The Maynard Doctrine: An autumn agenda item

Professor Alan Maynard looks at clinical excellence awards, clinical audit and individual clinicans’ performance – a significant item on the NHS’s autumn agenda.

You will recall GPs benefitted from the quality outcomes framework some years ago.

The taxpayer coughed up nearly a billion pounds and the GPs rushed to meet an array of process targets, many of which did little to improve patient health - but increased the comrades’ expenditure on cars and holidays for practitioners and their families.

Aneurin Bevan had to fill doctors’ mouths with gold to ensure they worked for the NHS in 1948. One gold bar weighing down hospital consultants wallets is clinical excellence awards. Chairman Lansley has asked the Review Body on doctors and dentists remuneration to review clinical excellence awards (CEAs) and report in the summer of 2011.

Come to the end of the party
Now is the time for us all to join in this review. CEAs are the consultants’ QOF. Awards are based on vague concepts of “contributions” to local and national NHS work, teaching performance and research productivity.

The first question to ask, as Adam Smith did over 200 years ago in his famous book, Wealth of Nations, is do we want consultants to spread their talents across all four activities or should we get them to specialise as purveyors of healthcare, rather than as teachers and as researchers?

When your cancer is damaging your kidneys, and your renal failure is giving you hypertension and heart fluctuations, does a consultant who is a good teacher or researcher improve your outcome? Doess being a jack of all trades and masters of none create a risk to our health?

Perhaps a research-active consultant will complement your diagnostic and treatment pathways with rapid innovation of economic-based advances in practice.

But does being able to “corrupt” the minds of medical students in your teaching help the patient?

Surely it is time to separate out medical academics and restrict their access to CEA largesse? Such issues should not be ignored in the CEA review even if it risks having practitioners of these dark arts descending into “mega-cluck”.

The past is a foreign country
One element of CEAs needing closer attention with or without the review is the implementation of five year reviews of past allocations and the questioning of whether such awards are for life or can be removed.

The impression given is that a CEA is like a dog - i.e. for life! But the consultant contract says review is needed regularly, and further, that CEAs can be removed. As they are not, should we believe that excellence is forever and exponentially rising? Would that we were all blessed with such qualities!

Perhaps a more explicit threat to CEA retention with thorough-going reviews by foundation trust boards might benefit taxpayers and patients?

CEA allocation should of course be related to performance. Clinicians are too slowly making audits national and comprehensive and agreeing systems to ensure the identification and management of outliers. However, their focus is on processes and outcomes. These are both essential elements of performance review.

However they have to be complemented with analysis of individuals’ activity rates and costs.

For instance: are good patient outcomes associated with high or low costs and activity rates? Or do good outcomes cost more and are they associated with slower work and lower activity rates?

Designing a three-legged stool
Clinical audit is an essential input into the allocation and retention or not of clinical excellence awards. But clinical audit should not be a one-legged stool. Rather, the three legs of outcomes/process adherence, cost and activity have to be brought together.

A nice issue to consider also is the capping of consultant rewards. The press would have us believe that millionaire Comrade Prime Minister Cameron wishes all civil servants, including doctors, to share his penury of an annual maximum salary of £142,000.

Does this mean that those being paid above this level, like the Medical Czars in the Department of Health and many “impecunious” medical folk in the NHS, will not only have big pay cuts but also be ineligible for clinical excellence awards?

What fun all these debates will be! The challenge is to ensure they are open, and do not get lost in cabals at boozy dinners fuelled by the excellent wines of the Royal Colleges and the BMA.