The Maynard Doctrine: Management needs measurement: time for the NHS to do better
Health economist Professor Alan Maynard says that NHS activity and performance measurement need to improve significantly.
The NHS has three problems with ensuring managers are adept at measurement and thus able to deploy their skills efficiently, rather than haphazardly.
Firstly, there is a paucity of data, particularly in primary care.
Secondly, there is an enormous stock of secondary care data which managers neglect.
Finally, there is the problem of the lack of skills which ensure that NHS data procured at high cost is not fully exploited by NHS management to improve patient care.
Primary care ignorance
The National Audit Office, in a report entitled Stocktake on access to general practice in England (HC 805, November 2015), listed general practice data limitations (figure 24). This depiction of the chronic ignorance of management and policymakers makes for depressing reading for anyone interested in improving primary care to ensure value for money.
Furthermore, all the data deficiencies listed have existed and been noted for decades. It is remarkable that decisionmakers prefer to “fly blind” when using billions of pounds worth of taxpayers’ money annually.
Neither the Government nor GPs themselves have been able to translate these oft-repeated problems into better information systems. How either party can tolerate this ignorance defies comprehension.
The GPs claim that their jobs have become more complex, but have failed to motivate themselves or the Department of Stealth to collect national data and demonstrate the nature of changes in clinical practice.
The NAO, in their assessment of data limitations, list the following issues which demonstrate the gross inadequacy of GP data across a number of areas fundamental to the efficient management of primary care:
i) No data collected nationally on the complexity of consultations
ii) No data is collected centrally on how many practices have closed their lists to new patients due to practice level capacity constraints
iii) No data are available on the types of booking schemes used by each general practice, such as the number of same day versus advance appointments, or rules when patients need to telephone to make appointments
iv) NHS England does not have information on practices using innovative appointment options such as Skpe or online appointments
v) On staffing and workforce capacity, the NAO list of ignorance is compelling e.g. inadequate data about full-time equivalent GP staffing data in practices; no data on vacancy rates; data on use of locums and agency staff data that are incomplete; incomplete data on administrative workload; incomplete data on nurses and practice staff
It is astonishing that a service costing billions of taxpayers’ money has been so poorly managed for nearly 70 years. The Department of Health has been grossly inefficient, re-disorganising primary care in a fog of hope and blind ignorance.
GP practices have operated narrowly and half-blind, focusing on their financial accounts and local process measures in the absence of national comparators.
An essential first step for primary care reform is to remedy these deficiencies, so that value for money can be demonstrated and mergers and restructuring can be implemented efficiently.
Alternatively, the Department of Health and NHS England can cross their fingers and hope GPs will generally do a reasonable job. Practitioners themselves can then bleat on that they are not understood by Whitehall, and continue to be grumpy and fed up with their lot.
Self-inflicted wounds by both parties do not ensure excellence in patient care from a limited budget.
Secondary care laziness
There is a mass of secondary care that the majority of clinical and non-clinical managers seem too lazy to exploit fully.
For instance: over the last 25 years, there have been a series of individual hospital consultants who have exhibited wanton disregard for the safety of patients, maiming and killing significant numbers by their poor practice.
In the late 1980s, a Bristol paediatric consultant surgeon killed and damaged numerous children with a poor technique. He was pensioned off!
“The fastest cutter in Kent”, a consultant gynaecologist called Rodney Ledward, rendered dozens of women incontinent. He referred damaged patients to ten different urologists for help, thereby avoiding high locality data which might have led to action. He died quite soon after his practices were detected.
Initially in in two provinces of Canada and subsequently in Northallerton, another consultant gynaecologist, Richard Neale was also associated with avoidable poor outcomes for dozens of women. He was given financial compensation to leave.
Finally there was the GP Harold Shipman, much loved by his patients and eventually “shopped” by the local undertakers for killing perhaps hundreds of women by lethal injection. He was imprisoned, and subsequently committed suicide.
What do all these people have in common?
In each case, retrospective analysis of routine NHS data showed them to be potentially dangerous outliers who should have been investigated by managers. Instead, data such as Hospital Episode Statistics, was collected and ignored by NHS clinicians and managers
Are things better now? Yes and no!
Surgical performance measurement and management
The cardio-thoracic surgeons of the UK and Ireland collect comparative data for complications and mortality. These data are fed back to practitioners and average performance has improved and the dispersion of events has narrowed.
Well done them; but with one reservation. In Pennsylvania and New York, a similar scheme of data collection, analysis and feedback had the same apparently beneficial effect.
However, comparative analysis of these data with other areas of the United States indicate that surgeons may have achieved this improvement by becoming more selective patient treatment activity, with consequent greater mortality for patients now excluded from surgery.
Despite such reservations, efforts by NHS England and its Chief Medical Officer Professor Sir Bruce Keogh in particular involve determined efforts to improve transparency in clinical performance. Currently, these efforts are primarily focused on extending the use of performance data in surgery. The development of similar work in medicine, psychiatry and general practice is challenging - but necessary
Comparative consultant activity rates
Over 10 years ago, the Department of Health published activity rates for consultants in each surgical specialism. This identified both the dispersion of individuals’ activity and outliers.
Those with low activity, some presumably exhibiting various forms of one the job leisure, should of course be questioning themselves and be audited by their clinical leads.
Of course, managerial action would have to take account of the limitations of activity data; in particular, their relation to patient outcomes, such as mortality, complications and PROMs. Do the very active surgeons have better outcomes and/or do some slower practitioners do equally as well?
Activity data could incentivise such inquiries
Pride and reputation are perhaps the most powerful of motivations of us all. However, these charts were discontinued. Presumably, their potential for embarrassing poor outliers was difficult to exploit.
Simple calculations and management, such as pressure to use median activity rates as a benchmark, age and case mix adjusted, might have been used routinely in audit and GMC revalidation
Quality of survival after health care
Ledward, “the fastest cutter in Kent” carried out hysterectomies in a hospital then owned by the private insurer BUPA in Canterbury. He did not kill these private patients, or the NHS patients he dealt with, but he did reduce their quality of life considerably.
BUPA’s response was to introduce what we now call patient reported outcome measures (PROMs) in 1998, and has since persuaded most private hospital data to collect these outcome data.
PROMs were introduced by the Department of Health in 2009, initially for hip and knee replacements, hernia repairs and varicose vein surgery. Using validated quality of life measure such as EQ5D (www.euoqol.com ), patients value their psychological and physical wellbeing before and after surgery. This facilitates measurement of functional gains to patients.
PROMs users and assemblers have confronted several problems.
Firstly, patient response rates have varied, and this has necessitated fines for hospitals that are poor performers.
Secondly, the use of PROMs data has been limited and fragmented. Some clinical teams have followed up deficiencies identified by PROMs, whilst others have lazily not exploited this potential to improve transparency and accountability. A sad waste of money!
Thirdly, few GPs have used these data to advise patients on treatment options and the timing of surgery. For instance: just over half of hernia repair patients report improvements in their physical and psychological functioning. Should more patients be advised by their GPs to choose watchful waiting, rather than instance recourse to the scalpel?
Conclusions: wasting potential
The NHS has to save and re-cycle £22 billion during the next five years. Consideration of the routine measurement and management of performance remains poor.
The Service is driven by the financial imperatives of budget control. Many able managers scrutinise financial accounts, and strive energetically to avoid deficits and dismissal for “inadequate” performance.
There is no equivalent effort invested in the management of performance data.
This deficiency undermines financial controls and solvency. It ensures that the potential of activity and outcome measurement in primary and secondary care is not exploited.
Consequently, clinicians’ performance could be improved and the fog of delusions swirling round politicians could be dissipated more efficiently - to the benefit of patients and taxpayers.
Management education and training requires substantial investment in the use of quantitative data. Currently, such investments are dominated by “airy fairy” activities which create employment for “gurus” and continued inadequate training for real world managers. It’s time for to get real and exploit the substantial investments made in NHS data.
Where there is a will, there is a way! Time for Sir Galahad (aka Simon Stevens) and his fellow knights in NHS England to rouse themselves and ride forth to mitigate ignorance and distortions that have long permeated the NHS.