The Maynard Doctrine: Evaluating quality initiatives

Professor Alan Maynard OBE challenges the Whitehall Village People to evaluate their initiatives around quality for cost-effectiveness

The Government has recognised that ‘it ain’t what you spend, it’s the way you have spent it’ that matters to patients. They are interested in whether healthcare makes you “better” or, as Hippocrates and Florence Nightingale both emphasised, does no harm!

Hospital healthcare harms one in ten
There is all too little evidence about whether healthcare makes you better and worrying evidence that it does patients harm: one in ten patients entering hospital experience an error. These errors range from the minor to avoidable and premature death.

After several decades of research demonstrating these problems, the evidence has trickled down in Whitehall Village and engendered the usual response: missionary zeal to eradicate the problems, in this case, by improving “quality”.

The current quality initiatives is reminiscent of the late Sir Raymond Hoffenberg who, as then President of the Royal College of Physicians, remarked in response to the Thatcher reforms in 1990 that “instead of making ready, taking aim and firing, the Government chose to make ready, fire and then take aim”!

New Labour trousers with deep, holey pockets

As it was in 1990, so it is with the current Thatcherites in New Labour trousers

As it was in 1990, so it is with the current Thatcherites in New Labour trousers. After splurging billions of pounds on the NHS, Ministers are now wondering where the health gains have accrued or whether much of the additional expenditure has gone into the pockets of drug dealers and the labour force, with all too little benefit to patients.

Academics aloft in their Ivory Towers predicted  this outcome at the outset of the Blair expenditure boom. They were ignored, as Ministerial advisers and civil servants did not like being reminded of how healthcare systems worked!

As a consequence, these guilty folk have now adopted a new religion: quality. The nice issues are whether it will work and whether it will survive the expenditure crunch induced by Thatcher-Blair “liberalism” of now-floundering financial markets

Reducing variation: does it work?
One strand of the quality initiative is the use of interventions to drive up and reduce variance in healthcare process standards in areas such as heart failure, heart attacks, pneumonia and hip and knee replacements. The US Premier-Medicare programme has this objective and been running for five years. Does it work?

North West SHA believes it does. They have piloted an emulation of Premier, and are now rolling out the package across the region. Evaluation has been commissioned. Other SHAs are impressed by the North West and are moving to adopt this approach as part of CQUIN.

But does the US system work? It all depends on how you define ‘work’. There is evidence that adherence to the process targets improves and the variance declines.

Outcome over process
But so what? ‘The operation was a success but the patient died’! Processes may be excellent: what about patient outcomes? Do you reduce or worsen avoidable premature mortality? Recent research shows no change - i.e. patient mortality does not appear to alter after considerable investment in setting, monitoring and incentivising changes in the processes of care.

Why? The impressive thing about this literature, like so much in healthcare, is that the evidence base is very limited in quantity and quality. Premier has invested resources to change practices - i.e. they have experimented on communities in the USA. Furthermore, they have marketing their brand successful in the UK and elsewhere. But where is the evidence of value for money?

Costing quality
Minsters and civil servants in Whitehall Village have invested much effort in improving quality. Their intent is welcome. However their practice may increase costs, with little benefit to patients in a time of acute fiscal difficulty.

Here are the challenges for Whitehall Village. Where is your investment in the evaluation of Commissioning for Quality and Innovation (CQUIN)? Where is your investment in the evaluation of patient-reported outcome measurement (PROMs)?

Or, as ever, are you planning to assert cost-effectiveness and blame the next Tory Government for their failures to put in place appropriate safeguards for the taxpayer and the patient?

Moreover, where is the Opposition in flushing out answers to these fundamental questions?