The Maynard Doctrine: The party’s over …

The party’s over: it is time to call it a day. After 60 years, there is a rising tide of attention being paid to changing clinical behaviour and measuring whether healthcare actually benefits the patient.

After a decade of generous indulgence with the Blair bonanza of increased NHS funding, the government has returned to that Thatcherite theme of demonstrable “value for money”. This change is occasioned not only by the recession (which shows little sign of reversing), but also by concerns about public sector productivity.

Traditionally, the “product” of the NHS has been waiting times and other measures of structure and process. Now NHS trust chairs get sacked if their mortality data are of concern to ministers and a media who have little comprehension of the subtleties of interpreting such numbers.

In the first quarter of 2010, the NHS will get PROMs (patient-reported outcome measures) data. These, too, will create a field day for the media and politicians to misunderstand! Yet in reality, this is progress - and particularly so if the roll out of PROMs is careful and considered.

However, such attributes as care and consideration may be difficult to create and sustain in an election year!

Medical unemployment
The party is also over for doctors. During the Blair bonanza, advisers made up estimates of the number of doctors that would be needed in the second decade of the 21st century and beyond. As recession bites and funding levels off at best, hordes of bright young things are emerging from medical schools old and new and looking for jobs.

Unemployment of doctors is on the agenda again and middle-class parents of these fledglings doctors will be mobilising their protests as their loved ones emigrate or seek jobs as bus drivers!

Ideally, the NHS should be able to drive down the pay of doctors when the supply of such skills exceeds demand, No doubt real wages will decline for these good folk. However some other nice issues arrive, in particular redundancy as hospitals seek a more efficient skill mix.

The Greek physician Herodotus, when visiting Egypt over two thousand years ago, remarked that that the practice of medicine was very highly specialised, with few generalists who could provide a more encompassing perspective.

History repeating?
Is history repeating itself? Any attempt by a hospital to improve patient throughput and minimise costs requires general acute physicians. These ‘gatekeepers’ have to assess patients for admission and, where possible, discharge them safely and quickly before referral on to more specialist colleagues.

Within a fixed or declining NHS budget, such practitioners can only be hired by getting specialists to become generalists - or by sacking specialists to fund the recruitment of generalists. Hence some quiet consideration of redundancy costs of doctors by some hospital managers who are really preparing for the difficult decade ahead!

This increasing attention to what doctors do will also lead to more detailed control of their activities, as activity, cost and outcome data are produced at the patient and consultant level and behaviours become more transparent.

Take for instance orthopaedic surgeons. These chaps are generally regarded as strong in the arm and not so good in the head! However, they are proficient income generators when it comes to maintaining their wallets (sometimes, it is alleged, at the expense of routine NHS work which they are contracted to deliver).

Pour encourager les autres
With pressure on resources and a demand to improve productivity, an obvious first step is to scrutinise the adherence of consultants to the work plans in their contracts. Thus we can plot what their job plans say in terms of theatre work for hips and knees, and then compare this with what they actually do.

The results of such simple plotting may make interesting reading, and clinical peers are generally fierce when “outliers” are identified.

The next step for all surgeons is to ask what is done in these theatre slots? Again the distribution can be plotted and outliers identified. If Mr Cool is doing far less activity (case mix adjusted) than Mr Smooth, then peers and management can focus on exploring why - and to what extent activity can be improved with no quality losses.

In the recent past, such issues have been assumed to be OK on the basis of trust but simple and routine analysis of what goes on in hospitals shows that some ‘chaps’ (most surgeons are after all chaps!) do not play the game. Greater transparency in who is doing what amongst medical staff will hopefully encourage everyone to be ‘good fellows’!

Captain Mainwaring was continually assured by his Scottish Dad’s Army colleague Private Fraizer that “we’re all doomed!” Not so with the NHS! The scope for productivity improvements is large, but requires collaborative management of resources, starting with a focus on medical inputs.

Real pay and pensions will be reduced, probably by Whitehall conspiracy rather than explicit and considered intervention (which, for instance, would introduce a sub-consultant grade; a longer incremental scale; and reformed clinical excellence awards).

Redundancies seem inevitable, as workforces are reconfigured and skill mixes altered to exploit substitution possibilities. Micro-management of clinical activity will be developed as a result of the profession’s failure to manage itself responsibly: the few deviants will impose major burdens on the majority of hard-working operatives.

The seeds for all this produced their shoots in 2009, and will blossom in 2010 and beyond if managers and their clinical colleagues can exploit existing data and swiftly remedy ‘unreasonable’ behaviour!