The Maynard Doctrine: The faithful following the foolish - blundering on into parsimony
Professor Alan Maynard OBE dissects the NHS and politicians’ approach to financially straitened times ahead.
The NHS is about to have a severe financial crisis due to bankers undermining the economy. The costs of our banking bail-out continue to escalate. The UK economy remains reluctant to return to 2007-08 levels of national income and growth.
But has the NHS really got this message yet?
For primary care and secondary care, the message is simple: ‘flat cash’ for three to five years - and continuing growth in patient demand. The NHS budget has to be re-engineered to provide more and better care.
Hence QIPP. QIPP means that clinical and non-clinical management has to improve the quality of care (Q); innovate continually (I); and focus on productivity (P) and prevention (P).
Where to start with that vague, uncosted and unprioritised policy ‘agenda’? Let’s start with prevention.
There are reports that Durham and Darlington PCT has allocated £1million to gritting the roads and pavements. Howls of protest have ensued, even though preventing accidents on rare winter days can reduce A&E demand and reduce pressures on orthopaedic teams to repair fractured neck of femur amongst the elderly.
As ever the hope must be that this response to innovate (I) and focus on prevention (P) will be evaluated carefully, rather than on the back of some grotty envelope - which is the NHS tradition of appraising the wisdom of investments!
The upstream slipstream
How many PCTs have used their commissioning authority to ensure NHS premises emulate primary and secondary schools and ban sugary drinks form their premises?
Come on guys, this is an obvious prevention (P) item to put in your annual reports (and putting this in commissioning contracts will discomfort hospitals to boot)!
Down in PCT Sleepy Hollow, the drains doctors (public health physicians) are drawing large salaries and mumbling about ‘need’ and other ill-defined issues … which are their stock-in-trade.
Why are they not campaigning through their College to tax sugary drinks and junk food? Even though growth rates for obesity are stabilising, we are still breeding a race of children who consume too much screen time while munching sugar and fat - training them to be heavy users of healthcare in the future.
It would be nice to see these folk target “Mr Clean” - Gary Lineker - who rakes in a nice income from potato crisp adverts for Walkers, owned by Pepsi.
The British Heart Foundation website shows how a packet of crisps a day in the school lunch pack up adds five litres of fat to kids’ diets and sets them up for obesity, diabetes and heart disease in later life. Pretty gruesome, Gary! Time to repent?
QUIP changing incentives
What about Q for quality and P for productivity in QIPP? Here we need to change incentives, surely?
Will the Tories, if elected in 2010, charge GPs for all referrals to hospital? Might this make them more careful in their referral practices? Should we also charge GPs when their patients turn up at A&E? This might encourage them to provide better 24/7 access to advice in the community.
Of course, to provide that advice you do not need GPs. Nurse Practitioners can do 70-80 per cent of what GPs do (and patients like them better!). So why not get rid of 25 per cent of GPs and replace them with more numerous nurses who could staff high street facilities and reduce hospital A&E pressures?
Too radical? Will we have to contract out services to the private sector, to get around the inevitable NHS conservatism?
The information prescription
The Tory solution to NHS austerity appears to be ‘information’ and ‘competition’. Very well - how much information? Information of what sort and what cost? And where is the evidence of the effect of this information on behaviour?
A religious incantation of the ‘i’ word word is all very well but how does information improve my knowledge? And does knowledge that I am a lazy, fat ageing fellow affect my behaviour and improve my health? Evidence is a bit poor, comrades!
As for ‘competition’ where is the evidence that it can be created and sustained? If it is put in place, where is the evidence that it improves the quality of healthcare provision? Evidence there is practically none!
However this does not prevent the ‘religious’ from believing this vague and barmy rhetoric!
So off we go into the age of NHS austerity, belching ambiguous and un-evidenced words that purport to be policy. No wonder we continue to waste household’s incomes in healthcare systems public and private, and give patients poor quality care.
Perhaps the NHS has to experience real pain if it is ever to grope towards economics-based policy in a systematic manner.