The Maynard Doctrine: Table manners at the healthcare feast - advice for Simon Stevens

TOP SECRET
Briefing from Professor Nala Dranyam, Kroy University, People’s Republic of Yorkshire to the incoming Chief Executive of the NHS, Simon Stevens

TABLE MANNERS AT THE HEALTHCARE FEAST

Dear Comrade Simon

Welcome to the increasingly parsimonious healthcare feast. Following four years of austerity during which the NHS “ring fenced” budget has been raided twice to fund social care (£1bn in 2011-12 and planned £3bn in 2015-16), NHS activity and adherence to performance targets has survived quite well.

This is a product of significant downward pressure on real wages. This has been the easy response to your predecessor’s demand to save £20bn over 4 years. Comrade Nicholson’s hope that NHS productivity would increase has proved difficult to fulfil. It is now your priority. The behaviour of clinicians and managers at the NHS feast are clearly deficient

Here is a list of actions that require your prompt attention.

1) Variations in clinical practice
Clinicians and their teams guzzle scarce NHS resources in often un-evidenced excess. You will recall that for over 75 years, there has been evidence of unwarranted variations in clinical practice. Before the NHS, Glover analysed the extraordinary variations in tonsillectomy rates (Journal of the Royal Society of Medicine, 1938).

McKinseys offered a simplistic analysis of variations in 2009; commissioned by Labour and lauded by them and Coalition ministers. As ever with management consultants, they offered contestable data about variations and no evidenced method of reducing them.

You will have seen American evidence of variations in healthcare expenditure in Medicare, a federally-funded programme for the elderly, and the private insurance sector. This shows that private sector expenditure variations are due to price discrimination, i.e. charging widely differing prices for the same procedure.

UK private providers also play these games. The excess appetite of US providers was epitomised by the scandal of one provider charging $1000 for a pap smear! Clearly, American healthcare providers are greedy pigs sustained by fee-for-service remuneration systems that permit excess access to the healthcare feast. You will be familiar with this after 11 years working in the USA for United.

Variations in US Medicare expenditure are indicative of different choices being made by providers at all levels of the system: state, county, hospital and individual clinician. US providers gobble excessively at the healthcare feast, particularly in post-acute care. As in the UK, commissioners of care (be they private insurers, clinical commissioning groups or health boards) need to improve providers’ manners and ensure a restricted, safe, evidence-based diet!

2)  Incentives
Health systems worldwide are trying to change the behaviour of public and private provider gluttons at the healthcare feast. Conservative safe eating (and clinical practices) could save 20 to 30 per cent of the cost of healthcare feasts, depending on which estimate you adopt.

But how can we alter the gluttony of providers? Should we pay ‘em or flay ‘em?

Improving the table manners of providers with financial incentives is the current Holy Grail of health policymaking. However, the evidence base in terms of the cost-effectiveness of financial incentives is poor. Measures of effectiveness are generally weak process measures rather than outcome-based, and most studies tend to ignore cost.

Furthermore, financial incentives are a statement by employers that they do not trust employees to do an honest day’s work. This undermines trust and, as Confucius argued, “without trust we cannot stand”.

The alternative to paying them or bribing them to behave at the healthcare feast is to flay ‘em. This route involves performance transparency and using reputation and duty as the motivators of change. It emphasises social dependence on trust, and the force of the embarrassment of outliers driving improvement. This approach is epitomised by the cardio-thoracic surgeons of GB and Ireland using transparency and audit to drive down their complications and kill rates in patient care.

3) Evidence-based policy
Our political masters and their opponents utter the rhetoric of evidence-based policy making and, then like true hypocrites, adopt policies that maximise votes. This is inevitable, but you must challenge them: not only in regard of healthcare but also with regard to health production.

Corporate-induced diseases produced by alcohol, tobacco and food should not be ignored even by a Conservative administration dependent on funding from corporate gluttony at the health care feast e.g. Big Pharma’s inexhaustible greed.

As with evidence-based decision making, there is a tendency to ignore inequalities in health and healthcare. The major cause of increased demand is not age but multi-morbidities.

A comparative analysis of multi-morbidities across income groups shows that the poor have more problems and earlier in their life cycle. Thus not only do the poor die earlier, the quality of their life is also inferior to that of more affluent citizens.

Can you persuade the NHS to develop efficient interventions to reduce these inequalities? Pressing the NHS to improve its performance with regard to equity has potential electoral returns and may keep protesters off the streets. At present, the NHS tends to tick boxes, but does too little in this crucial policy area.

One of the many challenges you will inherit is the transfer of “ring-fenced” NHS funds to social care. The transfer is essential, as recently both the National Audit Office and the Nuffield Trust and the Health Foundation have pointed out how social care budgets have been savaged since 2010.

Unsurprisingly this is creating bed blocking and misery for the old and vulnerable. These folk normally do not vote in large numbers but there is a significant risk that the patient lobbies may mobilise them.

Hence the “Better Care Fund “and the transfer of £3billion from the NHS to social care in 2015-16.

The NHS, with local authorities, is now planning how to use this money to reduce acute care. Sadly there is no evidence that investing in “integrated care” and the like reduces hospital admissions. (See for example the DH-funded Research Paper 97 from the Centre for Health Economics at York). You'd better read this, even if colleagues in Whitehall Village remain largely ignorant of how its contents will cause much dyspepsia among feasting NHS and local government managers.

With regard to the latter, they are even worse than ministers when it comes to harvesting the fruits of research. As ever, this is a product of academics’ weaknesses in marketing their “wisdom” and managers attending useless “leadership” courses that do not equip them to access and interrogate the available evidence. The consequence is that managers repeat the errors of their predecessors.

This is an inefficient and unethical use of taxpayers and patients scarce resources. I look forward to your reducing this waste by reforming “leadership education”, for starters.

Conclusions
Enjoy your tenure. We are confident that with your formidable skills you will be a success and not a David Moyes; poor soul.

The Secretary of State appears slow in making difficult decisions and anxious to wrest power back from NHS England, particularly when it gives him press coverage which may influence voters. Number 10 is anxious to get some difficult merger and privatisation deals done in time for the electorate to forget it by next year.

The Opposition promises “no top down” re-disorganisations, while indicating it will merge health and social care, which will be a massive “bottom up” re-disorganisation.

These folk will tax your patience considerably. Plus ca change; plus c'est la meme chose!

Fraternal greetings,

Comrade Nala Dranyam