Cowper’s Cut: Goodbye to a great, and regulating the regulators

It isn’t every week that we lose one of the greats. Last Friday afternoon, Professor Alan Maynard – one of the most influential health economists that discipline has seen – died in York Hospital (which he chaired for many years), after living for many years with renal cancer. Most of Alan’s life in treatment was of good quality, thankfully.

He retained his interest in work and his mental acuity. And healthcare in general, and the NHS in particular, will miss Alan rather more than I suspect it yet knows.

Of course, Alan’s family and many friends and admirers will miss him deeply. It isn’t easy to accurately contextualise the achievement of a great man a few days after his death – and without equivocation, I think Alan was and should be called a great man.

But his colleagues from the University of York put together a book of essays by and about Alan, which you can find here. Even though there’s one in there by me, I’d urge you to read it.

Alan was also an influential and witty columnist for HSJ for many years. His 2005 piece on market forces could have been written yesterday: “NHS managers are moving from a world in which they tended the till and ensured financial balance to a world in which flexibility in service provision and entrepreneurship will be at a premium.

“This transformation will have IT and data management at its heart. Hopefully this experimental policy will not only change management roles but also improve patient care.

“If it does not, the political likelihood of privatising all healthcare capacity will be increased.”

More alive than ever

What came first for Alan was never political dogma, but the interests of the patient. Health economics merely expresses this concern in the question “what is the best value we can get for our pound in healthcare?”

I’ve had the pleasure of editing columns by Alan ever since February 2000, when I started writing about NHS management. He was kind enough to join me as a regular contributor to Health Policy Insight. It’s hard to believe that his clear thinking, insightful, mischievous and unrelenting contributions won’t be coming any more. I’d give a lot to edit out all the many exclamation marks from Alan’s joyous copy one more time.

It may seem strange to say that I won’t remember Alan’s formidably huge intellect most. However, I think his fellow academics can and doubtless will place his achievements into appropriate context.

What I will remember most about Alan is his kindness. He loved a proper debate, and debated properly. Yet what was impressive about a man with so huge a brain was that he didn’t ever use it as a weapon to belittle.

Instead, he had the grace and style to use it as a firework and a fulcrum to encourage change.

Read the 209 replies to the tweet announcing Alan’s death. Read the comments on the book on his achievements. Despite a robust style, which didn’t let any nonsense pass unchallenged, Alan Maynard was much loved – and with good reason.

Alan Maynard believed that candour, clear thinking and evidence were the three vital things to making healthcare better. To this day, those three things are not yet the organising principles of all decision making in the NHS.

Yet they’re a lot closer to the centre than they would have been without Alan’s work and wit.

I think there are three ways to live on beyond your death: to create some durable art; to advance good ideas; and to push bad ideas back. For anyone in healthcare who wants to pay attention to Alan Maynard (and that should be everyone trying to run the NHS), he should be more alive than ever. It would be great if his influence were at the table in all decision making meetings – perhaps as the University College of London council was rumoured to treat Jeremy Bentham, “present but not voting”.

Quis custodiet ipsos custodes?

Alan’s last column touched on the key issue of regulation. It hasn’t gone away as an issue of pertinence.

Regulation and trust

It doesn’t seem unlikely that we rely heavily on regulation when we have lost trust. Baroness Oonora O’Neill’s Reith Lectures on trust remain a seminal listen/read about that vexed issue.

In an NHS of performance chaos, we have the brilliantly titled Refreshing NHS plans for 2018-19. Yes, it does sound like the worst marketing slogan imaginable. “Buy one refreshing NHS plan for 2018-19, get one free!”

And this coming week will see the publication of Dr Bill Kirkup’s latest report into Liverpool Community Health. The question for regulators and system leaders is this: will this be a performance of regulation, or just another rehearsal?

It’s an idiotic argument that regulation has no place in a safety critical industry such as healthcare. The non-idiotic question to ask ourselves is how do we regulate healthcare and social care effectively and efficiently – and oh yes, cost effectively?

The correct answer will likely have something to do with a sense of proportion. A great deal of the current NHS system architecture is best understood as a response to the catastrophic care failures at Mid-Staffs.

Talking to clinicians, I often get the sense that we have a wildly over defensive and uber legalistic NHS culture when it comes to performance, and particularly to complaints and errors.

That is not a sign of a healthy system. It’s one of the reasons I will keep on arguing that the NHS needs a chief anthropologist much more than it needs any chief inspector. One of my favourite cynical phrases is from another safety critical industry, aviation. US SouthWestern airline boss Herb Kelleher observes that “culture is what people do when no one is looking”.

Too much of the NHS system acts as if no one is looking, or hopes that threats of legal action will enforce amnesia. It seems they will have to learn these lessons the hard way.