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The Maynard Doctrine: Are policymakers and politicians stupid, ignorant, or both?

Health economist Professor Alan Maynard looks at NHS reform plans from 1974, and finds that all too little has changed.

An appraisal of the history of NHS reform since 1974 shows a naïve belief that altering organisational structures will improve the processes of healthcare and benefit patients in terms of their outcomes: i.e. improve their length and quality of life.

The links between structure, process and outcome are assumed, with reformers asserting unevaluated and un-evidenced conclusions from their repetitive and learning-light organisational reforms.

Furthermore, there is a disjoint between the often poorly-articulated and repetitive objectives of reform and the organisational changes actually put in place.

Reform, retro-style?
Thus in the first major post-1948 NHS reform, the objectives were as follows:

a) “Co-ordination of the planning and provision of all personal social services … with each other and with local government services”. Forty years later, NHS and local authority services remain fragmented. Norman Lamb, a current Minister of Health, hopes to “go where no man has gone before” and sort this! Good luck with that, Minister!

b) “Planning of services in relation to the needs of the people to be served … irrespective of whether services are provided in the home, in the doctor’s surgery or in hospital”. Forty years later, “joined up” care remains elusive.

c) “The more effective working of professional practitioners through provision of a structure and systems to support them administratively”. Forty years later, practice variations remain relatively unchallenged by the profession and managers. In many dysfunctional NHS organisations, the “them and us” culture corrupts collaboration and better performance management.

d) “Means whereby doctors and dentists can contribute more effectively to NHS decision-making”. Forty years later, many professional organisations tend to slow innovation rather than expedite evidence-based change which redistributes income and power.

e) “More uniform national standards of care”. So slow until the last decade and the work of NICE; but is their advice implemented? Is GMC re-accreditation helping?

f) ”Innovation and the rapid implementation of improved approaches to healthcare”. Forty years after this DHSS document and Archie Cochrane’s book (Effectiveness and Efficiency, 1972), improved health care delivery remains elusive.

g) “Clear, and flexible career structures for staff”. Still very elusive, as evidenced by the failure to substitute nurses for GPs and dental assistants for expensive dentists. Restrictive practices rule OK?

h) “Effective education and training of health service personnel”. Also still elusive after 40 years, as demonstrated by the reluctance of managers and clinicians to agree the use of comparative data, apply evidence from Cochrane and NHS-CRD and understand the rudiments of economics.

The source of these quotes? Department of Health and Social Security, “Management arrangements for the Reorganised National Health Service. HMSO, 1974, page 10. This was produced for DHSS with the support of McKinsey’s Consultants. Some might argue that McK’s have continued to offer the same remunerative (to them) advice over many decades.

Translating these reform hopes into practice, then and now, requires some simple innovations if we are to get past first base.

i) An integrated care record: instead of repetitive taking of personal histories each time a patient meets a practitioner in public and private health and social care, a unique identifier should enable all care workers and patients to access a real-time patient record.

ii) Cost data: patient level costing is essential to identify variations and inform investment decisions. The current reference costs remain inaccurate and an inadequate basis for decision-making, including setting PbR tariffs.

iii) Outcome data: further investment in specialty outcome data like that available for cardiac surgery and being implemented for a further 10 surgical groups; plus further investment in the development of patient-reported outcome measures (PROMs).

iv) Activity data: investigation of the relationship between activity volume and patient outcomes to evidence better the existence of economies of scale i.e. whether less providers doing more will improve outcomes (or kill less patients). Vigorous use of activity data to identify and investigate outliers.

v) Disaggregation of data to identify e.g. where there are clinical practice variations, where in the care process does the variation take place e.g. do such variations occur in the acute phase or the post-acute phase of a patient episode?

vi) Investment in staff skills that facilitate the timely analysis of these data i.e. reduce investment in qualitative “leadership skills” and invest more in quantitative skills. Integrate into incentive and appraisal systems reporting of efficient data use by clinicians and managers

vii) Systematic evaluation of all policy innovations to expand the evidence base and reduce faith-based ‘reforms’.

Politicians have for 40 years initiated reforms which focus on changes in NHS structures and which have had no systematic impact on the processes of care or patient outcomes. If we want to improve value for money, basic building blocks like those listed above are essential.

Sadly, such advice is consistently ignored. The preferred approach to change of governments, both Conservative and Labour, is the radical reform of NHS structures oiled by occasional dollops of new money from panicking politicians.

With a flat budget for five years, you might think policymakers would mend their ways. Instead we have crab-like progress, delayed by irrelevant waffle and a continuing preference for avoiding hard decisions.

The fundamental question that needs an answer is whether politicians’ and policymakers’ NHS reforms over the last 40 years have been the products of stupidity, ignorance, or both?