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The Maynard Doctrine: Revolution and reform - where is the evidence base? | Health Policy Insight
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The Maynard Doctrine: Revolution and reform - where is the evidence base?

Professor Alan Maynard asks, not for the first time (nor undoubtedly for the last time), where is the evidence to suggest that the proposed NHS reforms are going to work?

The Coalition Government, full of sufficient revolutionary vigour to bring a warm glow to Chairman Mao, is seeking to transform the public sector with radical reforms. Many of these reforms are intellectually intriguing … and as such, require careful piloting and evaluation.

Of course Oliver Letwin and his fellow gurus in the Cabinet Office are well aware of this challenge in areas such as justice and drug treatment reform. They are promising both pilots and evaluation.

However the feeling is that these processes will be superficial and consultancy-firm-driven i.e. done for too short a period of time, and with poor comparators. This was the practice of the preceding Labour government on too many occasions.

Richmond House drop the pilot!

’Where is the piloting and evaluation of the NHS reforms? If there is none, can we conclude the evidence bases for GP commissioning, the reform of Monitor and the creation of the NHS Commissioning Board are robust?’

However Letwin’s apparent willingness to pilot and evaluate, even if inadequately, has to be compared with his colleague across the road in Richmond House.

Where is the piloting and evaluation of the NHS reforms? If there is none, can we conclude the evidence bases for GP commissioning, the reform of Monitor and the creation of the NHS Commissioning Board are robust?

There is of course an evidence base from the 1990s about the successes and failures of GP fundholding and what subsequently evolved as “Total Fundholding”. The latter is very similar to what Lansley is now proposing.

Modest but significant successes of GP fundholding …
There were some apparent successes. The elective referral rates of GP fundholders compared to non-fundholders appeared to be three to four per cent less. This was a modest but significant difference; the causes of which we do not know.

But if we are speculating, then our focus might be on variations in admission thresholds and a more austere approach to referral when it cost the fundholding GP their budget.

The cost of this frugality in terms of patient pain and discomfort can now be analysed in terms of QALYs foregone by delays in referring. Initial estimates from the patient reported outcomes measurement (PROMs) data suggests that these losses are modest.

Consequently, if GP commissioning leads to greater consistency across GPs in referrals and greater consistency in consultant conversion rates, this may generate some savings.

Obviously, this outcome could have been achieved many years ago if PCTs and SHAs had not been sleeping on the job!

… but it cost more
The other noticeable evidence from the 1990s is that GP fundholding and total fundholding cost more! The ongoing delays in setting the per capita funding allowance for GP commissioning is indicative of familiar dilatoriness and political pressures to be austere in all matters.

With large staffing cuts at the PCT level, there seems some reluctance to afford GP commissioners the capacity to do their tasks efficiently.

It will all be different this time, take 53
So much for evidence from the past: what now about the evaluation of this new shift in the course of the NHS Titanic?

As managers and clinicians navigate the policy icebergs created by waves of evidence-free reforms from competing sets of well intentioned but deluded policymakers, we should look to Lansley’s proposals for evaluation.

The arrogance of successive Secretaries of State in producing reforms without pilots and evaluation makes clinical colleagues bristle with indignation. Having been hammered to articulate and produce evidence-based medical care for their patients; they reasonably look askance at the evidence free reforms imposed on them.

’Looking tough when reforming brings plaudits for politicians - even when toughness usually involves tilting at irrelevant “straw men” i.e. ignoring the fundamental problems of the NHS, evident for decades.‘

Why can’t politicians, who often pay ritual lip service to the notion of evidence, practice what they preach when it comes to policymaking?

Sadly politicians seem stuck in a rigid timewarp where organisational action is confused with changing processes and outcomes. Reform makes headlines; and even though, when implemented, it is nothing more than expensive “jumping on the spot”, it can make and break the careers of politicians.

Looking tough when reforming brings plaudits for politicians - even when toughness usually involves tilting at irrelevant “straw men” i.e. ignoring the fundamental problems of the NHS, evident for decades.

This evidence has been carefully produced by decades of tireless and long ignored generation of health service researchers. The politicians’ motto is “don’t confuse me with facts” - except when occasionally, it is useful so to do!

And for my next trick …
So where does this leave us? Outside the Department of Health at Richmond House there is much avowed intention to “pilot and evaluate”. This phrase has to be carefully scrutinised to ensure it is not merely short term or done by fly-by-night consultancy firms on the back of a fag packet.

In sleepy Richmond House, we await the policymaker’s pearls on evaluation. The fact is that if they were serious, the plans for evaluation would now be implemented so that “pre”-reform data can be compared with what comes after in terms of effect and cost.

But clearly, that is too much to ask.

As superficially clever but untested details about the NHS reform appear in the forthcoming Health Bill, attention will shift to its passage through Parliament. In the NHS, the pace of change is inevitable swift and anticipatory - as we expect of well-practiced managers used to implementing the whims and fancies of their maddening political masters.

Whether all this frantic activity will improve the plight of patients and taxpayers is assumed to be so by politicians who daydream in a world uncluttered by evidence.