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The Maynard Doctrine: Come on, Sir Galahad Stevens, lance the nonsense! | Health Policy Insight
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The Maynard Doctrine: Come on, Sir Galahad Stevens, lance the nonsense!

Health economist Professor Alan Maynard calls for Simon Stevens' digital extraction on non-evidence-based policy initiatives

Sir Galahad (aka Simon Stevens) is in an “interesting” position at NHS England. Post my Lord Lansley’s daft reforms, Galahad and his merry persons are supposedly independent arbiters of NHS policy, subject to the Department of Health annual contract.

However it is obvious that despite the law, the court jester (aka the Secretary of State) cannot resist regular bouts of hands on wheezes aimed at fruitlessly portraying the NHS as sailing onwards through untroubled waters.

Are there increasing signs that Sir Galahad is seeking to rubbish more vigorously many of these wheezes?

BCF: The Better Care Fraud
The Better Care Fraud, or Fund if you must, was a pre-election wheeze to ease pressure on social care, the budget of which was cut by 25 per cent during the Coalition Government. At the time sceptics argued that cutting the NHS budget and transferring funds to social care was unwise.

The questions posed were twofold. Firstly, is social care a complement or substitute for acute care? The dreamers asserted that it was the latter, and switching funds would therefore cut acute care admissions. Evidence to support this dream remains scarce at best, and mostly absent.

The second problem with the Better Care Fraud was timing, or the Sooty syndrome. It was assumed that at the wave of Sooty’s magic wand, social care schemes would be identified and implemented to give instant reductions in acute admissions.

Unsurprisingly, these dreams were unfounded.

Consequently, clinical commissioning groups are worse off financially. Local authorities are slow in grappling with the efficient use of these additional funds. And evidence of benefit to NHS patients and social care clients is as clear as the autumn mists.

It is encouraging that Sir Galahad is now reported as resisting further tranches of Better Care Fraud funding transfers. It has been rumoured that the Treasury twerps saw subsequent transfers as good public relations to con the legions of patients deprived of social care in recent years.

Of course, what is needed is not further skulduggery but increased funding of social care from tax revenues.

24/7 services
But what can Sir Galahad do about all another theatre of dreams, 24/7 doctor cover?

The enthusiasm of Cameron and Hunt in the Conservative manifesto and recent wheezes seems to know no bounds. Tossing £50 million to fund GP pilots of weekend cover is now reported in Pulse as resulting in an absence of patients and waste. Here is another policy 'triumph' to spin, or more likely bury in the welter of bombings, refugees and other clouds of despair in the media?

If sanity had prevailed, there would have been analysis of out-of-hours demand to identify peaks and troughs in primary care demand and in the demand for hospital specialisms.

Instead, the politicians rushed in where angels fear to tread with un-evidenced policy wheezes and an absence of costing: a fine example of Drunken Sailor Syndrome, amidst Osborne’s austerity and the erosion of the welfare state.

On our knees, we offer up prayers to Sir Galahad to patiently unravel the politicians’ waste and stupidity, and focus on what is cost-effective, and what can be afforded in a NHS heading for end-of-year deficits - despite barrel-scraping by desperate policymakers.

Increasing productivity
It is one year after the publication of the Five Year Forward Plan. How is Sir Galahad doing?

To recall: the FYFV asserts the NHS needs £30 billion in additional funds between now and 2020. £8 billion of this is to come from additional tax-funding, and £22 billion from increased productivity.

The timing of the additional £8 billion from taxation remains obscure and may be weighted nearer 2020 to buy additional electoral support from the NHS as the next election nears and the closing the fiscal deficit.

The acquisition of the £22 billion in improved efficiency is designed around two policies.

The first of these is mitigation of the age-old problem of unwarranted clinical practice variations i.e. doctors do different things to patients with similar needs and similar characteristics.

Jack Wennberg and his merry (mostly) men have been writing about this since 1974. In his American context, the conclusion is that “conservative, safe practice” could cut US Medicare expenditure by 40 per cent: enough the fund some grand wars!

The evidence from the UK is that similar savings could possibly be made in the NHS. As in the US and throughout all public and private healthcare systems, the question is HOW can this be done, and over what timescale?

Enter Sir Galahad’s Vanguard investments. Abjuring the letting of a thousand flowers bloom, he has sought to target funds and activity into dozens of experiments.

One, in Northumbria, seeks to emulate US accountable care organisation and appears to involve the abolition of the un-evidenced purchaser-provider split of “internal market”. Its leader is now the debut chief executive of NHS Improvement.

These experiments give rise to range of issues. Evaluation is needed to determine both the efficiency of individual “innovations” and the generalisability of demonstrably successful schemes for roll out into the NHS.

What timescales are envisaged to enable roll out of efficient schemes to produce the £22 billion savings by 2020?

The brave Sir Galahad already has many a dent in his armour as he grapples with the plethora of nonsense produced by Whitehall politicians. The wheezes of these folk are legend, largely wasteful and often the product pubescent advisers intent on entertaining the Daily Mail rather than the hard business of managing the NHS is very difficult times.

Hopefully Sir Galahad’s sword will increasingly cut these “poppets” down to size!