The Maynard Doctrine: On Nero, and fiddling whilst the NHS burns

Health economist Professor Alan Maynard explores how workforce issues, funding and social care gaps amount to an NHS conflagration

On Nero and fiddling whilst the NHS burns
The Department of Health and NHS England continue to produce a plethora of what the charitable might call innovations. As the Comprehensive Spending Review progresses, ’bold’ notions, such as allocating more NHS funding to social care, echo through the corridors of Richmond House.

As ever, life in the real NHS emulates the old Chinese curse: “may you live in interesting times”!

On Nero
The Emperor Nero was alleged to have been a wicked tyrant. It is reported that he set fire to oiled Christians to produce light. Amongst other misdeeds, including the execution of his mother, he set fire to part of Rome in order to clear it for a palace, fiddling whilst Rome burnt.

Latter-day tyrants are less barbaric, yet the consequences of their actions can be similarly disastrous. The current Government’s attacks on the public sector look to many to be a policy of slash-and-burn, with little care for the consequences for vulnerable sections of society.

In particular, the erosion of the NHS threatens millions of patients in need of care. The impression given by latter-day Nero, Jeremy Hunt, is one of public relations policy twiddles translated into short-term nonsensical media headlines, whilst NHS services are eroded.

Let us chronicle some of these alleged advances in NHS misunderstanding and misguided policymaking.

NHS workforce
Healthcare services are labour-intensive with doctors, nurses and related professions essential for the production of care. In days of yore, the Department of Health had workforce policies which quantified stocks and flows of health care professionals, and sought to nudge supply and demand of these complex labour markets into approximate balance.

These efforts seem to have largely been abandoned. The workforce section of the Department was hived off, as an economy which reduced public sector expenditure, into the privatised Centre for Workforce Intelligence.

Sadly, this organisation does not appear to provide systematic and regular estimates of shortages and surpluses of workforce, let alone produce timely policies to remedy deficient provision.

The Government has pledged to provide more doctors and nurses over the next five years. It proposes the provision of seven-day services in hospitals and primary care. These policies have massive implications for workforce levels, far in excess of the pledged (but unfunded) increases so far set out by the Government.

At the same time, there is reporting of GPs retiring early due to patient demand increasing excessively, and emerging F2 physician trainees migrating in significant numbers to sunny and more affluent climes in Australia and North America.

Thus Mr Hunt and the Government demand a plenitude of more doctors and nurses - just as the numbers of these folk willing to work here declines.

Where is the magic porridge pot?
It is time to increase urgently medical and nursing school numbers, and also to invest in complementary professionals such as physician assistants - and of course, to evaluate this policy experiment properly.

Yet with current levels of public spending austerity, there is little new money in the kitty to fund such essential investments. Modest pledged increases in expenditure - £8 billion in the period 2015-2020 - are unlikely to meet increased need produced by an ageing population and technological changes.

Can the Department of Health solve this problem by workforce contract changes? The sometimes generous terms and conditions of doctors contracts, and those of other personnel are clearly a focus for policy attention.

But NHS pension reform, radical surgery applied to Agenda For Change and new consultant and GP contracts - all involving more for less - hardly seem a good selling point, even for propagandists such as Messrs Cameron and Hunt. Such reforms would be difficult to enforce without industrial disputes, and might take years to implement, with resistance from powerful groups such as doctors assured.

What to do?

Pray immigration can be increased? Pray that that immigration can maintain the quality of staff inflows? Pray that arbitrary workforce contract reform and current incomes policies which have held nominal pay practically constant for five years, does not further increase emigration?

It is clearly time for Mr Hunt to get onto his knees, not just to offer up yet more hot air policies. Hot air is wonderful if ballooning, but it is no substitute for significant investment in the NHS workforce. Without such investment, notions of seven-day access to care appear to be pipe dreams.

Social care fiddles
Nero would perhaps be particularly proud of the social care policies pursued by the current crop of shifty policymakers.

An inevitable consequence of Coalition and current austerity policies has been a thirty per cent decrease in local government funding. Social care expenditure has consequently been slashed, with patients in moderate need losing all support and those in severe need only getting care in extremis.

Enter a superb wheeze! Hack the NHS budget and transfer funding to social care, depicting this as a revolution in social care provision. Hence the Better Care Fund and the evidence-free belief that this policy is cost-effective.

To add insult to injury, the Conservative manifesto and the lackeys in the Treasury are now contemplating further slicing of the NHS budget to ensure that ’bed-blocking’ will be mitigated this winter.

With the moronic media and fraudulent PR from Government, these ’robbing Peter, to pay Paul’ policies can be portrayed as a short-term success, at the cost of further undermining the NHS. There can be no alternative to enhanced social care spending, as even the Conservative Local Government Association assures us.

What to do?
The Conservative pantomime-mummers offer assurances that the NHS is still “safe with us”. The Labour opposition offers superficial and unconvincing waffle. Few governing Whitehall village are prepared to acknowledge the potential disaster that is the NHS.

Patient demand is increasing, due to the ageing of the population. The pharmaceutical industry has pipeline products that appear to be radical and efficacious, but extraordinarily expensive.

It is time to increase tax funding of the NHS, before it is inundated by screams for co-payments and further deprivation of Cinderella services such as mental health and care of the elderly.

Or should we just fiddle whilst the NHS burns?