The Maynard Doctrine: Evidence-based healthcare policy: please do it better!

Professor Alan Maynard OBE notes the lack of evidence for the 30-day unpaid emergency acute readmission policy, and politicians’ and policymakers’ poor use of evidence more broadly.

Politicians in all parties advocate the use of evidence in making difficult policy decisions.

Sadly, the translation of this principle into practice is generally pathetic. The current example of this is the imposition of hospital fines for patients readmitted to hospital within thirty days. DH evidence and medical opinion concurs in regarding this as daft.

The nice issue is this: from where do policymakers get their ‘evidence’?

Think-tanks vary in quality, from the barmy to the useful.

Itinerant gurus ply their trade: if located in London, and medically-qualified or ‘economists’, their often evidence-free noise has a disproportionate effect on the gullible and generally quite ignorant national media and politicians avidly reading evidence free drivel in the Daily Mail and Daily Telegraph.

Policy zombies
As a consequence of these burblings, the policy arena is infected with what Canadian Professor Robert Evans dubbed ”policy zombies”. These are discredited policies that are continually brought back to life by exponents funded by interest groups who would benefit (more money for cancer care and redisorganisation of the NHS on a social insurance basis, deploying extensive user charges).

In the Department of Stealth, recourse to evidence is uneven. The use of consultants results in general and broad sweeps of views and evidence which then are neatly packaged into reports that are accessible to time-pressed senior policymakers who generally lack training and skills to interrogate what is before their eyes.

Often, such reports offer some useful diagnosis but no evidenced advice on how to treat the problem. For instance, the recently released McKinsey report on recycling £15-20 billion in the NHS offers managers well-known problems for improved resource allocation, but no evidenced advice on how to resolve them

The Department’s specialists, such as operations research practitioners, economists and statisticians, are skilled but unevenly deployed. They should be used more, to confuse policy proposals with logic and evidence so as to offer better diagnostics and implementation advice. That this does not happen enough is evidence of the sidelining of analytical input.

Ministers and policy
Then there are Ministers. They have a highly-pressured life, and advisers who often lack the skills to filter evidence and offer good-quality intelligence to their bosses.

Like the civil servants, advisers’ priority is to keep Ministers out of the “slough of despond”. Engineering this is time-intensive for often talented and highly supportive individuals.

The opportunity cost is that the time available to confront NHS inefficiencies in novel and evidence-based ways is limited.

Academics and policy
The role of academics in Whitehall policymaking is limited.

Many of these people are busy meeting University research and teaching commitments: attendance at ill -ocused meetings in Whitehall village may not score highly on their private, let alone public, agenda. When used, academics tend to be treated as “free goods” and may not even be offered reimbursement of travel costs!

’The new Government seems as if it wishes to continue an amateur and unprofessional approach to policy formation. This will ensure that the NHS is endangered, as well-researched problems remain unmanaged and waste stymies the development of patient care’.

Furthermore, academics may be more expert in some areas than civil servants (let alone advisers). As such, they can be a threat, when they should be used collaboratively to ensure better evidence-based policymaking.

A nice example of this was the development of payment by results (PbR) for reimbursing hospitals. The Department acted as if this was a unique and original policy, when the evidence base was over 20 years old with much to learn from US and Australian experience.

Sadly some senior bods in the Department were determined to develop hospital tariffs in isolation from policy expertise of “know-all” academics!

As a consequence, English policymakers learnt from their own industry and errors, rather than exploiting swiftly and systematically the available international evidence base.

Always adopting the US model
However such “isolationism” is not always the case. The current explosion of policy innovation emulates American experimentation with financial incentives.

For instance: Commissioning for Quality and Innovation (CQUIN) is copying elements of the Premier-Medicare programme in the USA. The evaluative evidence from the USA shows that whilst incentivising adherence to process guidelines for some clinical care areas reduces practice variation, it does not reduce costs or improve mortality outcomes.

As ever, “confusing” policy with such evidence has not affected the energetic adoption of apparently failing US policies!

The silo trap
Outcomes such as this are a product of silo-ed policymaking. The politicians seek remedies for often ill-defined problems. Civil servants and advisers design solutions to these nebulous problems, all too rarely consulting evidence bases such as Cochrane, let alone academics up their ivory towers!

The causes of this silo mentality are many and complex. Trust is one issue, and this can be challenged by academic-style “knockabout” discussion methods that can be quite alien for some in Whitehall Village, who prefer not to ruffle feathers even if the bird is headed for the mincer!

The new Government seems as if it wishes to continue an amateur and unprofessional approach to policy formation. This will ensure that the NHS is endangered, as well-researched problems remain unmanaged and waste stymies the development of patient care.

It really is time that politicians, their shadowy advisers, civil servants and academics collaborated better to improve patient outcomes.