The Maynard Doctrine: It's the clinicians, stupid!

Health economist Professor Alan Maynard reflects on political learning and real reform

Fashions come and fashions go, but clinicians - primarily doctors - still largely determine what healthcare patients receive. They lead the teams that consume £107 billion of taxpayers’ hard-earned money a year. Their vagaries, waste and unwarranted clinical practice variations can determine your survival as much as their energy, humanity and efficiency.

However, they have been largely ignored by policymakers focused on NHS reform - perhaps because they are successful income-maximisers with considerable capacity to embarrass politicians with their lobbying expertise.

Yet gradually, even our daft politicians are recognising that continuous re-disorganisation of NHS structures have little impact on how these primary determinants of resource allocation known as doctors work. Currently, our political Lords and peasants appear to be reaching a consensus that may prevent more top-down and evidence-free reforms.

Go back to your constituencies and prepare for another Health Act
The potential outlier in this consensus is Labour. They have pledged to repeal the 2012 Health and Social Care legislation. Surely, comrades, you can get rid of competition and all that comes from  Alan Milburn’s “innovations” (which you now abhor) by repealing just Part 3 of the Act?

Furthermore, your health lead, an Everton FC supporter apparently, needs to think carefully about his pledge to merge health and social care activity and budgets. Shouting loudly like some football supporter may gain a few votes from Labour councillors lusting after the NHS budget but may also produce Lansley-style distress.

This is another evidence free leap of faith, which might best be piloted with evaluation perhaps? Come on Andy! Your team would not hire any old footballer! They would trial ’em! Can’t you do this in your NHS role?

Much America, only one Kaiser
Whenever the learned occupants of Whitehall village discuss integrated care, they all proudly announce they have been to, and recognise the efficiency of Kaiser Permanente in California. Is their adulation perhaps in part a product of local sunshine and wine, which has rotted their few remaining neurones? Kaiser does appear to be efficient, but it has never spread or been replicated in the USA, let alone in this colony of America in which the NHS operates!

Why is that? Look before you leap, dear things!

Other examples of integrated care cited by enthusiasts are Torbay in England and Canterbury in New Zealand. Some lessons can be drawn from these examples. The primary lesson appears be that the journey to integrated Nirvana takes time.

Lining up all the ducks in a row so that they agree on direction and incentives cannot be conjured up by some politician in Richmond House, Whitehall dreaming a dream and trying to legislate next day. The ducks include often wayward souls such as hospital consultants and GPs; groups as easy to herd as cats on cocaine.

The purchaser-provider split: past its sell-by date?
A more trying problem with integrated care is the purchaser-provider split. It maintains the fragmented provider budgets of hospitals, primary care and social care. Each of these “empires” fears income and power losses that integrated care may create. Nick Timmins’ tome on the Lansley reforms quotes Ken Clarke (the Secretary of State involved in implementing the Thatcher reforms): “If one day subsequent generations find you cannot make commissioning work, then we have been barking up the wrong tree for twenty years” (Clarke, 2008 in Timmins, 2012).

Has that day come? CCGs are price/PbR and quality takers: they buy blind largely? Tariffs drive up expenditure, with well-endowed CCGs now agreeing block grants with providers. Less well-endowed CCGs lust after such agreements which switch over-activity risks back to providers.

Nicholson’s challenge of saving £20 billion over the last 4 years was largely met by pay freezes PbR tariff reductions exceeding 10% since 2010 and “interesting” accountancy which included clawing back the unspent budgets of sad PCTs, even though they were often located in deprived areas. Have any of these devices been evidenced as efficient i.e. producing better quality care at least cost? How will the £20-30 billion savings needed in the next 4 years be harvested?

One temptation for politicians pledged to have no more top down reform would be to abolish CCGs i.e. the purchaser-provider split. Their abolition could save a few billion pounds perhaps? Tiny CCGs such as Corby (65,000 population) and Bradford City (circa 110,000) will probably perish/be merged as the 210 CCGs shrink to the circa 150 PCTs of yesteryear. CCG abolition is unlikely, but may yet tempt the impecunious mafia in Whitehall?

Does integrated care imply the abolition of the purchaser-provider split by merging all health and social care into one pot managed for the benefit of the community? Does the experience of NZ’s Canterbury imply this?

All change?
Budget pooling, either voluntarily-collaboratively or by explicit abolition of the purchaser providers split, may oblige the fragmented medical profession to collaborate. Instead of GPs and consultants sitting in their fortresses and occasionally lobbing insults at each other, might they work together to create evidence-based care pathways and reductions in long observed and unwarranted clinical practice variations?

Or will inefficiency be maintained? The medical myopia that has maintained inefficiency appears to be eroding, due to the combined influences of improved management and performance transparency.

The creation of centralised stroke services in London and the development of integrated care in NW Thames are indicative solutions being created and managed into practice by medical consensus. The lesson is cuddling the comrades can lead to productive change!

Keogh’s efforts to spread the use of comparative performance data to motivate change are based on his earlier work with cardio-thoracic colleagues who appear to have reduced mortality and complications by 50%. Now ten further surgical specialism and groups of physicians are to report their performance characteristics. Such transparency was advocated by Thomas Percival in 1803! At last, there is some progress.

Since 1974, the NHS has been re-disorganised regularly with little effect on clinical practice. Each reform has been based on the need to improve efficiency, and ignored the fact that the primary determinants of efficiency are doctors and their teams.

The nice question is whether policy makers are ignorant, stupid or both. It’s the clinicians, stupid! Motivate them to heal themselves!