Professor Alan Maynard decodes the White Paper’s literary and political influences

The primary characteristics of the recent White Paper on the NHS, Equity and Excellence: Liberating the NHS are incoherence and ambiguity. The consultation papers that have emerged subsequently do all too little to reduce the conclusion that Chairman Lansley is not sure where he is going.

’Incoherence and confusion are both an opportunity and a threat.’

Of course, incoherence and confusion are both an opportunity and a threat. Lack of clarity and control could derive the NHS into insolvency and create public commotion.

Yet it may also provide a test for the medical profession, particularly GPs. Are they capable, let alone willing to manage the efficient integration of the curiously fragmented primary, secondary and social care systems?

On the meaning of words
More of that later. Let us first focus on the meaning of words.

Some readers – though this being Health Policy Insight, it is hoped only a scant few - may be part of the “ignoranti” who have not studied the works of Lynn and Jay, authors of the Yes, Minister BBC-TV politics comedy series 30 years ago.

They should urgently remedy their ignorance, and others who are better educated might re-read these essential primers for those wishing to understand Whitehall.

The irony of ‘open government’
One of the early episodes of Yes Minister deals with subterfuge and evasion in dealing with the tricky policy issues around “open government”. It is highly pertinent for any consideration of the current White Paper on the NHS.

The discussion uses what Lynn and Jay call the “Law of Inverse Relevance”. The following quote from the authors illustrates this law’s current pertinence: “I explained that we call the White Paper “Open Government” because you always get rid of the difficult bit in the title. It does less harm there than on the statute books

“It is the Law of Inverse Relevance: the less you intend to do about something, the more you have to keep talking about it”. (Lynn and Jay, 1981)

What is the relevance of this law to the current White Paper? A colleague did a search to identify the number of times the Whiote Paper’s titular key words “equity” and “excellence” appear in the Coalition Agreement document.

She found excellence is mentioned three times (plus another three as part of discussion of NICE), and equity is mentioned twice.

Furthermore, she reports that these mentions of equity and excellence appears in two sentences: “The NHS is admired for the equity in access to health care it achieves; but not for consistency of excellence to which we aspire. Our intention is to secure excellence with equity”.

’The Coalition is not interested in equity, and its affection for excellence is muted and related to NICE.’

This appears to be an excellent example of the Law of Inverse Relevance. The Coalition is not interested in equity, and its affection for excellence is muted and related to NICE. The former is reminiscent of previous Tory governments, and indicative of the Liberal Democrats being neutered in the NHS debate.

The reluctant use of “excellence” is indicative of some in the Tory party wanting to undermine NICE, so that their supporters in the pharmaceutical industry can garner good profits from products which are not cost-effective.

Liberation theology
The other nice word used in the White Paper’s title is “liberating” During the Normandy landings in 1944, an anonymous American soldier entered a ruined French village and is reported to have remarked, “Holy xxxx! We sure liberated the hell out of this place”!(quoted in Miller, 1945).

Let us hope that Comrade Lansley is not using the term “liberating” in this context! But how can chaos and destruction be avoided?

Positive, small-c conservatism
A strength and weakness of the NHS is its conservatism. Managers and clinicians will strive hard to keep the show on the road despite the destabilising efforts of Whitehall Village.

Perhaps the bulwark of the battered NHS will be the professions. As I have argued previously (see Maynard Doctrines previous), they are both the problem and the potential cure for the ills of all healthcare systems, public and private.

Instead of remaining the complicit supporters of waste and inefficiency, the chaos produced by Chairman Lansley may stimulate greater scrutiny of outliers, improvements in average performance and appropriate protection of the interests of patients and taxpayers.

However, sweet words of endearment alone from the government will not be sufficient to move the professions. Life is full of difficult trade-offs. Hopefully, the Whitehall villagers will negotiate these with care. Their efficiency in so doing will be strengthened by careful reading of Yes Minister!

Our efficiency in detecting their deviousness will also be enhanced by careful study of the wonderfully insightful and funny work of Lynn and Jay!

Reference
Jonathan Lynn and Antony Jay, ‘The Complete Yes Minister’ Omnibus edition, 1989, BBC Books (The series is also available from the BBC on DVD)