The Maynard Doctrine: Managing ambiguity – is discretion the better part of valour?

Health economist Professor Alan Maynard  picks the three big themes of which we must beware over the implementation of the 2012 Health And Social Care Act.

Nigel Edwards recently wrote in the Health Service Journal that the Health and Social Care Act is, in my words, a dog’s breakfast.

If the initial White Paper had any logic (and we could debate that till the cows come home), then after over 1,000 amendments, those proposals turned into a vortex of horse manure which can confuse the public and NHS operatives.


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This may be a cock-up - always likely - or a conspiracy, although some might suggest that such an endeavour may be beyond the ability of our politicians!. Whatever it is, there are gross ambiguities which have to be managed with care.

Here are some with which to engage your grey cells:

1)  The future of the National Institute for Health and Clinical Excellence (NICE)
At present, NICE has three roles:
i) Technology appraisal of new pharmaceuticals and equipment
ii) Cost-effective clinical guidelines
iii) Cost-effectiveness of public health interventions

All three functions require the application of scientific methods. The activity which has annoyed commercial interests most is technology appraisal.

Big Pharma appears to have lost the plot, with business methods that are failing to bring new cost effective products to market. Furthermore, the patent life of products which have been “lovely earners” for Pfizer, GSK and Astra Zeneca are expiring with crunching effects on their profits as generic companies invade the market with lower (but not low enough!) prices.

The pricing is right?
In 2007, the Office for Fair Trading proposed that the Pharmaceutical Price Regulation System (PPRS), which has existed in various forms since 1957 and kept UK companies in the style to which they are accustomed, was to be abolished. It is proposed that PPRS be replaced by a system of “value based pricing” (VBP) in 2013-14.

Determining value requires rigorous economic evaluation, which NICE’s technology appraisal groups have developed well over a decade.

There is now a risk that this rigour will be thrown out of the window. Rumour has it that NICE will lose the technology appraisal function. It will be transferred to the Department of Stealth. This risks diluting a scientific approach with a potentially politically-corrupted approach.

Such dilution will be attractive to politicians, given industry lobbying powers and the desire of government to use of the industry to produce jobs and exports.

When the fight comes, my dears, we must stand up for NICE and science - and object to political dilution of rigorous and explicit methods of technology appraisal developed by NICE and largely now accepted by industry.

NICE’s work in this area is recognised as good throughout the world. Why destroy something that works?

2) Payment by results (PbR), Monitor and Foundation Trusts
The new NHS Act allocates the role of fixing tariffs to Monitor - which is also the regulator and protector of Foundation Trusts. This is daft.

Given the purchaser-provider split, the national commissioning agency is the NHS Commissioning Board (NCB). Its role is to commission health care directly (e.g. for specialist services) and indirectly via clinical commissioning groups. The NCB, as the demand or commissioning agent, should set prices i.e. should have control of PbR tariffs. PbR is a means by which a regulator can manipulate the activity of hospitals e.g. by cutting tariffs and incentivising day case surgery.

To allocate the role of price-setting to Monitor creates a conflict of interest. Monitor’s role is to regulate the supply of healthcare provided by Foundation Trusts - i.e. to protect their interests. To give them the means to succour FTs by manipulating tariffs seems quite silly, but is indicative of the confused nature of the new NHS legislation.

3) Primary care provision
Primary care provision is the orphan of NHS reform since redisorganisation became fashionable in 1974: does no one love primary care? Is it impossible to improve?

The political rhetoric is that primary care is of key importance in caring for patients. But Thatcher and Blair largely ignored it. They focused on attempts to create efficient commissioning and reform of hospital care, as epitomised by Hospital Trusts from Thatcher and Foundation Trusts from Comrade Blair.

So what to do with primary care? How will the commissioner of primary care, the NHS Commissioning Board, set rules and discipline deviants?
I offer some suggestions in a forthcoming paper in the Journal of the Royal Society of Medicine. As a taster, do you think Lansley and the NCB will go for competitive tendering of primary care and “Any Willing Provider”?

Conclusions
Out of the chaos of the current legislation, many if not most are asking ‘whither the NHS?’ (‘Wither the NHS?’)

One person’s chaos is another person’s opportunity. So scrutinise the legislation carefully. Where it is ambiguous, exploit the opportunity to do your own thing and march on!

But do keep you guns ready on issues such as those discussed here. Without your careful consideration and voice, patients will suffer and nitwits may triumph!

Politicians have to be persuaded to act sensibly. The ambiguities of the legislation should be managed in interests of the public - and not in the interests of sectional interests with access to the Secretary of State’s office.