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The Maynard Doctrine: What’s the alternative to Lansley’s reforms?

We have been inundated by protests about the NHS reforms championed by Andrew Lansley.

A media frenzy has followed the (sometimes parochial) bleating of trade unions - the most vociferous of which has been the BMA - and professional associations such as the RCP, RCGPs and the RCN; all of which have some tendencies to be what George Bernard Shaw entitled “conspiracies against the laity”.


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Palliation by forum
The Coalition tried to modulate this cacophony of protest with a well meaning but largely evidence-free palliative: the NHS Future Forum. Its minor conclusions were essentially ineffectual, and a media diversion which facilitated Coalition backroom deals that has made little difference to the un-evidenced content and ambiguous intent of the current reforms.

The challenge now is how to improve what is on offer by identifying sensible and efficient complements which can divert the reforms into directions which improve the lot of patients and taxpayers.

The reforms are unstoppable. How can the NHS be improved around the expensive re-disorganisation?

Boyle's Law and Keogh's Log
The resignation of the “heart czar”, Roger Boyle, is indicative of how medical advice in the Department of Health runs up against political opposition. Released from the “madhouse” after 11 years in which cardiac care has been improved significantly by a combination of money and a collaborative management approach, Boyle appears unenthusiastic about “competition” and the messy heap of reform changes.

He leaves behind some excellent medical colleagues. The Medical Director, Bruce Keogh, is an unsung hero of quality improvement. He and his colleagues pioneered the cardio-thoracic register which logs the relative performance of all heart surgeons in the UK and Ireland.

This work facilitated the removal of a few inadequate colleagues; a reduction in the differences in performance of operatives; and an improvement in average performance. All good things for patients and taxpayers.

The very old problem of recording performance
It is remarkable that such work is so scarce. In 1803 Thomas Percival, in a book on medical ethics, advocated the use of medical registers to improve transparency and accountability.

Over 200 years later medical professions worldwide are slow to create such obviously essential sets of comparative data. In the UK there are now registers for bariatric surgery and hip and knee prostheses; the latter twenty years` after the Swedes began to collect data to review the durability of prostheses and the relative proficiency of practitioners.

Despite the need for comprehensive registers and audit, the profession remains languid.

However, Keogh and colleagues are seeking to improve matters. Recently, it was announced that the RCGP and colleagues in general practice had been asked by the Department to suggest indicators to facilitate improved transparency and management of primary care.

This is long overdue as Lansley is giving budgets to a part of the NHS which is data-lite and evidence free.

So far, so good! The Department followed this up by announcing a data trawl of GP registers to identify what data were available to inform the selection and management of practice indicators. Good idea!

But now there has been an announcement that GPs can opt out of this trawl if they so wish. How does that compute?

Presumably, some GPs feel threatened by this work?

Good! They are responsible for patient care and taxpayers’ welfare - and compulsory involvement should be enforced by those who hold their contracts. If they object to inclusion or do not co-operate, their practice income should be reduced.

Political sensitivities should not be allowed to interfere with data collection and management of this rather unaccountable and vital part of the NHS. As with heart surgeons, poor outliers in terms of performance need to be identified and helped or removed from practice, preferably by peer pressure and management.

Noble endeavours such as this can be seen as attempts complement Whitehall efforts to improve productivity, almost regardless of Lansley’s reforms. How else can the NHS be steered into the realms of greater efficiency and accountability?

The number of Clinical Commissioning Groups is excessive and will no doubt be pruned; as happened with Milburn’s excessive number of PCTs over the last decade.

The NHS Commissioning Board is harvesting an increasing slice of the NHS budget as power is centralised and CCG’s budgets and responsibilities are reduced. How efficient will the NCB be?

A big saving is made up of many small savings
Undoubtedly there are lots of efficiencies to be garnered e.g. the Isle of Wight PCT has invested in inhaler training Instead of asthma and COPD patients blowing expensive drugs into the air, they are now using their expensive devices more efficiently and A&E admissions and other indicators show significant improvements. (This work also demonstrates that GPs and nurses are poor evaluators of whether patients use inhalers properly.)

The better management of drugs (especially generics) and of “specials” such as nutritional supplements, incontinence pads and other items can save hundreds of thousands pounds in local PCTs - as shown in Rotherham. GPs have little or no expertise or interest in nutrition. Giving the budget to clinical nutritionists not only saves money; it also improves the quality of care and patient satisfaction.

Every little helps, as a supermarket reminds us! Marginal and significant savings such as these can be used to transform practice and save money. As ever, the challenges are evidence of effectiveness and cost-effectiveness - for these and all QIPP policies.

So how can the NHS be improved even when the reforms are largely irrelevant? The answer is by quiet revolution, preferably led by clinicians with an emphasis on evidence.

Radical “solutions” such as the abolition of the purchaser-provider split may be medium-terms possible reforms - but in the meantime, incrementalism via vigorous dissemination of good practice and incentives for all to take up swiftly rules.