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The Maynard Doctrine: Transparency and accountability in theory and practice in the NHS

Professor Alan Maynard OBE minds the gap between political rhetoric about openness, choice and outcomes and the practical reality of lacking comparative data – and the implications for NHS redisorganisation.

The political rhetoric is of openness in all the workings of the NHS.

The practice is of avoiding confusing consumers with facts.

Both New Labour and the new Government must know that their advocacy of patient choice is empty cant unless consumers are informed about the risks involved in using healthcare facilities.

It is interesting to note the emphasis in The Guardian June 14th 2010 on NHS vascular surgery mortality rates. The international literature on such issues shows that variations in post-operative mortality rates are a problem in both the public and private sectors.

Doctors and data
The problem is doctors and their lack of transparency (with the honourable exception of cardiac surgeons). This is exemplified by The Guardian having to extract the vascular mortality rates using Freedom Of Information (FOI) legislation.

However, even when the data are available, there is the nice issue of case mix adjustment i.e. how much of the mortality is due to having more complex and elderly patients?

The crude and case mix-adjusted data should inform governance throughout the hospital and the NHS. The data should be used as a screening device but not as a diagnostic mechanism. Adverse results should generate a management focus on outliers, to determine data accuracy and causes.

Shifting average performance upwards

'If the mean or average performance can be improved, the gains to an organisation can be considerable'

However for those hospitals wanting to improve performance, particularly patient outcomes, the performance issue is two-fold: both on the investigation of outliers, and also on the shifting of average performance.

If the mean or average performance can be improved, the gains to an organisation can be considerable. Thus the management of governance must always have a dual focus: do you know and manage your outliers, and are you shifting mean performance to get better outcomes for your patients?

Ideally these foci should be part of the clinical audit processes of all specialties. Whether they are or not is unclear, since trust boards, let alone sleepy commissioners, often do not have routine reporting systems in place.

Instead, clinicians are trusted to audit - and many do - but these data are all too rarely the meat of boards’ discussions. Data such as that in The Guardian highlights the need to monitor and manage better these areas of “trust”, with a particular focus on comparative data (outliers and averages) and evidence of economies of scale - whether doing more of a particular procedure (such as vascular surgery) genuinely gives better patient outcomes.

It is sad if enhanced regulation is necessary, as the transaction costs of such activity are likely to be considerable. Again, these costs will be the product of clinicians’ failure to create systems of assurance that are transparent and accountable, and the failure of boards to ensure that such data are routinely reported and interrogated.

The impact on NHS redisorganisation
The implications of this material for the redisorganisation of NHS hospitals are considerable. The unfortunate abandonment of mature restructuring plans in London put patient health at risk and waste scarce resources.

Hopefully, restructuring in London and elsewhere can move ahead quickly, exploiting rather than ignoring the evidence base about economies of scale where they can be shown to exist.

Presumably by the time this is completed, the NHS Board will be working (at least in shadow form) and will take the rap for closing facilities.

However the politicians will not avoid the fury of anti- closure groups. The challenge for them is whether they can exhibit some maturity and educate the public about the consequences of failing to rationalise the hospital stock.

The issues resuscitated by The Guardian have been known for many years. Both the medical profession and politicians have chosen to ignore them, thereby exposing patients to avoidable mortality and morbidity, and wasting resources.

In the continuing absence of medical and political courage to protect patients and taxpayers, we must once again ask when and why this negligence will end.