The Maynard Doctrine:: Time for scepticaemia

Health economist Professor Alan Maynard suggests that it’s time for a little definition of what we actually mean by policy goals

Ministers continue to assert, in the true Thatcherite tradition, that they are interested in “value for money”.

However, when it comes to short-term political gain and favourable publicity in the press, they squander society’s scarce resources by funding schemes where evidence of cost-effectiveness is absent.

Likewise, they fail to ensure scientific evaluation of their usually evidence-free innovations.

It is time for policy analysts and commentators to distinguish between the rhetoric of the Whitehall machine and those damnable things called facts. Demanding evidence of thorough analysis, backed by hard evidence, needs to replace the everyday horse manure peddled by the government’s communications industry.

Some examples of the need for scepticaemia
a) In 1989, the Thatcher government introduced the purchaser-provider split or quasi-market
Subsequent governments, Labour and Conservative, have regularly re-disorganised the NHS in an evidence-free fashion, but the purchaser-provider split has survived.

Has it been an efficient use of resources to maintain a structure abandoned by once enthusiastic emulators in New Zealand, Wales and Scotland?

Or is it time to take stock and abandon the purchaser-provider quasi-market? Is it time to take up the advice of one of its architects, former Secretary of State for Health Kenneth Clarke: “If one day, subsequent generations find you cannot make commissioning work, then we have been barking up the wrong tree for 20 years”? (Kenneth Clarke (2008) quoted in Nick Timmins, Never Again? Kings Fund 2013.)

b) The Five-year Forward Hallucination
Last year, NHS England published its Five -Year Forward View (5YFV). This set out the need for £30 billion of additional NHS funding for the period 2015-2020. The £30 billion of additional funding was made up of £8billion of additional tax revenue and £22 billion of “productivity improvements”.

The Government has given a pledge - vague, in terms of timing and funding - to increase NHS budgets by £8 billion over the next five years.

Two questions need to be asked about these figures. Firstly, why should we believe the £30 billion figure? Secondly, isn’t the £22 billion figure merely pie in the sky?

The £30 billion figure is a product of scenario-mapping by economic gnomes in NHS England. The basis of their ruminations is unknown. The public and policy wonks have been asked to accept this figure, and have chosen not to develop alternative their own guestimates. Alternative public scenario-planning would be timely and appropriate.

How plausible is this figure?

What are the likely margins of error?

Instead of addressing such issues, policy wonks and (un)think tanks have accept it as the 11th Stevens Commandment. Time to question and replicate on the back of a publicly-accessible fag packet.

Of course, acceptance of this figure is useful in the propaganda wars of NHS funding. Get a high figure in the mind of the public, and NHS funding may be assured?

However, a weakness of this argument is the £22 billion productivity improvement that must be gained to ensure survival. Much or some of the productivity gain in health gain does not involve saving money, but improving the quality of care and patient outcomes from the same sum of money.

The consequence of this rearrangement of inputs and enhancement in quality/ outcomes for patients is that resources are not freed up to fund increasing demand caused by multi-morbidities in the population.

Healthcare planners currently have little knowledge about the balance of productivity gains that manifest themselves largely in quality improvements with little resource savings, and productivity gains that maintain or improve quality/outcomes and also free up resources to contribute to the £22 billion icon. We bumble in the dark, praying for enlightenment and good luck.

c) Workforce non-planning
The current shortages of doctors and nurses are in large part the product of the Coalition’s incompetence. By freezing wages, the previous government made it very attractive for nurses to leave NHS employment and work for agencies at higher wages.

As a consequence, NHS hospitals not only have expensive recruitment problems but also have to pay increased costs for transient labour. Unsurprisingly, this leads to both to financial and quality problems emerging in NHS trusts. Such brilliant daftness is awesome!

During the election, competing parties advocated the production of more doctors and nurses and/or advocated probably inefficient policies such as 24/7 for hospitals (Maycock et al, 2015). Such hasty policies were un-costed and highlighted the practical absence of NHS workforce planning. The time for finger pointing and urgent remedial action is upon us!

d) Whither analysis?
While the purchaser-provider split , the Five Year Forward View and workforce planning anarchy should be major targets for scepticaemia and better analysis, resources are also being wasted by daft politicians fiddling whilst Rome burns.

In 2014, Health Secretary Jeremy Hunt decided to boldly “innovate” with payments to GPs for identifying citizens with dementia. GPs, ever-anxious to butter their crusts, began to test more patients. Even if the tests used for dementia diagnosis are accurate, which is debated, why increase diagnosis rates when we have no cost effective intervention to treat patients with dementia?

Answer: like the Cancer Drugs Fund, this was a fatuous demonstration of the use of publicity to garner votes and demonstrate “concern” for patients, whilst wasting resources and depriving other patients of care from which they could benefit.

e)  The GP “quality and outcomes framework” (QOF) initially drove up process measures of performance at the cost of £1 billion a year. After 3 years of QOF funding performance improvements flattened off. After 11 years and £11 billion, has it been value for money?

Over 11 years incentivised items and targets have been altered to improve “bang for the buck”. Sometimes this has followed NICE advice, but sometimes NICE’s advice has been “lost” due to the opposition of the ever efficient generator of restrictive practices, the British Medical Association!

Conclusions
It is time for scepticaemia “an uncommon generalised disorder of low infectivity. Medical school education is likely to confer lifelong immunity” Drs Petr Skrabanek James McCormick “Follies and Fallacies in Medicine, Tarragon Press, 1992) in response to the policies of Government, NHE England and in all areas of NHS policymaking.

Time for Trust and CCG managers to politely demand evidence of the worth of endless “bumf” from the Department of Health and NHS England.

Time for these managers to evaluate their ‘innovations’, and demonstrate their efficient use of society’s scarce resources.

All need to migrate from fantasyland to the real world of difficult choices and anxious patients - and their carers.