives and weekend working (7-day services)
The Quality and Outcomes Framework of the Labour government was a system of incentives (bribes) to GPs. It cost around a billion pounds; produced some improvements in the processes of care in the short to medium term; but no evidenced effects on patient outcomes. Now it has been largely abandoned.

The idea of pay for performance (P4P) in health care has produced an industry for politicians’ reforms and academics’ funding for evaluation, but evidence of demonstrable cost-effectiveness is scarce.

Mr Hunt has not been infected by pay for performance largely because he has lacked funding. He has, however, engaged in contract reforms. The most notorious of these was the junior doctor contract conflict. Its purpose was to increase staffing out of hours, particularly weekends.
The debate about weekend cover and seven-day staffing to improve patient care created an intense academic debate and the enthusiastic support of Mr Hunt.

This debate has now gone underground. The policy effects of Hunt’s rhetoric are unclear, despite lots of headlines. Can we truthfully say there is now excellent 24/7 cover across the NHS? If patient outcomes have improved, is this because or in spite of Mr Hunt’s efforts to improve care?

Answers there are few. The policy scandal erupted, and is now extinct amongst the murk of financial deficits and the easing of waiting list targets.

Hunt assessment score: D+ for caution in using physician incentives and the failure to evidence the effects of his 24/7-weekend working hyperbole.

ii) Judicial reports
Mr Hunt has placed a high value on the pursuit of improved quality, and one manifestation of this is the funding of public inquiries. These reports have two important characteristics.

Firstly, they are very costly to produce.

Secondly, their recommendations are often evidence free, un-costed and ignored. For instance: the Mid Staffs hospital report (2013) offered a flood of recommendations (290 in total!). But these lacked prioritisation, and in some cases real evidence of benefit. For instance, do the recommended improvements in nurse staffing ratios improve patient outcomes and by how much at what cost? Is investment in nurse staffing a better use of resources than improved transparency and accountability of nurse processes and outcomes?

Mr Hunt’s blind acceptance of the Francis report ensured much publicity for him, but little evidence-based action

Hunt assessment score: D-, for identifying a problem but using an invalid method of investigating and producing improvements cost-effectively. Hopefully, he will learn that judicial inquiries may be effective at divining issues, but are useless in offering prioritised and demonstrably cost effective policy improvements.

Iii) Institutional reform
In the absence of intelligence and significant additional funding, Mr Hunt has indulged in instructional reform. Since his predecessor Alan Milburn visited a single Spanish hospital and used that to create Foundation Trusts. FTs have flowered and died away. What difference did they make? Costly, but no evidence of benefit?

Then we have large investments in clinical governance such as the revalidation of doctors and the inspection and appraisal of hospitals and GPs’ surgeries. Is there evidence that the hugely costly reforms to the Care Quality Commission following the Francis report are cost-effective?

And what are the effects from other regulatory policies like revalidation?  Are these interventions intended to create patient benefit, or simply a palliative for the bleating of MPs and the Daily Mail? When it comes to such institutional reforms, the maxim seems to be ignore the cost and assert the benefits i.e. don’t confuse me with facts.

Hunt assessment score: F, for failing to challenge unproven policies

Workforce disasters
Mr Osborne’s wage cap, like most policies that interfere with the market, is having disastrous effects. As wage increases have been restricted, agencies have benefited by buying nurses’ and doctors’ services and renting them out at inflated wages. Consequently, the NHS wage cap has led to increased expenditure of £3 billion and the development of tax avoidance schemes of a grossly inequitable nature.

The public sector pay cap together with Brexit and the devaluation of the UK-£ are affecting staffing levels across the NHS. Mr Hunt is now seeking to increase the quantity of doctors by expanding medical schools. The effects of this will take a decade to produce specialist staff, and compensate for largely uncharted emigration.

In an effort to restrict the definition of the NHS that was ring-fenced, Mr Hunt has allowed the abolition of nursing bursaries in his cutting of NHS Education budgets. With large debts from the loans system, nurse recruitment and migration may be affected adversely.

Could the NHS gradually refund nurse student loans as they graduate and stay active in the NHS? Or should policymakers accept that the combined effects of Brexit and the abolition of nurse bursaries will guarantee severe nurse staffing challenges?

Hunt assessment score: D - the workforce effects of austerity are largely outside the remit of the Department of Health. Desperation about NHS funding has acerbated staffing problems. Workforce plans are fragmented and very poor.

Conclusion
Secretaries of State for Health are pawns in the policies of the Governments of which they are members. Mr Hunt appears to be an amiable and well-meaning minister, but his performance seems superficial, fragmented and determined by short-termism. i.e. par for the course for ministers over the last decade

Despite this assessment, he will survive. Like his Cabinet peers and Prime Minister May herself, a sense of unreality pervades the Government. Collectively, they are like Nero, fiddling with themselves while Rome burns.

For Brexit and the NHS, they produce irrelevant policies aimed at media headlines rather than resolution of the country’s many challenges. In the case of the NHS and social care, these policies fail to recognise that staff are reaching the end of their tolerance of making do as their eroded incomes oblige them to go to the food bank.

They, like their patients fear that care is being eroded by neglect that will wreck the NHS. A rudderless and weary Government blunders on, with Mr Hunt enthusiastically endorsing disaster.