The Maynard Doctrine: Simple Simon says

The new chief executive of the NHS in England is rightly challenging his one million plus employees. They consume £110 billion of scarce public resources providing care for a population exhibiting complex co-morbidities.

Patients are often poorly managed in a fragmented system of provision where unwarranted variation in practice and quality is the norm.

Doctors and evidence
Evidence-based change is elusive both in treatment and ‘service redesign’. Doctors have been educated, to varying degrees, to follow NICE mandates and guidelines and take notice of systematic reviews in the Cochrane database.

They still have a wicked tendency to focus on clinical effectiveness to the neglect of cost-effectiveness. This is often epitomised by their ignorance of the financial consequences of what they do

Managers and evidence
Compared with doctors, managers are generally ill-equipped in the use of evidence and the ability to design efficiently the evaluation of new policies. Simple Simon (SS) said at the NHS Confederation conference in June “service redesign should be tested as rigorously as new treatments.

Amen! Let us all adhere to this gospel! But why is this demand being made by SS?

A batty economist like the present writer inevitably analyses such a problem using Econ101 i.e. what are the failures in this market, and are they on the demand side, the supply side or both?

The supply of evidence
Let us start with the supply side: who are these researchers up their academic ivory towers? They aspire to be well paid Professors, and the route to such “canonisation” requires that they are proficient at plundering public and private sources of research funding. Indeed their performance indicators often now require them to harvest £1-200,000 pounds a year to maintain job tenure.

However, loot is not the only criteria by which they are performance-managed. They are also required to publish in high-quality, peer reviewed journals. No kudos for these folk by disseminating and publishing in what they often snootily call “comics” such as the Health Service Journal (let alone Woman’s Own or ‘quality’ newspapers!)

Researchers are rewarded with increments and additional research funding by publishing in The Lancet, Journal of the American Medical Association, the British Medical Journal and the New England Journal of Medicine. For health economists, the nirvana of publication is Health Economics and the Journal of Health Economics.

Sadly, there are few managers who read such prestigious “comics”. Consequently whilst the knowledge base progresses at the margin, managers generally fail to keep pace with developments.

Slowly, progress is being made - but it is maddeningly slow. Take for instance the “highly ambitious” (for which, read ‘daft’) Better Care Fund proposals. They require integration of services so that social care investments reduce hospital admissions.

DH-funded research has shown that investments outside the hospital (social care) appear to reveal additional patient demand rather than reduce the demand for hospital admissions. Published as Research Paper 96 by York’s Centre for Health Economics (CHE), this has been reported by the British Medical Journal, and apparently given SS cause for concern.

CHE Research Paper 97 demonstrated that the main cause of increased demand for health care was not age but co-morbidities, much of which appears before the age of 65. Again, this was disseminated nicely in the Health Service Journal.

So why are researchers such as these Yorkies getting their output out to a wider public at last? Incentives are the answer! The current Research Assessment Exercise is focused not just on research income and publications in “good” journals, but also on demonstrating “impact” on public policy and science.

So the supply side of evidence about “service re-design” is getting better incentivised - but how can the demand and use of evidence amongst managers be better organised?

The demand for evidence
NHS managers should be one of the primary consumers of health services research. Sadly, much of it passes them by. How can they be better equipped to exercise their demand for evidence?

The first focus should be improved “leadership” training. Promotion in management should not be solely affected by inadequate courses at eminent establishments (i.e. nice nosh and touchy-feely material).

Instead, managers need to be trained in statistics, economics and epidemiology so that they can access and apply the result of research colleagues.

Such training must generate the capacity amongst managers to ask the right question. Efforts by academic colleagues to identify managers’ priorities are often very frustrating. All too often, managers want answers to lots of ill-conceived and vague questions. Clear focus and prioritisation is elusive.

Also (back to Simple Simon), they need the skills to understand evaluation design and work with academic colleagues to carry out meaningful rather than “toytown” evaluations. The National Institute Health Research in conjunction with the NHS has established university research capacity to assist NHS managers to do proper (rather than crackpot) evaluation of service re-design. These academics are seeking NHS partners: inquire at your local university to access these networks.

The Better Care Fund programme has created a storm of ‘innovation’. True innovation is an activity that results in reduced cost for the same patient outcome, or an improved outcome at the same cost. How many Better Care Fund innovations will demonstrate such efficiency?

Currently, there is no collection of data to identify replication (we need a national data of who is doing what evaluations in policy change, please!). There is evidence of blunderings into service changes before evaluation design is agreed and baseline data are collected.

A neutral observer might conclude that the Better Care Fund panic has induced a madhouse of feverish managerial activity, from which little new knowledge will be gathered. Hopefully this will be proved wrong but in the meantime no wonder SS demands proper testing!

Someone should compute the opportunity cost of this policy churn, including the requirement for five-year plans which Russia and India gave up years ago.

Conclusions
Muir Gray has long advocated the creation of management posts for knowledge officers: folk with the skills to use and integrate evidence and evaluative techniques in hospitals and commissioners. This might be helpful: it would need evaluation!

However, most of all both academics and NHS managers should listen to what Simon says and stop wasting taxpayers’ money by drunken optimism in un-evidenced and unevaluated experimentation on innocent patients! Simon says service re-design must be tested. But please: not in the amateur way which dominates usual managerial practice!

Staying in the game
If you listen to the song “Simple Simon Says” on the web, you will note that if you follow SS’s instructions “you will never be out” of the game!