The Maynard Doctrine: Building NHS reforms on sand - whatever happened to evidence-based policymaking?

Professor Alan Maynard suggests that evidence for a primary care-led NHS is seriously lacking.

When an expensive system of healthcare such as the NHS is accused of having “failed”, there are two urgent needs: firstly, to define what is meant by this term and secondly, to present evidence of both “failure” and the evidence that proposed reforms will remedy the system’s deficiencies.

Sadly the current reforms fail either to define the failures or to offer an evidence base for reform.

The National Hospital Service reforms
During the last two decades, policy has been driven by investment in the hospital sector to “remedy” elective waiting time problems. This expensive investment has involved hiring more consultants, with little evidence of increasing productivity either in terms of average activity or outcomes.

It has, however, meant that the volume of elective activity has increased. The nice issue which needs evidencing, is whether the health gain of this activity is the same as in the past - or whether the marginal gain of doing more is declining. Are we getting as much or less “bang for the buck” from expanding activity?

To put it more provocatively, are treatment thresholds declining to ensure employment for all these nice, new consultants or are really needy patients gaining substantially from treatment?

In a recent British Medical Journal (January 22, 2011), it was noted that the last audit of cholecystectomy was carried out in 1997. So answering questions about thresholds and complication rates is obviously not so easy! As ever, policy and investment appears to be based on faith, rather than evidence.

Reining in the acute sector
Reformers should challenge where the hospital investment has gone and what health gains have been produced. They might also note that the power of hospitals has been such as to distort PCT funding away from community and primary care that might reduce the demand for institutional care.

Why should we expect GP consortia to behave any differently I wonder? Better control of hospital activity is urgently needed.

Where is the evidence that demonstrates that investment in primary care is cost-effective? Take for instance the GP quality and outcomes framework (QOF). This is a splendid example of provider capture.

Five years ago, academics noted that a considerable part of the QOF was lacking an evidence base i.e. GPs were being paid large dollops of cash to provide services of no observable benefit to patients. (Fleetcroft and Cookson, 2005).

To those that have shall be given

’Who’s afraid of the BMA? Answer: the Department and politicians!’

This week in the BMJ (January 30th), there is a splendid article demonstrating that the hypertension element in the GP-QOF appears to have rewarded practitioners for what they were already doing and produced no improvements in process or patient outcome.

Very well done, Department of Health! It is remarkable that the Department of Stealth continues to promise reform of the QOF, but delivereth nowt!

Who’s afraid of the BMA?

Answer: the Department and politicians! After all, ‘tis best to waste the taxpayers’ money and keep Hamish Meldrum and his colleagues happy. Isn’t it?

The trade unionists at BMA House favour the QOF becoming part of the GP’s general remuneration. They must be joking, surely? It is generally used to hire nurses to achieve the QOF.

Better to use it to pay nurses directly for tasks which evidence population health gain.

Data poverty
How administratively efficient is primary care? Primary care is data-poor - there is no national system of activity reporting similar to the hospital episode statistics.

In other words, we are broadly unsure what GPs do.

Instead, we have the QOF and prescribing data. The former shows increasing uniformity in practices because of the cash rewards. The latter, drug prescribing, shows large variations in cost and volumes: as ever, the dominant ethos is the John Wayne Syndrome which asserts, “a GP’s got to do what a GP’s got to do” - yet government and GP colleagues often know little about what GPs do!

A nice example of administrative efficiency is the payment of capitation monies. A colleague’s father reached the age of 65 and received a request to present for a retirement ‘MOT’ from a GP practice. The gentleman concerned had left the practice at age 6! Surely the practice has not been paid a capitation for 59 years for no services rendered, as the patient was signed up to another practice in another area?

The characteristics of primary care are variation and lack of transparency. This is a poor basis for Lansley’s reforms, which are to rely on GPs to guide commissioning and enhance patient welfare. The organisation of primary care, with its partnerships and arcane payment systems, is an anachronism untouched by evidence and accountability.

Which is hardly the basis for efficient reform.

As for evidence that the proposed reforms will be efficient, charities, academics and the media seem to be pulling their punches in emphasising this is a faith-based process. Perhaps all are too concerned about their funding and prosperity to hold our leaders to account?