The Maynard Doctrine: The risks of another bout of NHS musical chairs

Professor Alan Maynard assesses the impact of the "blank" White Paper and associated restructrings and power shifts

The White Paper published earlier this month was in effect a “blank paper”, lacking detail of both the Government’s objectives and how reform was to be achieved.

Since then, Sir Humphrey and his fellow civil servants have striven mightily not just to put flesh on the bones, but also to reveal vital parts of the skeleton which were omitted from the “blank paper”.

Strive so well as they may, there is still a risk that this reform will turn out to be another bout of musical chairs, taxing for all involved but failing to deal with fundamental issues needing reform.

Neo-Gosplan - co-operative ‘State Planning Agencies’

’It is obvious that any market needs regulation.’

Take for instance the Soviet Gosplan (State Planning Agencies): the NHS Commissioning Board, Monitor and the Care Quality Commission

It is obvious that any market needs regulation, and in the case of the NHS, failure to devise efficient mechanisms can lead to social disturbances which would horrify Cabinet and cause knee trembling throughout the Coalition.

’Monitor is to ensure financial probity - but can the pursuit of profits (or at least solvency) by FTs be carried out without recourse to quality controls? CQC is in charge of quality, and they will pursue quality - but with how much regard to finance?’

The three State Planning Agencies have enormous agenda, and will need to co-ordinate their activities. Monitor is to ensure financial probity - but can the pursuit of profits (or at least solvency) by FTs be carried out without recourse to quality controls? CQC is in charge of quality, and they will pursue quality - but with how much regard to finance?

Of course, we are told Monitor and CQC will collaborate. But has this happened in the past? And what are the incentives now that will ensure efficient co-operation and collaboration? No doubt we will be assured by the usual platitude storm, but problems seem certain under existing “plans”.

’Will ‘clinging-on-by-the-fingernail’ foundation trusts be able to finance quality inflation?‘

But what of the NHS Commissioing Board? They will, for instance, over the years get 150 NICE guidelines to implement as part of commissioning.

What are the quality-CQC and financial-Monitor implications of these and other commissioning devices? Will ‘clinging-on-by-the-fingernail’ foundation trusts be able to finance quality inflation?

Monitor – the provider insurer of last resort
Monitor is also to tax all providers, public and private, to create a risk pool which can be used to bail out failing trusts. What will be the basis of this taxation?

If the greater risks are taxed more, these marginal entities will be driven further into insolvency. Or are the best endowed to be taxed more, to keep the marginal and often badly-run trusts in business?

Why should Plain Crap FT be bailed out by Staggering Along FT? And if this is judged right and Plain Crap cuts its quality to stay in business, how will Monitor and CQC reconcile their anxieties about patient safety?

Remember Mid Staffs?!

Don’t mention competition policy
Furthermore, is such cross subsidisation consistent with competition policy?
The “blank paper” seems keen on competition - but risk pools will reduce the incentive to be efficient and save Plain Crap FT from going out of business when this might be in the interests of taxpayers and patients.

There is a grave risk that the State Planning Agencies will maintain the status quo, when what is needed is reform.

’Risk pools will reduce the incentive to be efficient and save Plain Crap FT from going out of business when this might be in the interests of taxpayers and patient.’

The State Planning Agencies, in their already large and expensive enclaves, are to get many of the functions of the disappearing arm’s length agencies. Their self-governance and external scrutiny by Parliament will have to be first-class, but sadly this is unlikely given past track records and the way Whitehall operates.

Beneath these agencies are the GP consortia, where PCT staff are already competing for jobs in the face of staff cost-cutting of forty five per cent. To obviate the risk that many GP consortia will turn into “PCTs in drag”, the government is proposing to make GPs risk share by putting part of their income at risk if their consortia fails to deliver quality and financial balance.

This is a nice idea, Sir Humphrey, but how will you get the trade union to accept these bowel-loosening risks for its members?

If agreed, they would bind in GPs to management: at what cost?

If rejected by the most powerful trade union in the land, how will the comrades be incentivised?

By profit-sharing in GP consortia perhaps? Now there is a nice, controversial idea!

The ambition of the “blank paper” is to be admired; even if the paucity of detail is a disgrace. However, if the State Planning Agencies and GP consortia are not incentivised and managed well, we may sadly have another reform involving an expensive session of musical chairs and little gain for taxpayers and patients.

Let us pray that the civil servants and the on-going consultation processes can remedy the vagueness of our political masters and save the NHS and the country from the civil commotion caused by efforts to reform undermining the financial survival of the NHS!