The Maynard Doctrine: Cutting costs in the NHS

Professor Alan Maynard welcomes greater attention to costs and quality, but warns that doing the right thing brings a fresh set of dilemmas along with it.

The NHS budget is set to stabilise.  Indeed with a Darzi-enhanced NICE and the impact of ageing on NHS demand, the real rate of growth of NHS budgets over the next five years may be negative.  

Why?  The financial crisis has induced recession and the short-term Keynesian solution to unemployment is for government to spend.  However this, plus the cost of supporting the banking system, has created a fiscal deficit of unparalleled proportions.

As the UK economy recovers in two to three years’ time, this deficit will have to be reduced radically, with higher taxes and less public expenditure.  Hence, there is a threat to NHS funding - particularly after the election.

Time – at last – for real reform?
This threat makes healthcare reform urgently necessary.  For decades, reform that reduces evidence free variation in clinical practice has been advocated vigorously in North America and Europe.

In England in 1976, the Government demanded in Priorities Fort Health And Social Care that NHS managers address the issue of variations in the uptake of day surgery and differences in hospital length of stay.  The Department pointed out that only with such improvements in efficiency could the NHS survive a zero rate of growth in funding in 1976-77.

In more recent times, Frank Dobson when Secretary of State in 1998 reiterated the 1976 theme: reducing clinical practice variations benefits patients and saves money.  Subsequently, the Commission for Health Improvement (CHI, 2001-2004), the Healthcare Commission (2004-2009), the Darzi report and the Commission for Quality and Care (CQC, 2009-????) have sought to set standards and reduce variations in clinical practice.

’ NHS managers have been reluctant to translate the evidence of clinical practice variation into safer, high-quality care because they feared that clinical colleagues would react adversely and damage the effective pursuit of government performance targets’

Don’t scare the doctors
However, NHS managers have been reluctant to translate the evidence of clinical practice variation into safer, high-quality care because they feared that clinical colleagues would react adversely and damage the effective pursuit of government performance targets.  The consequent substantive damage to patients and taxpayers is now set to haunt them.

“Efficiency savings”, “cost improvement programmes” - call them what you will - mean managers, clinical and non-clinical, now have to focus on reducing the cost of services whilst preserving good patient outcomes.  Hospitals must urgently implement PLICs (patient level information and costing) to identify cost variation and vigorously manage its reduction.

Benchmarking the costs of common procedures is urgently needed also to focus management change. Similar benchmarking of lengths of stay and service characteristics such as the extent of day surgery, particularly with a focus on the 50 health related groups (HRGs) that generate the bulk of most hospitals business, is also necessary to identify outliers and shift average practice to more efficient levels.

The optimists argue that reducing variation and improving quality will save money.  The word “quality” needs careful definition.  Setting national standards of care as NICE recommends and benchmarking may improve care processes and reduce variations in clinical practice.

However, adherence to practice standards and benchmarks has to be complemented by measurement of patient outcomes to ensure that the benefits of health care in terms of improving the length and quality of life of patients are the best possible. Simple reduction of costs and benchmarking of utilisation may damage patient health if carried out in isolation from outcome measurement and management.

Investing in outcome measurement
The Government is investing large sums in outcome measurement.  It is expanding the publication of mortality data and, beginning from April 2009, will develop a comprehensive system of patient reported outcome measurement (PROMs).

The tender to supply PROMs is about to be published, but the cost of this radical initiative is not known.  Furthermore, the management of the results of the PROM system will also be significant.  For instance, early pilots show that for hernia repairs, cataracts and varicose vein procedures, a significant minority of patients do not experience improved quality of life.

How will this be managed?  Are patients being treated inappropriately?  Or are the instruments used to assess physical and psychological wellbeing before and after such procedures inappropriate?  

’ Whitehall is ever captured by the “sexy”, and loves to try to run before it can walk.’

The political and clinical challenges involved in the management of such data, particularly if published on the NHS Choice website, may well be very demanding for managers used to hiding behind a” veil of ignorance” about such matters!

It will also be “challenging” for patients and practitioners. How will patients make their choices? What to do with poorly-performing practitioners? Sadly these issues are being lost in the rush to do the sensible thing and measure patient outcomes.

But what’s new? Whitehall is ever captured by the “sexy”, and loves to try to run before it can walk.