The Maynard Doctrine: After U-turns and Utopia, reality bites - fiddling while Rome burns

Professor Alan Maynard gets back to the real issues of NHS reform: funding and quality control.

The protracted “listening exercise”, with everyone paying too much attention to the trivia of reform and the protracted machinations of the Forum and sundry pathetic politicians offering ambiguity, has disguised two underlying maladies: funding and quality control.

These twin forces could seriously undermine the NHS.

Enough has been said about funding. Cameron and Osborne will have to dig into our pockets, and allocate increased funding. Expect parsimony, delay and continued rhetoric!

Purse-strings may well relax when we are all pained by the final Mid-Staffs independent inquiry report. There but by the grace of God go other organisations.

Quality in austerity
Quality is the central concern, as austerity bites. The paucity of funding growth and The Nicholson Challenge means that management is focused on controlling expenditure and ensuring it does not exceed income. This focus risks the eye being taken off the control of patient care and staff.

Go and ask your local hard-working colleagues in the NHS about their work environment. Can they assure that all is well? Or is there increasing evidence of problem denial, non-response to concerns raised by staff and patients and deflection of concerns to protracted administrative processing?

Hopefully, you will get assurances. Yet a more pessimistic outcome might be casual evidence of such problems. All of which may be indicators of the loosening of quality control - and the seeds of scandal, in the Mid-Staffs mode.

Welfare
Patient and staff welfare issues are of importance. Of equal importance is herding clinicians to follow guidelines. Ideally PCTs, clinical commissioning groups or insurers would refuse to pay for procedures unless guidelines are followed.

Guidelines might specify the conditions and severity that create a case for treatment and also the procedures and prostheses to be used.

Thus, using patient reported outcome measures of a specific condition (e.g. the Oxford hip score) or using a generic quality-of -life measure such as (EQ5D or SF12) a specific disability threshold might be specified, above which a procedure would be reimbursed.

Below this national threshold, “watchful waiting” would be prescribed.

Thresholds
Available data about patient outcomes for hernia shows that nearly 50 per cent reported no gain using EQ5D. Is there a problem with this measure? Or does this indicate that watchful waiting is appropriate for non-symptomatic hernias? If the latter, surgical activity rates could decline considerably, and cost savings would contribute to the achievement of the Nicholson challenge.

The creation of PROM-informed thresholds nationally would reduce the current considerable variations in thresholds, enhancing efficiency and equity.

Can clinicians accept such Stalinist directions from the NHS Commissioning Board? Hopefully they will see the logic, even though if insurers follow suit, private practice income may be “sadly” damaged! National collections for impoverished orthopaedic surgeons would clearly be needed.

Can the incremental development of such an approach also lead to better management of costs? If thresholds become more systematically set, analysis of cost variations within them will be “interesting”!

If procedures are guideline-based and threshold adhered to, cost variation between consultants for similar procedures would be expected to narrow.

National medical exams
To further incentivise clinical change, a focus on the regulation of the medical profession is timely and long overdue. Setting national exams for all medical school undergraduates is long overdue. The GMC sets the curriculum; but the medical schools do their own thing with local variations.

Thus for instance, management and economics training is uneven - and often poor. US Medicare have recently given medical schools several billion dollars to ensure they instruct soon to qualify doctors in the history of the evolution of the US healthcare systems, and the rudiments of economics and management.

Action by the GMC
It is time for the UK GMC to emulate these American developments and relate re-accreditation to doctors’ knowledge of such matters. This would be a ‘shocking’ departure from current practice, whereby many graduates in the dark arts of medicine are very ill-equipped for managing society’s scarce resources.

‘If the Coalition were really interested in reforming the NHS, it should focus on the vagaries of GMC regulation and easing the complexities of removing the very few inadequate practitioners who consume inordinate amounts of management time in hospitals and primary care.’

GMC “Good Medical Practice” should include an obligation for clinicians and their teams to manage within finite budgets and follow guidelines. Failure to do this consistently should create a prima facie case for failure in the long-long-long-awaited GMC reaccreditation processes.

The role of the GMC is to protect the patient. However, its machinations sometimes appear to put the protection of doctors before the interests of patients. Hospitals with two or three inadequate doctors find it hard to get rid of them - even when they seriously affect the productivity of the organisation.

If the Coalition were really interested in reforming the NHS, it should focus on the vagaries of GMC regulation and easing the complexities of removing the very few inadequate practitioners who consume inordinate amounts of management time in hospitals and primary care.

That this is not a focus of Coalition or Opposition attention is further evidence of a lack of understanding about how healthcare systems fail to provide low-cost, high-quality care.

Instead of the trivia of current re-disorganisation efforts, it is time to invest in real consumer protection by reforming the GMC and making the Royal Colleges more accountable for the public subsidies they receive!

The current reform controversies epitomise the problems of change - i.e. focusing on the irrelevant and the unproven. This increases pressures on the public purse and should convince the electorate that the Tories are rather useless in designing and implementing reform, and Labour has no better policies.

U-turns and Utopia
The cult of the amateur rules with the NHS Future Forum made up of well-meaning but analytical-and-evidence-“lite” members delivering superficial nonsense to an uncritical government characterised by U-turns and vacuous assertions of Utopia being round the corner.

Would that life were so simple! It ain’t.  Politicians fiddle whilst the NHS faces serious damage due to weak clinical management, funding paucity and elusive productivity changes.

Will Stalinism from the NHS Commissioning Board prevent potentially mortal problems terminating the NHS? Depending on your preferences, let us turn to Moscow, Jerusalem or Mecca and pray for deliverance from nitwits who fiddle while Rome burns!