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The Maynard Doctrine - Conservative health policies: signs of confusion?

Professor Alan Maynard OBE reviews the consistency and coherence of recent pronouncements on Conservative health policy.

In a recent speech, leader of the Conservative Party David Cameron spelt out his views on NHS policy. He said:

“A Conservative Government will measure the performance of health care providers by the health outcomes they achieve, like increased life expectancy for cancer sufferers and higher quality of life, instead of the processes they follow. And we will pay NHS providers according to their ability to deliver improved outcomes” (Monday November 2nd, 2009.)

Separately Andrew Lansley, the Conservative Shadow Secretary of Health declared at a conference organised by The Economist newspaper that “more information” and “more competition” are key items in the Party’s policy agenda. The intent seems to be to have hard budgets for hospitals and practice-based commissioners (PBCers) / GP fundholders (GPFHs).

Incomplete appeal
In terms of intent, these statements have some appeal but are incomplete.

Let us deal with Mr. Cameron and his focus on outcomes first.

In terms of achievability there are some nice problems. The 1845 Lunacy Act required the nation’s healthcare institutions to measure success in terms of whether their patients were “dead, recovered, relieved or unrelieved”. Furthermore, practitioners who failed to measure outcomes were to be fined £2 (equivalent to £10,000 in 2009 prices).

Lunacy Act data were collected in psychiatric and acute general hospitals until 1948, when the NHS was created. Now both the Conservatives and the current administration wish to recreate what the Victorians established. Sic tempora, sic mores.

Lower NHS incomes = interest in outcomes
Since April 2009, patient-reported outcome measures (PROMs) have been collected in all public and private hospitals using NHS funds.

However, these PROMs measures are only for four interventions. Moreover, the roll-out of the comprehensive NHS system , let alone the production of broadly-accepted, risk-adjusted data to inform policy, is years away.

So Mr Cameron is to be applauded for his support of PROMs - but during much of his expected first term of office, he may not have these outcome data he requires to lead the NHS into greater productivity.

He could of course use mortality data - i.e. a measure of failure. However, these data are problematic.

Death as an outcome measure
For instance: if mortality was used as a primary productivity measure, there would be an incentive for hospitals to discharge patients to die at home and in hospices. Many patients may prefer this, but variations in local circumstances would affect the location of death and the measurement of “failure”.

An associated problem with the use of mortality data as a performance measure is that the numbers are small. This is a particular problem when managing the performance of practitioners. Small numbers makes risk adjustment difficult, and creates ambiguity in such an assessment measure

It’s the clinical process measures, stupid!
With few PROMs data and the best use of mortality data as a general indicator rather than an unambiguous indicator of quality, what can be done? The Conservatives apparently dislike process measures such as waiting times, but appear to fail to consider the use of clinical process measures.

Researchers at the Dartmouth Medical School in the USA have emphasised the need to reduce clinical practice variations for decades. One of the Dartmouth team, Elliott Fisher, has argued that if practitioners in the US Medicare system could be persuaded to adopt the safe conservative practices of their peers, thirty per cent of the budget could be saved.

Similar evidence of wasteful variations in clinical practice is evident in the UK NHS. But as in the USA, British policy makers are slow to establish well-evidence-based standards for healthcare with clinicians, and enforce them with cost-effective incentives.

Thus Mr Cameron may be sensible to move on from Labour’s process measures. However what are now needed is clinical process guidelines that oblige clinicians to provide what is proven - rather than what is sometimes wasteful. Such waste deprives patients of care from which they could benefit!

” One interpretation of Mr Cameron’s statement is that the focus of Conservative policy will be institutions. However the need is to alter the behaviour of individuals.”

Whither incentives?
The application of NICE and Royal College guidelines (for instance) for heart attacks, heart failure, strokes, hip and knee replacements, pneumonia and cardiac surgery may save lives and free resources for other uses. However, such outcomes would have to be measured carefully and would require incentivisation.

But who should be incentivised? One interpretation of Mr Cameron’s statement is that the focus of Conservative policy will be institutions.

However the need is to alter the behaviour of individuals. If institutions are incentivised with fines and rewards to improve performance, how can they pass on the pressure to change to clinicians?

The policy issue is which works best, incentivising doctors or hospitals? Time to experiment carefully and evaluate Mr Cameron?

A tentative welcome
Cameron’s Conservative health policies can be given a tentative welcome. Outcomes are the future - but in the interim, process measures to encourage evidence-based clinical practice will have to be deployed carefully, with financial incentivisation that demonstrably improves patient care and gives taxpayers better value for money.

Competition: a poor fit in healthcare
What about Andrew Lansley’s proposals? His declaration about the need for more intervention reflects his leader’s interest in outcomes. This is good - but the Conservatives must recognise that if (like Labour) they go too fast on PROMs, inevitable blips in their development may destroy their acceptability for a generation.

There is also a need to focus on how such data will be used to improve efficiency. The main user of such data will be the NHS, and that is where investment in its application must be focused. Patients may be inferior drivers of change, when compared with clinical peer pressures - particularly augmented by marginal bonuses and penalties.

Mr Lansley also wants “more competition”. There is little evidence that competition in public and private healthcare systems has been an efficient means of driving much-needed change in the provision of healthcare. Competition is expensive to create and expensive to sustain, as capitalists are always the enemies of capitalism - and bent on destroying competition that may undermine their profits and quiet lives!

So caution is needed with this policy, if failures evident in the international policy literature are not to be repeated.

Managing trading relationships
If PBCs / GPFHs and foundation hospitals with hard budgets are to be the Conservative way forward, there is a need for other elements in these trading relationships.

Firstly, the notion of local negotiation of tariffs will guarantee inflated bureaucracy and delays in settling contracts and cash flow. PbR needs urgent reform (as has been evident for some years [Street and Maynard 2007]) - but local negotiation of tariffs could bring chaos.

A second element - absent in the Conservative reforms - is the need for a NHS banker. Some PCTs and hospitals have surpluses and others have deficits. Is it not time to develop an internal NHS bank which facilitates fund transfers with low interest loans to oil fluctuations in  providers’ and purchasers’ cash-flow?

Without this, avoidable deficits will proliferate.

A related issue, ignored by both the Conservatives and Labour, is the issue of NHS capital. As foundation trusts’ surpluses shrink with deflated tariff levels, how will they fund renovation and new build?

In the Conservative and Labour ideal world, where all hospitals are FTs, how will these providers access capital funds? Capital deprivation in the NHS is already very evident, and for the existing or a future government to ignore this is a recipe for imposing serious damage on the quality of NHS care.

So what can we conclude about Conservative policy as it emerges? The answer is “could do better”! Hopefully, they will do better as the election nears and the travails of office loom larger.

We can only hope that they assume office with more sophisticated notions of policy change than are evident at present.

1) Street, A and Maynard, A, 2007. Activity based financing in England: the need for continual refinement of payment by results, Health Economics Policy and Law, 2,4,419-28, 2007.