The Maynard Doctrine: Ten NHS Commandments for 2012.

Health economist Professor Alan Maynard acknowledges the festive season of goodwill with the generous provision of ten commandments for the NHS in 2012

The expensive diversion of NHS reform will drag on until April-May as their Lordships scrutinise their backsides. Of course the NHS is in turmoil of wasteful change, and the pressures from this will accelerate as 2012 matures.

So how to keep your head above the waters of Whitehall drivel? Here are ten commandments for NHS managers in 2012. Ignore them at your peril.

Each should be built into local commissioning and the work of the NCB (also known as the NHS Commissioning Board). Management teams’ performance should be scrutinised in relation to adherence to these commandments, with personal failure leading to dismissal as set out in new employment contracts.

The first group of commandments relate to the stupid propensity of NHS managers (this category includes doctors and nurses, of course) to collect data, send it to the Department of Health / the NHS Information Centre and ignore it locally.

Managers indulging in such behaviour should be shot if they fail to invest in analytical capacity to use these rich data to improve the productivity of their organisations

Thus:

Commandment 1 - Thou shalt not report hospital reference costs that are clearly inaccurate, and thou shalt by end 2012 ensure that these cost data are accurate and based on high-quality PLICs: patient level information and costs.

If thou cannot identify which of thy activities (e.g. ENT) are making a profit and which are making a loss by June 2012, hasten thee to a labour matched to thy skill-set. Such as portering.

Commandment 2 - Thou shalt not ignore Hospital Episode Statistics (HES) data and the variations in clinical activity that these reveal. Thou shalt identify low activity outliers and ensure thy Medical Director has an adequate explanation of their work activities. Thou shalt have at thy fingertips data from HES such as: the number of COPD / asthma / other “frequent flyers” who, due to thy negligence, are receiving poor care; and the number of avoidable and non-avoidable readmissions.

If thou art a CCG price-and-quality maker, thou shalt require the local GP practices to integrate their information systems and provide thee with activity data by October 2012. Failure to do this should lead to practice incomes being cut in a one per cent monthly escalating fashion, starting at 10 per cent

Commandment 3 - Thou shalt not ignore mortality and patient reported outcome (PROMs) data. The Department of Health (November 3rd, 2011) and Dr Foster (November 28th, 2011) have published mortality data for all NHS trusts in England. Dr Foster has augmented this with data on mortality after simple procedures and patient views about care. These are useful data, which reveal how often trusts do not know what they should about their own data and time trends therein.  

In addition to mortality data the Department of Health has invested heavily in PROMs. This programme requires the collection of quality of life data before and after treatment: the first 2009 tranche of PROMs focuses on hip and knee replacements, hernia repairs and varicose veins.

As ever, NHS managers have responded unevenly. Some are collecting data for all patients having these procedures; some have been quite poor. In 2012, comparative tables of PROMs success will emerge which will show outliers in terms of treatment outcomes and variations in treatment threshold choices.

Layabouts should not question their local data, which is a product of their competence: if it is poor, please resign! But thou shalt ensure use of thy cost and activity data to improve patient care.

Commandment 4 - Thou shalt do something about practice variations in thy locality. Doctors do different things to patients with similar needs and similar personal characteristics Start easy, e.g.

a) why do thy local orthopods use different prostheses? Why do their PROMs vary? Why do their PROMs intervention thresholds vary?

and

b) offer thy patients with wet age-related muscular degeneration (i.e. they are going blind) the choice of Avastin as opposed to Lucentis. Avastin is used in the USA and the UK private sectors, and will save thee thousands of pounds as well as annoying Genentech (who hold the patents for both products) Go on: move!

Commandment 5 - Thou shalt reap economies of scale in diagnostics and purchasing. The supply industry exploits the NHS by fragmented the market and offer discount in a manner that maximises their profits.

The NHS has continually failed to get its act together in contracting for volume and getting discounts not just for some local markets but for the whole NHS. Time to stop being ripped off by industry and place the wellie on the NHS foot!

Radiology, pharmacy and pathology are often carried out on too small a scale in the NHS due to “local autonomy” and myopia. Both purchasing and diagnostics needs to exploit private expertise to ensure scale and economy.

This commandment also requires a much more aggressive attitude to the pricing of pharmaceuticals where the industry rips off the NHS. Take the example of Thalidomide: an ancient out-of-patent drug used in cancer treatment. Its price is £298 for 28 days’ supply This is too high by far for an unpatented drug, and as Government policy advances towards “value-based pricing”, it should take a much tougher stance by becoming a price-maker rather than a price-taker - even if such a policy flusters Tory supporters amongst the drug dealers.

Commandment 6 - Thou shalt manage skill mix in hospitals and in primary care. The NHS is in an enduring state of permanent revolution, with local innovators altering how they deliver care to patients. The remarkable characteristic of these local changes is that they are rarely evaluated, and if reported as a “success” in a trade magazine such as the Health Service Journal, usually exhibit crass stupidity in evaluating effects and costs!

Experimentation without evaluation should be rewarded with dismissal. The evidence base indicates, with moderate certainty that nurses can carry out 70-80 per cent of GP tasks equally as well as physicians. With triage to a small number of practice GPs, primary care could be largely nurse-delivered and if the nurses were substitutes rather than complements, expenditure could be reduced.

The evidence base about nurse substitution in hospitals is thin, as nurse researchers have paid too little attention to the issue and where they have carried out work they have focused on qualitative measures of effect and ignored cost-effectiveness. But just look at your hospital and see how the skill mix varies! Time to experiment and evaluate to confuse us with some facts?

Commandment 7 - Thou shalt exploit fully the potential of contracts of employment. NHS employees, some of whom are paid very poorly, face reduced incomes like the rest of austerity Britain. Agenda For Change (A4C) has been a triumph and a tragedy. A4C was a triumph in that it was put in place to replace the chaos of preceding systems; a tragedy in that promotion gateways have been easily breeched and pay inflation has resulted due to incremental drift.

The contracts of employment of doctors in primary and hospital care are excessively protective of workers, and make very expensive and difficult removal of the small number of poor outliers who cripple performance.

If CCGs begin to contract out work to private suppliers who offer less holiday entitlement, lower pensions and other less favourable conditions of employment, how will the public sector react? Fury! However with austerity, CCGs will look for lower-cost, higher-quality providers, and this implies quite clearly erosion of NHS terms and conditions of employment.

Commandment 8 - Thou shalt contract for service provision from competing public and private providers with due care and attention. The Private Finance Initiative (PFI) was an exercise in aggressive contracting by the private sector and the ripping-off of the public sector. Hence the creation of £40 billion of debt and high returns to the owners of PFI contracts which haunt the NHS and the education sectors.

CCGs will have to contract aggressively and carefully. They have to benchmark performance and set clear financial, activity and outcome targets which have to be performance-managed scrupulously. To do this, they should work in groups and with great care to avoid another PFI-like disaster.

Commandment 9 - Thou shalt use the payment by results (AKA activity) system of hospital tariffs imaginatively. For an average NHS hospital, about 60% of their income comes from tariff activities. The rest is a product of local deals, often involving dubious trade-offs such as “we will accept that global sum if you ignore all CQUIN breaches”!

CCGs need to be much more aggressive than many PCTs today in concluding such contracts. The Government should state quite clearly that PbR tariffs are maximums which CCGs can undercut with volume-price details and other bargaining devices.

Whitehall Village (that is the Department of Health, the NCB and Monitor) may wish to fine-tune the tariffs (i.e. squeeze them and further incentivise them with penalties for not providing cost-effective day care); but CCGs should be freed to bargain locally to economise on their budgets and press local providers to improve productivity.

Failure to achieve patient safety, ‘never’ events and other quality issues (e.g. inaccurate reporting of activity and outcomes) should be punished by CCGs paying below tariff and contracted prices. No more fuzzy local deals, comrades!

Commandment 10 - Thou shalt only invest in public health if there is evidence of cost effectiveness. As epitomised by health inequality reports such as the Marmot review, there are gross inequalities in health in the UK.

However, mere reiteration of this problem is inadequate. What is also needed is an evidence base of the relative cost-effectiveness of alternative ways of reducing inequality and improving public health. This is sadly lacking, as NICE have discovered as they try to advise on the cost-effectiveness of competing public health wheezes!

Sadly, the ‘drains folk’ have provided lots of emotion; often poorly-designed evaluations of the plethora of policies they advocate; and an almost complete absence of evidence of cost-effectiveness. Such luxurious preference for faith-based policymaking can no longer be afforded. The public health folk have to be data-and-evidence-driven, or sacked.

…
It is evident that these 10 commandments are major challenges to conservative and usual NHS practice. They require transparency and accountability in ways largely absent from existing organisations whose modus operandi is income-expenditure balance and often data-free assertions that ‘all’s well in our organisation’.

All is not well in many NHS organisations as exemplified by practice variations routinely shown in research and increasingly in private and public expressions of concern.

The bottom line is this question: do you want the NHS to survive the madness of Coalition politics? If your answer is yes, follow these commandments - or you will surely perish on the sword of change.