The Maynard Doctrine: NHS England And The Holy Grail (of NHS productivity gains)

Health economist Professor Alan Maynard gives a masterclass in the taxonomy of knights and productivity ruses

Sir Galahad (also known as Simon Stevens) is continuing his search for a means to bridge the £30 billion funding gap in NHS finances in period 2015-20.

In doing this, he has a 'clutter and chaos' of sad knights at his side. How are Sir Cameroon d’Austerity, Sir Nick de Loans, Sir Milibandde Van Blanc and Sir Nigel de Beer shaping up?

Sir Cameroon is reputed to have a short attention span, and prefer briefings on one side of A4, rather than having to wrestle with tedious tomes of advice. He tends to give Squire Osborne de Moneybags control over economic policy. This empathises the destruction of the nanny state, and its replacement by small government.

Remarkably, the savage funding cuts this has imposed has had little effect on the peasantry. It is the fulfilment of policies from the 1980s when Lady Margaret, the black/white witch from Grantham, was casting her spells.

Like Lady Margaret, Sir Cameroon recognises that systematic undermining of the NHS could lead to the peasantry revolting.  Lady Margaret preferred private insurance as a means of funding healthcare. Furthermore she introduced tax subsidies for the elderly to increase the affluence of well-to-do folk able to afford expensive risk-rated health insurance premiums. Despite her wishes, she ended up structurally re-disorganising the NHS and pumping more money into it.

A rabid mob of his squires make Sir Cameroon’s life a misery. They not only want to break up well-established and fruitful alliances with foreign johnnies, these squires also prefer the destruction of the NHS and its replacement by private and profitable institutions seen in colonies such as the USA.

Sir Cameroon’s solution is to maintain support for the NHS but hold its funding at 2010 levels. Pestilence and decrepitude are increasing the demand for care. To meet this inflation in demand, the Holy Grail of productivity must increase.

One lackey, Comrade Nicholson (hero of the Soviet Union First Class) tried to save and re-cycle £20 billion in the period since 2010. In addition to wage freezes for peasants, a system of smoke and mirrors is alleged to have saved cash. However, whether there were actual productivity gains is not debateable.

Sir Galahad estimates that productivity gains in the next five years can achieve £22 billion, and Sir Cameroon, if he survives, consequentially had to pledge an additional £8 billion to” save” the NHS.

Squire Osborne in his Autumn Proclamation is proudly offering £2bn annually post-election. Whilst this may warm Sir Galahad’s heart, it covers up the productivity issue in a fog of uncertainty.

Sir Cameroon’s Minstrels will complement this bung with diverting songs of joy.  'Heavyset' Minstrel Hardy from the Department for the Abolition of Local Government has slashed social care funding, creating distress amongst the frail elderly and further neglect of children in need of care and protection.

His fellow-comedian, thin Minstrel Laurel from the Department of Ill Health complements the antics of his partner with jokes such as the Better Care Fund and evidence-free policy wheezes designed to divert and amuse the ignorant.

Sir Cameroon’s Squires behave as if a policy or a funding bung a day will help the NHS work, rest and play in electoral peace.

My old man said 'respect the white van/And don't dilly-dally on the way'
But how are Sir Galahad’s other “supportive” knights shaping up?  Sir Milibean de Van Blanc has acolytes traditionally wedded to the NHS. Squire de Balls has recently suggested plundering bankers’ fines to fund a NHS bung. Labour are promising to out-bid their rivals by promising £2.5 bn a year of increased in NHS funding in 2015-20.

Squire de Burnup is promising stupendous 're-re-disorganisation' of the NHS, and reversing Sir Cameroon’s foolish changes. The focus on this, and the funding antics, demonstrates the superficiality of understanding about achieving the Holy Grail of increased productivity.

Time to polish your armour and do better, lads!

Liberal schmiberal
Then there is Sir Nicholas de Loans. He is a plausible fellow, but following support for foolish reforms of Higher Education he is in trouble. Recently he and his mates lost their trousers in a conflict with UKIP near Rochester castle.

His squire, Lamb de Slaughter, is a caring fellow - but despite demonstrating his concern for the poor and disabled, he has been unable to deliver significant change. The mentally ill and folk with learning difficulties have traditionally been neglected. They (like the young) often do not vote, after all.

UKIP if U want to
The final bold knight is Sir Nigel de Booze. He is a slippery fellow.

Having announced his preference for private insurance funding of the NHS, he retreated and said that the proposal was for mere discussion. He then plumped for tax finance, in the vaguest of terms.

This havering is indicative of Sir Nigel’s lack of understanding of how to pursue the Holy Grail of increased NHS productivity.  Clearly, this fellow would (if in a position so to do) make a difficult ally for Sir Galahad.

Try a little patience
So what can Sir Galahad do with this “shower” of dubious allies? Clearly the virtue of patience will have to dominate in the period up to the May 2015 Tournament between his supposed allies. He will have to emphasise the female side of his personality: as the apocryphal poet has it, “patience is a virtue, possess if you can, It is often found in women but rarely in a man”.

In addition to patience, 're-treading' NHS England is under way: this has to be executed with aplomb!. Or perhaps two plombs, to gove us some growth.

Policies such as the Outcomes Framework need careful attention. Currently it is a misnomer, as it focuses on activities which may or may not affect patient outcomes. Can the links, if any, between, improved activity and patient outcomes be quantified?

Reducing “unnecessary” A&E attendances may curtail immediate utilisation - but with GPs often elusive, patients’ health may decline and create increased costs?

Output management with asserted rather than evidenced outcome links is naughty! Activity targets, such as those in the Outcomes Framework, have opportunity costs, as well as hopefully significant benefits.

Neglecting GPs
NHS England’s local offices have neglected GPs.

In part, this is because of the Department of Health/NHS Employers selling out to those masters of restrictive practices, the British Medical Association. (I would have loved to have been a member of a trade union as effective for its members as the BMA!)

The BMA has, through the GMS contract, cosseted GPs and stymied the reform of primary care. GPs can work part-time and make a nice income. Their performance, in terms of unwarranted clinical practice variations, is as mysterious to managers as the secrets of the Universe.

CCGs are now to co-commission primary care. They cannot do much worse than NHS England, can they?

A cute sector
Then there is the hospital sector! A working hypothesis, to be denied by evidence, is that these vital institutions have robust islands of very good practice, strangled by seaweed tentacles that hold back improvement and maintain the status quo of poor practice.

Atul Gawande’s books and Reith lectures overview well-recognised problems awaiting amelioration by good professional practice by all concerned.

The costs of CQC and Monitor are considerable; and may palliate the concerns of the good Knights mentioned above; but are no substitutes for professionals healing themselves.

Minstrel Laurel has got the transparency issue into his melodies, but this alone is inadequate. Financial or non-financial incentives are also needed.

For instance if the Royal Colleges are to maintain their charitable status and their grand wine cellars, they (and the General Medical Council) should earn their keep and translate essential performance transparency in radically altered behaviours. Patients should also demand comparative performance data. Without it, patient consent is a fraud!​

So can the NHS thrive, despite the Knights of the Royal Order of Scallywags who control purse strings?

The problem at present is the focus of the competing nincompoop knights on funding. Like Don Quixote, they are spending time charging a financial windmill that the public can understand i.e. “It’s OK folks! A little more dosh will sort the NHS!”

This ensures the peasants miss the fact that Sir Galahad needs another £22bn, and we know not how to achieve it through productivity gains.

Good luck Sir Galahad - and do help NHS peasants to wear down inertia and restrictive practices.

You must surely also enable the citizenry to see that the current storm of competing financial promises is mere short-term electoral engineering that obscures the possibility of NHS degradation in the near future.