The Maynard Doctrine: pre-electoral questions about NHS spending

Professor Alan Maynard OBE casts a critical eye over the information divulged by the Health Select Committee. Medical unemployment; nurse substitution for GPs; and the delivery of real efficiency increases; and management consultancy spend  all come under acerbic review.

Recently, the Select Committee on Health of the House of Commons published its annual report on Public Expenditure. This sets out DH responses to Select Committee written questions, and is a goldmine of extraordinary information.

It can be accessed via the House of Commons webpage (HC 269-I, January 2010).

Mixing metaphors, with pearls from a goldmine!
Let me extract some pearls from this seam of wondrous information!

1) What are we to do with the increased number of doctors coming out of medical school?

The annual output of medical schools is currently at 6,000 per year, and looks likely to remain at this level for the next three years. Each year, less than 3,000 doctors retire (tables 71a and 71 b)

Consequently, the NHS has to employ a net increase of 3,000 per year. As these cohorts ascend into maturity and expected affluence, the GPs amongst them will hope to at least earn the average current pay of £108,000. And the consultants amongst them will hope to earn an average current wage of £120,000.

Thus if this 3,000 don’t brain drain overseas, or don’t work part time due to family demands and leisure-induced high income, who will be sacked to keep them in the style to which they are used?

Or as in other markets, if there is excess supply will the price which equals wages -  fall? Count on the BMA “loving” the ideas of doctor unemployment and /or reduced wages! They will mobilise all those nice middle-class mums and dads to ensure that their Verity and Sam is employed at a good wage!

Unlike other trades, both middle-class parents and the BMA generally assume that doctors cannot be unemployed!

Tell that to city employees, workers in manufacturing and the poorly paid in public services!

2) Nursing problems

In nursing, the situation is reversed: the number of graduates is 3,000 less than the number of retirees. Should we retrain our excess supply of doctors to be nurses, and pay them nursing wages?

Of course, the real issue is that in times of financial difficulty, we should be substituting nurses for doctors. Sadly the gnomes of Whitehall have increased the supply of the wrong sort of labour.

Nurses - 30,000 of whom have full prescribing rights - should be substituted for GPs with GP list sizes doubled and the number of GPs employed halved. Nurses can do anaesthetics, endoscopy and routine surgery. Why employ expensive doctors when nurses can do the tasks at lower cost and equally well?

The usual doctor response to such queries is ‘who would you, a patient, prefer?’ To which we should answer that practitioner who has the best outcomes and is most friendly.

Is that the doctor or the nurse? A patient like nurses more, says the evidence!

3) Pensions
The NHS has to be made more efficient. To do this, we must increase patient flow and employ less labour. Pension awards for GPs cost £1.5 billion in 2009 (table 74b).

The report does not include consultant pension costs as far as I can detect. This is naughty dissembling!

4) Arm’s length bodies
If elected, the Tories have pledged a cull of arm’s length bodies and quangos. Table 125 has some nice data.

What do you make of the NHS Litigation Authority costing £1.825 billion?

NHS Professionals costs £298 million, and should surely be privatised?

The NHS Business Services Authority costs the taxpayer £688 million and I bet you are unsure what it does for the NHS - let alone the taxpayer (just look at their website to see what £688 million buys!).

The National Blood and Transplant Service cost £528 million.

The Health Protection Agency costs £290 million.

The Healthcare Commission cost £77 million (its successor, the4 Care Quality Commission, is making NHS organisations pay to be licensed and generate the income to employ their 2,000-odd staff).

The Council for Social Care inspection cost £183 million

And the NHS III (institute fr Innovation and Improvement) costs £90 million.

In all, arm’s length bodies cost £4.372 million in 2009.

Surely whoever wins the election, there will be blood, sweat and tears in these organisations?

5) Consultancy spend
Table 117 is entertaining reading!. The Department of Health spent £125 million on consultancy services in 2009.

To put that in context, about 30,000 hips could have been replaced if that sum had been spent on patient care.

Ernst and Young topped the table with £12 million (3,000 hips), with McKinsey’s getting a mere £9 million (2,250 hips) poor dears!

Table 122 sets out the NHS spend on management consultancy, broken down by primary care and hospital trust, which totals a further £129 million. Kings College FT tops the league with a spend of £29.3 million. Guys and Thomas spent a mere £12.2 million. Newcastle FT spent £6.5 million on consultants

The nice issue for both DH and the NHS is why do they need to hire consultants?

Is it a reflection of the inadequacy of their management capacity? Is it (in the case of the DH) a response to daft “efficiency savings” which restrict their capacity to do their job? Remember item 4 above, and think how many of the DH tasks have been outsourced!

Another issue arising from DH and NHS spend of £250 million on consultancy is this: how good is it? Where are the audits of consultancy quality? Where is the transparency and accountability in these processes that cost 30,000 hips being lost from both DH and NHS spend on these services?

Surely it is time for the National Audit Office and/or the Audit Commission to focus on this issue?

Conclusion
These are just the tips of the iceberg of the questions arising from this extraordinary document. MPs on the Select Committee questioned Sir David Nicholson, David Florey and colleagues and the transcript is on their website.

However this questioning could be improved. The wriggling of discomforted civil servants could be enhanced. The Public Expenditure document could be better designed and indexed.

And the public should be more demanding in ensuring accountability for the £105 billion they give up to fund the NHS.

More anon!