The Maynard Doctrine:: The irrelevance of NHS structural reform

In all healthcare systems, politicians continually strive for the Holy Grail of system improvement. This goal breaks down into three elusive targets: macro-economic expenditure control, equity and efficiency.

The upheaval inherent in the current NHS reforms may undermine expenditure control. This is well evidenced by NHS chief executive Sir David Nicholson continually telling managers that financial balance is an imperative and failure in this domain will lead to their dismissal.

Whilst the word “equity” is in the title of the White Paper, the term is only used twice in the whole document. Clearly the Con-Dem coalition regards ‘fairness’ of minor importance in the healthcare market.

But will it work?
So will the Lansley reforms improve efficiency?

Answer: why should they?

Continuous reform has changed organisational titles in the NHS every few years - purchasers have been called health boards, primary care groups, and primary care trusts; and now they are to be GP commissioners.

Managers and their staff within these organisations have either played musical chairs and moved into jobs within new organisations  or accepted early retirement and redundancy packages that have cost the taxpayers billions over the decades.

Typically these reforms have taken two to three years to bed in, during which time managerial functions have been ‘distressed’ - with consequent losses in efficiency.

Worth the opportunity cost?
Are these losses compensated by subsequent efficiency gains? There is little or no quantitative evidence of any beneficial effects of continuous organisational change in the NHS.

During the last decade, improvements in processes and outcomes (such as they have been evidenced) appear to have been the products of increased funding and “targets and terror”, including the financial rigour implemented by Bill Moyes and his team at Monitor, the regulator of foundation trust hospitals.

These effects on NHS performance have been initiatives of central government and Monitor. These reduce, rather than increase, local “autonomy”; the rhetorical aim of the preceding and present governments.

Why does redisorganisation fail?
But why has reorganisation of NHS structures had little or no effect?

The fundamental reason for this failure is that it has not affected clinical practice. As reform sweeps through the NHS, GPs still see their patients and prescribe as they have always done and refer in variable ways to their hospital consultant colleagues.

Consultants and their teams manage emergency referrals and alter elective treatments patterns to meet national targets coming from the various organisations of the state e.g. the Department of Health. Monitor, the Care Quality Commission (which licenses providers to improve patient safety and quality), and the National Institute for Health and Clinical Excellence (NICE).

Not only do clinicians - be they doctors, nurses or whoever - tend to carry on regardless of the whims and fancies of passing politicians and civil servants in London, most have little idea of the nature of reform.

Doctors and nurses do not have to demonstrate skills in management and economics to get certified as fit to practice by those educationally-inadequate organisations called Royal Colleges.

Furthermore the General Medical Council, which was supposed to reaccredit medical practitioners a decade ago and generate some degree of consumer protection, has proven pathetically slow in reacting to medical scandals.

So what are the lessons of healthcare reform in England?
Three lessons predominate any review of the period:

1)  Changing NHS organisational structure has had little or no impact on clinical practice, and it is the behaviour of doctors, nurses and their teams which are the major cause of both excellent care and inefficiency

2)  To the extent that clinical practice is improving, this is a product of central government initiatives such as “targets and terror” (i.e. improved financial and non financial incentives), NICE, National Service Frameworks and the actions of Monitor and CQC.

3)  The current NHS reforms may worsen performance and undermine expenditure control if the Department of Health and the new NHS Board fails to defend and augment the national intervention policies that have improved efficiency in recent years. There is a risk that the baby of past efficient reform at the centre will be thrown out with the bathwater!

Even if the competing provider and commissioning factions can be persuaded to implement the Lansley reforms, they will be largely irrelevant if clinicians of all types cannot be persuaded to engage collaboratively in using evidence to improve the delivery of healthcare to patients.

As these competing factions strive to get a “good deal” for their constituents, government must not bow to pressures that undermine existing institutions (e.g. NICE) and payment systems (e.g. the GP quality outcomes framework) that can be made to work even better to improve care.

Please can we avoid spending £2-3 billion on the processes of healthcare reform and - once again - providing little gain to taxpayers and patients?