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The Maynard Doctrine: Productivity, produce or production? The £22 billion challenge

Health economist Professor Alan Maynard casts doubt on the £22 billion efficiency challenge

Sir Galahad Stevens’ Five-Year Forward View of pursuing the NHS Holy Grail of increased productivity requires the politicians to pledge £8bn and the NHS to garner massive and improbable productivity gains of £22bn, to resuscitate the NHS over the period to 2020.

The politicians seem to be on board, except for UKIP who have exhibited gross ignorance of how markets work by advocating private insurance as a means of funding the NHS.

But is it time for Sir Galahad to review carefully the development of his five year plan for the NHS? The noble knight’s plan has induced feverish activity in the NHS.

The rhetoric of evidence-free 'integrated care' has led to NHS England producing lucre to fund 'vanguard' organisations ready to change the ways in which services are delivered to patients.

So will this produce demonstrable innovation? Here, we have to be careful and define the meaning of innovation.

Innovation is change which demonstrably cuts costs for the same (or even better) quality and quantity of care. As NHS managers throw existing services into the air, have they read and applied Evaluation Techniques 101?

In the United States, and in particular in relation to the massive Medicare programme, politicians and policy makers are singing siren songs similar to those of Sir Galahad.

Indeed, our good leader (having been brought up in the tradition of the Commonwealth Fund of New York and his Harkness Fellowship) sings from the same hymn sheet.

This combined worship starts from the premise of fragmented delivery structures and massive unwarranted clinical practice variations. So far, so good! US Medicare is a mish-mash of fragmented entitlements for elderly patients and inefficient delivery systems lacking integration of patient journeys for many folk with complex multiple morbidities. (1)

This sounds familiar to us all in the NHS, and indeed in all healthcare systems in the developed and developing world.

Tradition and incentives encourage providers to defend their domains, budgets and jobs; even as they join the chorus of criticising what their self-interest defends.

Integration is the answer. What's the question?
In the US, both the federal Medicare system and private insurers have been unable to unscramble this inefficient and inequitable mess. Now they, like Sir Galahad, are pounding along on their chargers in pursuit of the Holy Grail of increased productivity via the integration of healthcare.

The characteristics of both bold endeavours are similar. In the US, the reformers advocate replacing fee-per-item-of-service with bundled payments for an integrated care package and capitated provider budgets. In England, the argument is 'let’s bundle primary, secondary and social resources into capitated budgets which fund integrated care for patients'.

Another American policy wheeze is accountable care organisations (ACOs). The purpose of these organisations is to make providers accountable for both the cost and quality of care, and give them shares in savings.

US Medicare is also experimenting with global budgets. Perhaps English emulation may follow, given the chaos of 2015-16 PbR tariff-setting?

Little in these US developments is novel for NHS policy wonks. Furthermore the results of the evaluation are generally not encouraging. (1)

However, there is a vital lesson that Sir Galahad and his knights should learn: if you alter service design, you use society’s scarce resources and you have an obligation to evaluate the costs and benefits of your policies.

Our politicians pay lip service to evidence-based policymaking. A nice example of this was the creation of NHS Direct over a decade ago. This involved the funding of a well-designed evaluative pilot study at Sheffield University.

After a year, the then Secretary of State, Alan Milburn (special adviser: one Simon Stevens) decided to ignore the future production of results, and fully implemented the programme across the NHS. His impatience and hypocrisy in paying lip-service to evaluation and evidence is typical of reformers in UK health and social care.

This compares badly with US health policy reform. The changes in US Medicare are subject to evaluation. Instead of letting politicians and policy makers produce 'improving' evidence-free fantasies (the tradition in England), policies are subject to rigorous evaluation.

Why is Sir Galahad ignoring the practices of his American mates? He is condoning the potential frittering away of scarce NHS resources on variations of his two preferred models of change. This is immoral.

Like our American cousins, we have an obligation to add to the evidence base with well-designed evaluative studies; and not confuse it with a welter of opinionated horse manure!

The alternative to a scientific approach is poorly-designed, back-of-a-fag-packet studies popular throughout the NHS. These typically fail to articulate a hypothesis; fail to identify and measure costs and outcome with substantive before and after data; and fail to meet other mundane requirements of quasi-experimental study design. (2)

What is needed is the investment of NIHR research resources and quantitative designs into Sir Galahad’s five-year plan. This would imply no quick fixes, and avoid massive short-term change of uncertain cost and effect which palliate politicians’ desire that 'something must be done'.

It also requires an acceptance that the £22 billion efficiency saving over the period 2015-20 is unattainable. Proper evaluation takes time. Both the Americans and the Brits have little evidence to efficiently drive down clinical practice variations and fragmented healthcare delivery.

Sadly, it is likely that the fiction of the £22billion savings target will be retained, and the NHS will indulge in a fury of well-intentioned, expensive and ultimately unproven change.

Haven’t we learnt owt from previous NHS re-disorganisations? Plus ca change, plus ca meme chose! For Sir Galahad too?

1) D Blumental, K. Davis and S Guterman, Medicare at 50- moving forward, New England Journal of Medicine, 372, 7,671-77 (February 12th, 2015)

2) Craig, P, Cooper, C, Gunnell, D, Haw, S, Lawson,K, MacIntyre,S et al. Using natural experiments to evaluate population health interventions: new Medical Research Council guidance, Journal of Epidemiology and Community Health, doi:10.1136/jech-2011-2000375