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The Maynard Doctrine: On Canute, mushroom management and digging holes

Health economist Professor Alan Maynard on tide-turning, mustroom management and hole-hollowing

The post-election logic of the Government NHS policy is as elusive as a piece of soap in the bath. But then, perhaps we are expecting too much of the Government’s attempts to keep the NHS show on the road.
Let’s review three areas of their post-election NHS “innovatory” activity.

The King Canute Problem of wishful thinking  is no substitute for evidence based policy

You will recall that King Canute apparently tried unsuccessfully to stop the tide coming in by telling it not to, and got his feet wet.

The employment of agency staff costs the NHS over £1 billion last year. Paying premium rates for staff who are here today and gone tomorrow is expensive and may affect the quality of patient care.  The government’s ‘solution’ has been to demand the NHS cut such expenditure to £400 million. How?

Setting ridiculous targets for poor brow-beaten NHS managers is part of the established repertoire of those lost in the Whitehall Village fog. The local managers will, as usual, rush about seeking to deliver the un-deliverable. They may sack some physiotherapists and occupational health workers and some essential secretaries to free up nurse funding, but cutting agency spend by £600 million plus is impossible

The agency cost policy demonstrates nicely that Mr Hunt is King Canute: demanding the impossible of harried minions rushing from pillar to post to achieve the latest madness emerging from Richmond House. Management time could be better spent on more productive activity.

Hunting a strategy
What should Hunt do? Firstly, he should require all agency staff trained at public expense to pay back the costs of their training. The funding of nurse education is inefficient and inequitable. Why should nurses get bursaries and fees paid, when most other NHS staff have to pay fees? The taxpayer is funding the acquisition of general skills marketable at home and abroad, in the NHS and with private employees. Time for change.

Secondly, NHS employers should be enabled to demand that agency workers’ pay income tax. Allowing agency staff to pay remuneration into companies to reduce tax liability is a legal but unacceptable use of money funded by taxpayers.

Hopefully, Canute-Hunt can implement these policies, rather than merely set more impossible targets and hope that the tide won’t come in.

The art of mushroom management
The mushroom management approach involves keeping staff in the dark and feeding them bullshit. In the NHS, this is complemented by what Pope Francis in a recent edition of the Harvard Business Review called “organisational Alzheimer’s”: the failure to recall past experiences and use them to inform future actions, which afflicts most NHS organisations. It produces repetitive and duplicating efforts, such as innovations to improve A&E flows and mitigate bed-blocking problems

Mushroom management manifests itself in the NHS in cumulative layers of manure. Edicts about safety and quality pour out from Whitehall. Lawyers such as Francis produce un-costed, un-evidenced and unethical reports, and demand further dollops of regulation. The result is a high-cost dungheap of competing quality indicators.

These are used by CCGs and hospitals to measure their performance. When local NHS dashboard items turn red, blind panic ensues, with narrowly-focused responses rather than system-wide appreciation of the nature of the problems. Management myopia is ensured by Whitehall policy, which focuses on the un-evidenced quick fix and further layers of mire.

Sadly, most of these measures are of uncertain validity (e.g. mortality rates, BMJ July 2015). It is rumoured that the English NHS has 300 quality indicators absorbing the attention of managers. It is time for change.

The current Government demands the reduction of regulation in the private sector. It continually bleats that red tape inhibits entrepreneurism and attempts to improve in industrial productivity. When it comes to the public sector, the red tape argument turns into a regulatory jungle, cumulatively added to by ‘events’ and with no attempt to avoid duplication and produce an evidence base

NHS managers, ever-anxious to do Whitehall biding (however daft), use their time creating and scrutinising dashboards, when they should be using quantitative analysis to understand and improve the performance of their organisations.

Would the Department of Health be kind enough to list all quality and safety indicators and offer evidence of their efficiency? When the next inevitable NHS “crisis” emerges, could Hunt and his fellow politicians zip their tendency to increase the indicator stock? Doing something to quieten the Daily Mail’s hysteria involves resource use which otherwise could be deployed to improve patient care.

When you are in a hole, stop digging
Chancellor George Osborne is determined to shrink the size of the state and, through austerity, balance the budget. For some, this is illogical and especially cruel to the disadvantaged. The NHS, after near-flat real-terms funding since 2010, has shown remarkable resilience and good management by controlling the inevitable and widening gap between parsimonious funding and increasing patient demand.

In the current year, the budget has been increased by £2billion, and up to 2020 £8 billion in extra tax funding is promised.

It is guestimated that another £22 billion is needed over the next five years. This is to be magic-ed by mythical increases in NHS productivity: Sir Galahad Stevens continues to pursue this Holy Grail, bless him!

Despite the usual accounting chicanery of depleting capital investment and conjuring up reserves and underspends, all seem agreed that if the NHS does not end 2015-16 in deficit, it will be a miracle or the product of political jiggery-pokery.

As ever, the on-going parsimony has considerable risks. Financial pressure inevitably diverts the attention of local management to money. Board meetings focus on the plausibility of monthly financial plans, with the risk that quality erosion takes a back seat and may be enhanced by misguided financial pruning. The NHS managers’ lot is not a happy one!

The service’s financial fragility is compounded by Hunt announcing additional un-costed initiatives which add to the parlous state of things. The Government seems intent in rousing the ire of the medical profession. The 24/7 policy, uncosted and unevaluated by Government, is proposed for primary care and hospital provision.

These policies are being pursued in a highly distorted labour market; the product of government incomes policy and wage restraint since 2010. Retirement has increased; recruitment is a problem; and agency costs continue to increase.

The Government has meagre funds to pursue 24/7. Consequently it has decided to face down the medical profession and seek to impose a new contract, without filling mouths with gold as is traditional. Whilst it is amusing to see Government confronting the most powerful trade union in the land, the British Medical Association, it is also frustrating. Blaming the slow development of 24/7 on the doctors is not good industrial relations, and may be a vote loser.

All this assumes of course that hospital 24/7 is efficient and fully costed. It is not as Meacock et al in Health Economics have illustratedM.  24/7 has a high opportunity cost, deriving many patients of care from which they could benefit.
Please, Mr Hunt: when you are in a financial hole, don’t add to the NHS’s misery with poorly-evidenced new policies.

All governments have a tendency to be Canute-like, announcing policies that are blatant nonsense. All governments attack red tape in industry, while blindly increasing it in the public sector. All governments dig holes, and do not learn to stop when they should.

As ever, the NHS has to grin and bear the often outrageous nature of politics and the desire of Ministers to manage the storms (real and imaginary) created by a distorted media and the desires of extreme ideological factions in Whitehall Village.