The Maynard Doctrine: NHS care - waltzing into an ebb-tide?
Health economist Professor Alan Maynard is far from convinced that things are working out well
The NHS is in crisis due to inadequate funding: a product of ideologically driven policy choices favouring a smaller public sector. The crisis is the familiar product of competing political parties and the famines and feasts in funding, often of biblical durations of seven years.
Government continues to waltz along as if there is no problem in the belief that the Service will cope. Indeed it is remarkable how patient care has survived the current funding famine induced by the Conservative government.
Yet after months of failing A&E, cancer and elective waiting time targets NHS England has recognised the inevitable: patients will have to wait longer as a matter of policy.
So much for rhetorical blathering from Cameron, May and other merchants of ambiguity about the NHS Constitution and related pious statements that the NHS is safe in the Government’s hands. It seems more like the NHS is being strangled silently and insidiously by those same hands.
Each time policymakers switch from plenty to paucity and vice versa, they indulge in energetic re-disorganisations of the structures used to deliver care to patients. Successive governments over decades have fiddled with processes and structures, using large investments in public relations exercises to convince an unquestioning public that all will be well.
Many of these changes have little effect on patients’ perceptions of care, but consume billions of pounds in redundancies and recruitment. Some policy changes show slow signs of sanity emerging from the wheeze-storms of successive governments (such as the measurement of outcomes or success in improving patient care).
There is little evidence of significant effect of these successive ‘reforms’ in terms of increased efficiency and equity, which would justify the opportunity costs of change. Neither should such evidence be expected. Many reforms are merely expensive palliatives to calm the public until after the next election.
Politicians loudly declare the need for evidence-based care, but have usually disappeared into obscurity and highly expert consultancy roles before changes are rolled out let alone impact on long-suffering managers and the public e.g. Andrew Lansley’s elevation to a non-executive directorship at Roche pharmaceuticals was Cameron’s reward for wasting scarce NHS funds.
Continuous re-disorganisation: mere PR exercises?
The 1980s saw the Thatcher administration seeking to control public expenditure and hold NHS budget growth at a modest level. Rather than increase funding, ministers sought to manage the NHS: this took the form of for instance of an annual performance review where ministers interrogated Regional Health Authorities using newly introduced “performance indicators”.
It also involved the creation of general management and managers, following the Griffiths review.
Throughout the 1980s, we saw advocacy of private funding and the slow growth of private health insurance. A government ‘think tank’, the Central Policy Review Staff (1983) proposed the replacement of tax funding of the NHS with private insurance.
Political pressure caused by individual patient crises around the 1987 general election led to the Thatcher reforms and the creation of the purchaser-provider internal market - and subsidies to the elderly to buy private insurance.
These reforms also created hospital trusts and medical audit. These changes were eased in with some additional funding. One of the successes of these reforms was GP fundholding
GP fundholding was abolished in 1997 when the Blair government gained power. Labour ideologues asserted that it had failed. Early in that administration, Blair pledged to bring NHS funding up to the European average. The large increase in funding was accompanied by the emergence of Primary Care Groups (later Trusts), based on GP fundholding now shown to be evidenced; provider “foundation trusts”; national targets to improve specific diseases; and regulatory agencies such as the Modernisation Agency and the Commission for Health Improvement (the precursor of Care Quality Commission)
The Tories in 2010 promised in their manifesto no more top-down reforms of the NHS. As usual with a lazy Cameron, he had not read his introduction, let alone the content of Lansley’s reform proposals published by Conservative Central Office in 2007. Consequently, another bureaucratic upheaval occurred with the utterly wasteful 2012 re-disorganisation. (Clearly an Eton education precludes Prime Ministers from reading boring NHS reform proposals produced by chums.)
In 2014, rather than have another set of reforms. NHS England was empowered to be Maoist and let “a hundred flowers bloom and let a hundred schools contend”. Bottom-up, expensive anarchy is now possible. This reform involves 50 Vanguard organisations (named after the biggest and last battleship in UK naval history which never fired a shot in anger [i.e. a complete waste of money]), and 44 Sustainability and Transition Plans (STPs are better known in the trade as Sticky Toffee Puddings).
Mao’s Cultural Revolution, like the current NHS upheavals, was evidence-free. It led to great distress for the population of China and the marketisation of its economy.
The current bottom-up STP reforms tend to divert attention from ministers providing an opportunity for denial if trouble emerges. These changes raise fundamental questions.
For instance do vertical mergers of primary, secondary and social care produce greater efficiency? And do horizontal mergers of competing hospitals give better value for money? There is some evidence that provider competition produces greater efficiency (i.e. lower costs and or better outcomes). The current STP policies by reducing competition may worsen the performance of the NHS.
Curiously, a public weary from Brexit and weak politicians in government and opposition responds like punch-drunk victims of fake news by ignoring the feasibility of STP and Vanguard reforms - even though their radical nature is likely to upset many apple carts!
Change, when evidence-based, is essential - but unlikely to succeed without further funding, especially to finance capital investment to replace decayed infrastructure and ageing equipment.
Having led the legions of NHS employees into battle with almost weekly un-evidenced policy wheezes, the simpering Mr Hunt has now sanctioned NHS England to sound a retreat.
As Mr Stevens at NHS England mobilises his lions to do the bidding of the Whitehall donkeys, the general public seems comatose and immune to the damage being inflicted on them by seven years of inadequate NHS funding.
How will the decay in public services such as the NHS, education and social care for the young and old be contained and reversed by a bankrupt government more concerned with trivia such as defending Gibraltar and converting “nasty” red EU into UK blue passports, rather than the protection of the social welfare of the population?
Or maybe government won’t bother to reverse the decline of public services?
Is the tide ebbing on the NHS system of universal health care, funded by taxation and free at the point of use?