6 min read

The Maynard Doctrine: What the NHS Mandate misses, or ‘Another Episode Of Nero Playing His Violin Whilst The NHS Burns?’

Health economist Professor Alan Maynard suggests that the NHS mandate may have missed out most of the critical issues

The NHS Mandate is a nice wish list from the Department of Health outlining what Ministers and their officials think would be nice for the NHS Commissioning Board to deliver to us all. As ever with these endearing Departmental pontifications to the Commissioning Board, providers and CCGs and the electorate, we have no idea how this wish list was divined and there is little indication of how the NHS can proceed to this new nirvana in an evidence-based way.


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Whilst Whitehall Village fiddles away on Mandates many NHS staff must feel this is indicative of an unawareness of the strains being handled by local managers and clinicians. Central government appears to be in cloud cuckoo land judging by the mandate.

The challenges of maintaining quality and access to care are immense in a healthcare system increasing strangled by austerity and the pursuit of savings, often barely disguised as cuts

Changing quickly
Hospitals, primary care and budgeting have to change in short time periods, and with local politicians educating their constituents rather their fuelling their opposition to evidence-based change.

How might we deal with these “minor” issues?

Some problems:
1) Hospital tariffs are being squeezed vigorously over the next three years. Hospitals will have to cut costs, endangering quality and access, or go bust.  At least 10 and maybe as many as 20 per cent of Foundation Trusts are likely to go bust in the next three years. The fate of non-FTs may be even darker. This will present DH, the NCB and politicians will a nice little pre-election quandary - i.e. where to hide?

In principle, hospital insolvency presents a nice opportunity to merge and reconfigure local provision. The Whitehall edict says ‘sort this in 2013 so as not to mess the election landscape in 2015’.

Pigs may fly! The combined effects of wretched vote-maximising MP trying to save their local hospital (this may means inflated costs and killing and maiming patients with poor-quality care) and ‘consultation’ rules means the likelihood of prolonged chaos and confusion is considerable, and despite the energetic superb efforts of NHS managers to keep the lid on the NHS pressure cooker.

The re-configuration accelerated by hospital failures has to be evidence-based, rather than be characterised by emergency / ad hoc responses to “events”. It has to confront the fact that fewer hospitals mean less competition in urban areas. If competition is still in the Coalition lexicon, then how is it to be furthered? Creaming services to private sector competitors is a nice, evidence-free “solution” - with great risks.

There is little evidence of pro-active, transparent and principled management, criteria by which change will be evaluated and funding of the analysis of change. In part this is due to the Cameron-Lansley redisorganisation of the NHS, the costs of which must now number some billions of pounds in terms of pensions, redundancy and the opportunity costs of establishing new structures (Time for an FOI on this?).

2) Meanwhile there are rumbles in the primary care jungle! Bevan would have liked to have nationalised GP services in 1948, but these excellent private sector capitalists beat him up and he had to concede “independent contractor“ status to them. For over 60 years they have prospered, motivated by care for their patients and the number of noughts in their bottom line.

Like Foundation Hospitals since PbR, money is an important driver of activity, with both groups doing the “Oliver Twist”: demanding more money, when asked to improve the quantity and quality of services. GPs now also face declining incomes and through the quality and outcomes framework (QOF) and other devices, they are increasingly tied into service provision levels which are costly to provide and administer.

The natural consequence is that, like FTs, GPs are anxious to cut their costs. How can this be done? One possible route is to reduce capital costs by merging or federalising facilities and using specialty nurses to replace GPs and provide care for chronically ill patients. These service delivery changes may be rapid and radical, as they are driven by the desire to maintain practitioner income. Furthermore, they will be accelerated by the public’s desire for 24/7 access now met by often very imperfect out-of-hours cover.

But once again, we can ask basic questions. Firstly: are federated practice groups and large practices more cost-effective, and what are their effects on health and healthcare equity? Secondly: what about that political nostrum “patient choice”? What if patients prefer membership of a small practice? Are they to be denied it? Evidence and public involvement seem to be in short supply.

3) CCG funding will be contentious, particularly with the NCB increasingly top-slicing the budget to keep itself in the style to which it was used to in Whitehall village and to provide “specialty services” (a rapidly inflating concept!). As the NCB creams the budget, CCG are increasing scrutinising their capitated budget allocation levels.

The potential for thermo-nuclear war in this area is quite considerable, as the NHS struggles to meet growing patient demand with austere funding. The budget allocation process sets out “fair” targets for funding, but many PCTs / CCGs are allocated more and less than target fair funding.

The idea since 1976 (when this capper started) was that annual growth funds would be used to “ease” the funding of below-target authorities towards their fairer needs-based allocations. Purchasers funded below target are even more anxious in austerity to oil this rusty easing process.

This is problematic, as one purchaser’s gain is another purchaser’s loss. For over 30 years, consecutive governments have been reluctant to speed the equalising process e.g. by easing down the allocations of over-endowed areas to their target levels.

There are a number of reasons for this. Some authorities are incapable of spending their allocations, even when their local communities are socially and economically deprived. They may have poor primary care, slow referral to hospital and higher mortality rates due to poor service quality. They exhibit “excess” needs-based funding in relation to activity, investing in one locality in a boat to “treat” naughty boys and young men (which may or not be cost-effective!).

Such authorities do not deserve additional funding. Rather, they need managerial change to ensure the quality and quantity of care provided to their deprived populations is improved swiftly using often unspent allocations

Another reason for sloth in moving budget allocations towards greater equality is that losing authorities would have to rationalise services radically. London has done this successfully with stroke services.

But most of the London authorities still have above-target allocations. London rules England in very many ways; one of which is retention of over-generous budget allocations protected by the political mafia!

The Coalition is unlikely to alter allocations in ways which are damaging to their supporters. But such inertia when “we are all in it together” could be seen as especially hypercritical when the Government and the Department of Stealth espouse equity as an essential part of the NHSCB’s mandate!

Bankruptcies amongst FTs will be significant, offering opportunities for rationalisation and opposition from patient groups and twittish MPs whose policies have created these nice challenges.

Large-scale change in primary care will be driven by efforts to reduce costs and maintain declining GP incomes. This will lead to mergers to create 100,000 and more population practices and federations of practices, as well as increased use of nurses.

The paucity of NHS funding will lead to intense debate about budget allocations, with some authorities significantly below target and others well above them. Frightened London and southern politicians will be reluctant to cut allocations to shore up authorities elsewhere!

This reform turmoil will be largely un-evidenced. However, even more crucially it will not be evaluated systematically. Instead, we will have Coalition folk asserting success and opposing politicians crying failure; both sides cloaked in a veil of ignorance (as usual).

Add to this the PCT-CCG switchover and the Francis report on Mid-Staffs *** and the NHS is going to be a controversial policy area to “entertain” us all! But don’t worry folks! The NHS Mandate tells us ever so clearly how to manage these “minor” issues!

Don’t you sometimes think there is a touch of Nero playing his fiddle in Whitehall whilst Rome-NHS burns - i.e. a dislocation of politicians from reality? The NHS Mandate should have prioritised the explicit and vigorous management of these issues.

***Professor Brian Jarman pointed out on Twitter (November 27th) that in 2002, the then-regulator, the Commission for Health Improvement (CHI), reported that most aspects of Mid Staffs clinical performance was in urgent need of improvement. The Francis report will no doubt tell how and by whom this clear warning was ignored.