3 min read

The Maynard Doctrine: Snot rite!

Professor Alan Maynard explores choice, the ‘listening pause’
comedy governeance and competition through the prism of a new conceptual framework.

The journalist Lucy Mangan, apparent creator of the “Tory boy” phrase in her long-running column in The Guardian’s Saturday colour supplement, was writing recently about the “snot right” problem in higher education policy and the NHS.

Taking this useful concept, let’s analyse the current “content” of the “listening exercise” on NHS reform.

The want of choice
Firstly, does the public want choice? Ben Goldacre has noted that government data about choice is allegedly from the British Social Attitudes survey but when you inspect the data to evidence the government’s assertion that 95 per cent of NHS patients want more choice support for their contention is noticeable by its absence.

It seems, therefore, that this choice assertion is nowt more than a Whitehall fraud i.e. “snot rite”!

What we patients want, surely, is not blind choice of alternative providers of largely unknown quality; but an assurance that our local providers are in good fettle and are observably proficient in the dark arts, and occasional science of medicine.

This requires comparative performance data and rigorous regulation to ensure the average quality of patient care is continually improved and the few poor performers in the tail of subspecialty disciplines are moved to Whitehall to serve tea and crumpets to ignorant politicians and the wise Dark Lord, Comrade Sir David Nicholson.


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Dear old Cleggie and his mates are demanding “reform of the reforms” during the listening exercise. All these demands are pretty basic, easy to fudge and thus will ensure the Coalition’s welfare and Old Nick’s safe Tory seat at the next election.

Comedy governance
Firstly he wants “democratisation” of the governance of GP consortia. The usual suspects would become part of these new, (in effect) old-style Health Boards i.e. a nurse, a local councillor or two and perhaps also a passing tramp would become members of the board!

How well I remember the workings of such organisations in the 1990s - e.g. we used to place bets on which councillor would go to sleep first, which would snore first and how the chair would deal with the consequent noise!

And now, another generation may experience this bliss. Enjoy!

However, this window dressing demand for better governance is “snot rite”. Summat much more sophisticated is needed - i.e. careful use of evidence by folk who understand how to use data.

Cleggie also wants a slower implementation of the reforms. It does take time to paint the new signs replacing “Bloggshire Failed PCT” with “Bloggshire Wonder GP Consortia”, and for selected staff to succeed in this new and expensive bout of musical chairs.

But come on, Cleggie! The additional time needed for this re-disorganisation is not that great. Some delay is now to be expected, though, to demonstrate the efficiency of Cleggie’s intervention!

‘Competition based on quality, not on price’ ,shout the opponents of the reforms and dear old Cleggie. Comrade Lansley and his cronies give a different message about competition, each time they are asked. This is indicative of not knowing what they are talking about. Nothing unusual there.

Why use competition (take 4,317)

’The blunt fact is that if the NHS is to prosper in a period of gross austerity, prices will have to be manipulated and quantities of service provided rationed.‘

Competition is a means to an end, in healthcare as elsewhere. The social goal is either lower prices and assured quality or improved quality at the same cost. Quality measurement as ever remains limited - and if competition is privatised, contracts will be “commercial in confidence” i.e. lack transparency to demonstrate either cost or quality (like current PFI contracts).

A form of price competition is already in use i.e. aggressive manipulation of PbR tariffs. There is increasing recognition that this policy will be used aggressively to achieve the £20 billion NHS “savings”, and also that it has the same likely consequences as price completion i.e. it creates concerns about care quality and the destruction of established NHS hospital providers.

The blunt fact is that if the NHS is to prosper in a period of gross austerity, prices will have to be manipulated and quantities of service provided rationed. If Cleggie denies this, then he has to show how efficiency is to be improved by alternative means. Such as Sooty’s magic wand.

From decades of experience, we know that exhortation has negligible effects on the lumpen proletariat of NHS worker bees!

The bore-in around this fastuous ‘listening exercise’ is likely to create much froth bit little substantive change. The large group assembled by Cameron to discuss the legislation contains well-intentioned and carefully-selected people. They now have to prove they have the wisdom and expertise in terms of their ability to use evidence to guide policy efficiently.

The worry must be that like dear old Cleggie’s waffle, we will conclude from their machinations that their conclusions have the usual characteristics of hot air.

This process is clearly snot rite! But it will facilitate the Coalition ploughing on and completing the legislative process by the year’s end, which was always their intention.