The Maynard Doctrine: The opportunities and constraints of managing a clinical commissioning group in the new NHS

Health economist Professor Alan Maynard dissects the direction and dentures required for CCGs to stand a chance of success.

The purchaser-provider split in the NHS has failed because PCTs have been price and quality takers rather than price and quality makers. This failure is caused by Whitehall controls and a reluctance to invest in analytical skills in most wannabe commissioning organisations.

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Can Mr Lansley’s clinical commissioning groups do better?

Or will they suffer the fate of PCTs, and be re-disorganised within 5 years?

Using data
If public health and other NHS bureaucrats had used available public data in a co-ordinated and systematic national fashion, many challenges could have been made by purchasers. Why have they largely failed to hold providers accountable by asking questions such as:
1) What is the variation in mortality after coronary artery by-pass surgery? Who are the outliers who are more successful at killing their patients? What is the distribution of re-admissions after CABGs, and who are the poor performers? Are guidelines adhered to or ignored?
2) What is the variation in mortality rates after hip and knee replacements? Who are the outliers in terms of mortality, re-admissions and patient reported outcome measures (PROMs)? Do consultants ignore NICE guidelines and use prostheses inefficiently or do they all use the same devices, acquired at a discounted cost for volume? Or are they all exercising “clinical autonomy” in a way that is wasteful and endangers patients?
3) What is the local admission rate for “frequent-flying” patients with COPD? Is a local high / low-frequency rate a product of intervention strategies; if so, of what sort? Or are there no interventions to improve COPD patients’ quality of life, leaving them leading miserable lives as cash fodder for the local hospital?
4) What is the variation in mortality rates after acute myocardial infarction (heart attacks)? Who are the poor performers, and is their performance a product of ignoring guidelines?
5) What is the variation in mortality rates for heart failure patients? Are guidelines adhered to?
6) What is the variation in pneumonia deaths and are guidelines followed?
7) What is the variation in mortality after stroke and are guidelines adhered to?

Starting somewhere
These questions could be used as starters, with CCGs interrogating hospital episodes statistics (HES) data and local dignitaries from provider organisations, particularly relevant clinicians. Ideally, this should be done collaboratively, sharing data and analysis costs.

The Care Quality Commission should use such exchanges of analysis as an essential element in the registration of hospitals: CQC inspections should be based on rigorous and extensive use of HES.

Data should be shared also with the General Medical Council, whose role it is to protect patients from poorly-performing doctors.

So what?
Imagine a world in which CCGs and providers progressively developed these simple analyses. What then would happen if, despite transparency, there is inadequate change in the performance of hospitals and practitioners? So what can commissioners then do?

Here lie some nice problems. Let us start with GPs incentive structures. The GP QOF needs to be reformed to ensure referrals are made to efficient producers of services whose mortality, morbidity, PROMs and readmissions rates are reasonable.

GPs should have PROMs administration and management as part of QOF. Current resistance to this from powerful boys and girls in the guild are evidence of how useful this might be!

The hand in the till
Better use of data would show marginal provider units fit for closure, with resources shifted to more proficient providers - hopefully operating fully 24/7. However, closing units and altering service configuration is complicated by the ‘hand in the till’ problem.

All professionals (including academics) dislike change which reduces their income. Rationalising services for residential and nursing homes potentially threatens GPs’ income.

Closing community hospitals may be resisted for similar reasons, with GPs forming coalitions with local citizens to protect their incomes in the name of saving local services.

Show us the money
To mitigate such unprofessional behaviour and practice, GPs’ incomes should be public by source and by level. Not a wholly popular idea; but how else to illustrate conflicts of interest? More ‘civilised’ countries in Scandinavia make all tax returns public; something which we Brits should emulate!

A farewell to the national tariff (as was)
Manipulating GP incomes when services are poor and when commissioning is inadequate is difficult. Incentive rigidity is also a problem with hospital tariffs.

PbR tariffs should be guide prices, with CCGs freed up to bargain them down for buying in bulk and for failure to deliver good-quality services. Transaction costs could be reduced by CCG clusters collaborating with analysis and pressure to ensure prices reflect value for money.

Pressuring change on the small number of consultant outliers is also difficult, given current contract and incentive systems. It is crazily difficult to ‘move on’ an inadequate performer, with long periods of introspection whilst clinicians are on gardening leave and locums have to be funded to maintain patient care.

There is a need for urgent reform. Poorly-performing doctors (and academics) should be given every opportunity to mend their ways - and if irredeemable, removed.

Hospital managers are unable to apply pay cuts or decrimental scales to any of their staff, due to national agreements. Furthermore with Agenda For Change they have been slow to use appraisal to reduce incremental pay inflation. An obvious object for reform to reward clinical behaviour is the system of clinical excellence awards. The Pay Review body delivered a report to the Department of Stealth and No 10 in July - but it lies unused, when urgent change is needed.

The dog’s dentures
Without such radical changes in analytical capacity and doctors’ incentives as these to transform CCGs into active purchasers, CCGs will be what PCTs were: toothless bulldogs.

Achieving such radical change will be difficult as managers - clinical and non-clinical alike - lack the skills needed and have been reared in the tradition of sticking fingers in the dyke; rather than re-structuring it to avoid disaster.

Without such a revolution, and the development of evidence-based price-and-quality-making by CCGs, the erosion of the NHS is a real risk; with right-wing nutters and policy wonks in the Metropolis eager to break up the NHS with insurance schemes and other inefficient and inequitable wheezes!

Will the Department of Stealth and the NHS Commissioning Board enable CCGs to carry out their tasks efficiently?

Or will incentives continue to be perverse and local freedoms to innovate be stifled?