The Maynard Doctrine: Memo for Simon ‘Sir Galahad’ Stevens: a message from Merlin

Dear Sir Galahad,

Your noble intentions in pursuing the Holy Grail of increased productivity in the NHS have been noted. As you know, I am a ‘shape shifter’ (i.e. I can appear in a variety of forms). This has enabled me to attend covertly various meetings in Whitehall village and Quarry House, Leeds and listen to the often chaotic burblings and confused intentions of those in charge of NHS policymaking.

The cacophony (as you can imagine) has been considerable because the imminence of the election and the Stalinist efforts of the Coalition to curtail expressions of panic.

Here, my intention is to set out some of the jolly undercurrents swirling around Whitehall village as you try to steer the NHS to safer ground and the politicians clutch at straws as NHS performance and public concerns grow more critical.

Haunted by the ghost of Andrew Lansley
The Lansley legislation, like Marley’s ghost, is haunting the Coalition. It is a fine badge of gross incompetence. For instance: it gave the task of setting hospital tariffs to Monitor, with consultation with NHS England.

Tariffs have become a Whitehall weapon of choice, powered by technocrats intent on fine-tuning a blunderbuss! Whilst some day care tariffs have speeded up change, the combination of the 2009 emergency tariff policy and the continued cutting of all tariffs are ensuring more trusts go bust. The tariff regime of “one size fits all” lacks credence. Squeezing hospitals until their pips squeak is surely a short-term tactic?

Continued parsimony creates emaciation with explicit and disguised erosion of quality and financial balance. Is it not time for radical review of hospital funding?

Why are we waiting?
Another creaking piece of Whitehall weaponry is waiting times. As part of the Blair bonanza of increased NHS funding, waiting time targets directed attention to the necessity to increase capacity for elective procedures.  Consequently NHS hospitals and Independent Sector Treatment Centres invested and thrived, capacity was increased and targets were met.

Austerity policies, particularly wage freezes, inadequate equipment and other investment, and an absence of workforce policies is now increasing waiting time pressures. This is a consequence of Coalition policies and non-policies i.e. naïve neglect. You can rev the engine and accelerate activity within limits, but eventually, without oil and maintenance, the system disintegrates.

These limits are now quite evident as all NHS operatives strive to maintain the performance of an over-stressed and under-equipped service.

Currently, the politicians are playing blame games for A&E 4 hour target breaches.
Patients waiting in A&E are happy to wait if there is a sudden emergency, such as a local train crash or road accident which produces casualties. Currently, they may have to wait because of lack of consultants, inefficient staffing mixes and increased demand.

Process measures? Why not outcomes?
But remember: this target is a process measure. The ultimate issue is outcomes i.e. if targets are missed, what effect does this have on mortality and reductions in the quality of life of patients? Most A&E departments triage in less than ten minutes. If minors wait for six hours, is population health much worse?

Judicious discussion of process targets such as waiting times seems to be absent from the brain cells of Whitehall village folk, in part due to media hysteria. Such targets for cancer diagnoses are clearly sensible.

But are all the rest so wise? If minors had to wait over 4 hours, the time costs might persuade them to go to a GP or pharmacist instead. Would this be efficient, especially given the NHS’s incapacity to recruit A&E consultants and increasingly GPs too?

Meeting waiting time targets are increasingly difficult because of the neglect of workforce issues. During one of the Department of Health “efficiency” drives, workforce planning was out-sourced to the private sector. An organisation called the Centre for Workforce Intelligence (C4WI) was publicly-funded to analyse workforce needs and supply. Sadly it seems that C4WI has failed. Indeed, some cynics have dubbed it the Centre for Workforce Ignorance.

Working in a consequently evidence-free workforce environment, political plonkers in all parties say that more doctors and nurses can be produced in the way rabbits are pulled out of hats. The reality is that doctors take 10-15 years to train up, and nurses need 5-6 years before the “benefits” of University education are complemented and/or corrected with experience at the rock face of healthcare practice.

Currently, young graduates are reluctant to enter general practice because of nagging politicians creating higher workload, increased bureaucracy and reductions in generous pay levels created by the Quality and Outcomes Framework. Young things choosing hospital medicine see the frantic nature of departments such as A&E, and steer clear. However, other specialties are also facing major recruitment challenges.

Why? Where are all these young things going? Surely not all of them are flocking to sunny Oz to be overpaid and underworked in the sunshine? A decade ago, medical school intake was increased. What has happened to all the resultant increases in the stock and flow of doctors?

If there were efficient workforce planning, such questions could be answered with ease. Sadly this and the preceding government chose not to be confused by facts, let alone policies to mitigate workforce shortages which undermine waiting time targets and the quality of patient care!  But maybe there is cause for optimism as NHS England cranks up, establishing a National Workforce Commission in December. Better late than never, dear things?

What can be done about workforce problems?  Undermine the consultant policy of similar pay for all, and pay more in unpopular specialties such as A&E? Create a two-tier consultant grade? Fund such changes with the abolition of consultant distinction awards? Complement this with a ”slavery” clause in all doctor and nursing contracts, obliging recipients of our generous subsidisation of their education to work for 3-5 years in the NHS on completion of training?

While Whitehall fiddles, thank goodness for the immigrants who keep the NHS going! They are estimated to make up 35% of the NHS workforce.

Poor you, Sir Galahad! You must feel that running the NHS is like wading through a swamp infested by brain-dead, person-eating alligators! The issues mentioned here have long pervaded Whitehall discourse but action is constrained by what the Daily Mail can cope with and the whims and fancies of Sir Cameroon d’Austerity and his merry band of scallywags!

Keep fighting! Don’t let the bastards get you down!

Best wishes for 2015.

Your old mate Merlin