The Maynard Doctrine: Continuous Revolution (again)
Health economist Professor Alan Maynard wonders, not for the first time, whether we shouldn't perhaps be evaluating some of the latest round of NHS redisorganisation
You will recall that Comrade Lansley’s 2012 Health and Social Care Act redisorganising the structures of the NHS and was described by Comrade Sir David Nicholson as, like the Great Wall of China, being visible from outer space.
Comrade Lansley has now been dispatched to the House of Lords and a non-executive role on the board of the Swiss drug dealers in expensive cancer drugs, Roche Pharmaceuticals. Nice one, Andrew!
Mao-Tse Stevens, while denying in his 2015 Five Year Forward View (FYFV) that he was intent on letting a “thousand flowers bloom”, organised a series of weakly-funded initiatives focused on structural change at the local level (Vanguards), and now blathers around “Sustainability and Transformation Plan” (STP) wheezes.
Post the FYFV, local innovators had to compete for funds to experiment in a variety of ways. Chairman Si was seemingly having no truck with gross structural reforms or unconstrained diatribes from NHS England.
Similar eruptions of reform have affected the behaviour of other healthcare systems. Concurrently, capitalist imperialists in the USA have, following the Obamacare reforms, been seeking nirvana as well. They needed to control the increased expenditure inflation resulting from the extended Federal funding of private insurance coverage.
The American reforms involved the discovery of 'value': the relevance of focusing on role of improved patient outcomes when controlling costs.
Consequently, there have been efforts to alter payment systems from fee-for-service to capitation and notions such as the 'medical home' with cash limits and a primary care focus.
Sound familiar?
The intent of innovation in the NHS and the USA is (as always) to demonstrate either lower costs with the same effect, or similar costs with improved outcomes. Workers in the NHS Kremlin (Quarry House in Leeds) have been required to establish baseline data and monitor progress in terms of improved innovation results. Any pilots that proved weak are to be exterminated, with associated managers paraded through the streets of their home towns in sackcloth and ashes (or quickly promoted to other jobs?)
So far, so good in principle for the apparently restricted intentions set out in Chairman Si's Five Year Forward View.
Yet these good intentions have been eroded by the Stevens reform virus spreading uncontrollably.
How?
The Five-Year Forward View has been augmented by yet further 'reforms' which are unevaluated and appear to be largely ad hoc. Reform should always be defined as experimentation deserving of careful evaluation.
The Department of Stealth has a research budget of over half a billion pounds. Yet the NHS reforms outside the FYFV ambit are not being funded to determine whether they are pie-in-the-sky or the best things since sliced bread!
What reforms am I referring to?
What have the following institutions in common?
A proposed single provider hospital trust for the greater Manchester “Poor” House?
The Royal Free London hospital chain?
Ipswich and Colchester hospitals merger?
Basildon and Thurrock and Mid Essex Hospitals Trust merger?
University Hospitals Birmingham Foundation Trust and Heart of England Foundation Trust?
Salford Royal and Pennine Acute merger?
Birmingham Women’s Hospital Trust and Birmingham Children’s Trust?
Nottingham University Trust and Sherwood Forest Hospital Trust (with the chief executive of the former wisely declining to take on the latter’s PFI debts of £20 million a year until 2043!)
Yes, my loves: you have got it! There is a tide of hospital redisorganisations or mergers!
What is the evidence base for this latest thought of Chairman Si and his merry bunch of anarchist innovators?
These providers' thesis seems to be that bigger is better. Is it?
One potential problem with this thesis is the creation of monopolies, which may be inefficient due the lack of competition. There is an English literature which indicates that in urban areas, there is evidence that competition among specialised hospitals is beneficial in some specialties.
Hospital mergers may encourage specialisation. There is a limited literature on economies of scale (the bigger-better thesis). For instance: the centralisation of stroke services in London brought improved outcomes for patients. Concentration of cancer services has also improved outcomes.
However, in paediatric cardiac surgery there appears to be inadequate specialisation. This continues despite the Bristol disaster in the 1980s where many children unnecessarily died due to poor care. Local patient groups protest against the rationalisation of services on the basis of survivor successes, with inadequate regard to family outcome failures.
Patient resistance to change is a powerful influence on improving resource use e.g. centralisation of A&E facilities. Such changes may be potentially cost-saving to the NHS. However they may impose significant travel costs for patients and their relatives.
The contentious debate about moving Leeds paediatric cardiac surgery to Newcastle or Manchester may ensure better outcomes for patients due to economies of scale. However, travel and hotel costs for parents ensure resistance to change which may not be beneficial for their offspring. Patient survivors protest, and the dead tell no tales!
For merged hospitals, the scope for exploiting economies of scale to improve outcomes and/or reduce costs seems limited. Private sector evidence of industrial and service mergers remains ambiguous.
US hospital evidence indicates that where there are local hospital monopolies their prices are higher. Does that imply for England that costs will be higher where local monopolies, enhanced by mergers, prevail?
Where is the evidence, please?
Then there is primary care!
Mergers in primary care are also proceeding apace. Naturally, we might expect again that such reform-experiments would be accompanied by evaluation. What is the efficient size of primary care practice?
Clearly the daft duplication of 'back office' facilities across many small practices, when rationalised, can save money.
An NHS England pharmacy gnome asserts that duplication in the number of pharmacies, if dealt with by 3000 closures, could also save money. It is apparently time for reform of local duplication in pharmacy! Stand by for squeals of delight from private equity-owned Boots.
The current inadequate funding of primary care imposes significant waiting times, especially if you wish to see your preferred physician.
If you are a patient with renal failure, cancer and heart disease and in receipt of significant medications, seeing a doctor unfamiliar with your multiple morbidities in a 10-minute slot may be unsatisfactory for the patient and the clinician.
Is bigger better, in terms of process, outcome and cost? Comrades, you are experimenting on patients, so why not evaluate?
What is the effect of skill mix difference on primary care processes, outcomes and costs? The Cochrane collaboration review of this shows how pathetic the evaluation of this issue has been. It remains central to the efficient provision of primary care. So let’s continue to neglect it and avoid confusing ourselves with facts!
Conclusions
Chairman Si's Five-Year Forward Plan decried the risk of a “thousand flowers“ blooming, but reform efforts have proliferated in response to his quest for £22 billion of NHS savings over five years.
The NHS is experiencing continuous revolution; as ever, driven by opinion rather than evidence.
Sadly you cannot stop local innovators running riot, as well as the comrades in the Kremlin reforming with a plethora of unevaluated wheezes including an epidemic of primary care and hospital mergers and the “STP zika virus”, which shrinks intellects and imposes significant wasted managerial time.
Both local and national managers should recognise that all reforms are experiments which merit systematic evaluation. The absence of this ethic has dominated pathetic leadership initiatives for decades. Time to deploy the Daleks into the wonderful world of leadership investments!
Even if this were to change, a remaining problem would be the funding of evaluation. It beggars belief that Department of Health research funds are not prioritised to fund continuing epidemics of NHS reform.
Chairman Si has let the reform cat out of the bag: it may prove to be a tiger. His decision to let a “thousand flowers bloom” nationally and locally is continuous revolution on a scale similar to Comrade Lansley.
The challenge is whether his reforms produce superior outcomes and lower costs compared to the Lansley, Milburn and other 'great' reformers of the last four decades.
To demonstrate such success, perhaps the House of Commons Select Committee on Health might focus on two initiatives: evaluation of reforms, particularly those outside the remit of the Five Year Forward View; and its funding from the Dear Leader Jeremy’s research coffers.