The Maynard Doctrine: So what now after the election?

Professor Alan Maynard OBE reviews the post-electoral options available to the next secretary of state for health

The votes are in, and the British electorate has proved unable to choose between the devil they know and the uncertainty of the deep blue Tory sea. Possible coalitions look potentially frail.

So what now?

Imagine no recession …
Imagine you are a new Secretary of State for Health in the new Tory-led government. What would you do? Apart from panic and seek sanctuary in a monastery?

A primary imperative is macro-economic expenditure control. So what to do with Payment by Results (PbR)? By depressing PbR tariffs and introducing a parsimonious two-part tariff for emergencies, the risk is that desperate hospitals will increase activity to keep both marginal revenue flows inflating and insolvency at bay.

Tackling acute inflation
The desire of some to make PbR tariffs a maximum with local negotiation looks like a cul-de-sac. Firstly, commissioners are feeble and are going to be decimated. Secondly, the transactions costs of such “trade” are considerable and the effects de-stabilising. Thirdly, tariffs have been cut already and the scope for further pressure when costs are inflating may be limited.

Consequently, the more likely fate of PbR is block grants with continuing emphasis on generating cost data and using the tariffs as guide prices but not a reward system. Such a development could top off inflationary pressures induced by PbR incentives.

A farewell to PbR
So goodbye to PbR, perhaps … but what else may evolve from the electoral uncertainty? The primary driver for change in the supply of healthcare is likely to be uncertainty.

Participants in the “healthcare feast” that is the NHS need to fear the consequences of making mistakes. This fear has to be driven down from the “suits in management” to clinicians.

Creating incentives for innovation and economy in clinical ranks requires three things:
- the exploitation of existing contracts of employment;
- their reform; and
- the creation of systems of transparency and accountability.

Actually listening to clinical audit
Whatever happened to clinical audit? The consultant contract gives clinicians time to audit their practices. But how is this used?

CQUIN and the clinicians themselves are beginning to use professionally agreed benchmarks to identify, discuss and change outlier performance in relation to comparative cost, activity data including adherence to evidence based practice guidelines (e.g. in stroke, heart attacks and hip and knee replacements), and outcomes, especially patient reported outcome measurement (PROMS).

Focusing this work on the medical profession and developing systems which drive it through medical practice will be difficult, as clinicians do not generally fear the consequences of their mistakes. Attempts to increase transparency and clinical accountability to peers, local management and the GMC for revalidation have failed in the past. How can this passivity be changed now?

If the profession fails to introduce peer review and audit - policies reiterated regularly since the time of the Thatcher reforms - the use of untested and potentially highly disruptive financial incentives and extensive privatisation seems unavoidable.

Faith-based policymaking
There is a faith in Conservative and Liberal Democrat ranks (and amongst some Labour politicians) that privatisation will unleash innovation and increased economy in healthcare delivery.

Sadly this is not always evident in what the private sector does. Indeed private enterprise in healthcare often exhibits many of the inefficient attributes of the NHS!

How can private organisations be induced to drive change to catalyse economy in the NHS and amongst their private rivals?

’Private provider monopolies can disregard customer needs just as effectively as public provider monopolies‘

Travelling to London on the East Coast railway as I do, the effects of privatisation are not encouraging. The private GNER gave way to private National Express. Both withdrew due to financial problems, leaving the line in public management where prices remain high and quality is declining at the margin - in terms of hotel care in particular.

Private provider monopolies can disregard customer needs just as effectively as public provider monopolies.

So what now? With NHS spending consuming nearly twenty per cent of total public expenditure, the NHS is not safe in any politicians’ hands.

Daft solution to ill-defined problems will certainly cloud its future. Will a minority government move cautiously and use evidence, or will it throw policies and practices into the air in the ubiquitous hope that, by clumsy trial and error, it will find something which increases efficiency, protect the interests of patients and give them a dividend at the next election - which may happen quite soon?

The old Chinese curse intimates: “may you live in interesting times”. These ahead promise to be fascinating - though potentially not in a good way.