The Maynard Doctrine: “In God we trust. All others bring data”
Health economist Professor Alan Maynard reviews mainstream healthcare reform strategies’ cyclical and unfocused nature, and suggests some potentially effective approaches instead.
The reluctance of managers and policymakers in public and private healthcare systems to use data and evidence is remarkable. In a world nominally governed by achievement of objectives such as efficiency, equity and expenditure control, decision-makers blunder around repeating the errors of yesteryear and usually being paid large salaries for their failures.
Policymaking by myopic politicians
Take for instance the incessant desire of politicians to re-disorganise the NHS. Since 1974, these chumps have ‘reformed’ the structures of the NHS with little clear benefit to patients and taxpayers in terms of improved processes of care and better patient outcomes.
Rarely have serious studies evaluated these ‘reforms’ or required answers to fundamental questions such as ‘is the purchaser-provider divide efficient?’ Instead, politicians and their ever-compliant civil servants shift the deckchairs on the resolutely buoyant Titanic; rather than using their intelligence to improve the navigation of the Good Ship NHS
The American version of this myopia is even more political and evidence-free. When leftie Democrats like Clinton and Obama are in power, they seek to reform the supply side of their healthcare systems.
Thus in the 1990s, they favoured health maintenance organisations (HMOs). Now Obama is developing offspring of HMOs; called accountable care organisations (ACOs).
HMOs and ACOs are supposed to incentivise economy in the provision of healthcare. They are not well-evidenced, being based on faith rather than solid data.
In Republican periods, the conservative administrations adopt a different policy focus: demand-side reforms, involving increased use of charging: co-payments and deductibles. They implement the familiar rhetoric of ‘think’tanks funded by potential commercial beneficiaries: ‘waste’ can only be reduced if patients pay. Of course, such charges are taxes on the ill that reduce their utilisation with adverse effects on their health status.
Whether it is the HMOs and ACOs of the Democrats or the user charges of the Republicans, the effects are the same. After some marginal effects, expenditure inflation resumes; inefficiency is preserved; and equity gets inadequate attention.
The short-term effects of such policies have no long-term effects on the table manners of the provider pigs at the healthcare feast, nor on their farmer friends, the private insurance companies and government bodies such as US Medicare.
Similarly, in the NHS, continuous re-disorganisation occasionally has marginal effects but evidence of sustained improvements in healthcare outcomes is as rare as hens’ teeth. The reforms may temporarily (at best) deflect the snouts of the provider pigs from the trough in which they luxuriate. Yet their main effects are loot for consultancy companies, and large redundancy payments to managers who then cycle back into consultancy.
Why is it so difficult to reform public and private healthcare systems?
Management of healthcare systems
In the NHS, there is much managerial talent, characterised by the Little Dutch Boy Syndrome. You will recall that this good lad found the dyke leaking and threatening to collapse and inundate the land. So the noble fellow stuck his finger in the dyke hole, and saved the dyke and his community from inundation.
In the NHS, the dyke is money. Any manager who allows his organisation to leak into deficit can expect re-location to a Gulag, and sometimes even dismissal. The more senior the casualty, the more likely it is he/she will be located to some NHS office to count pins and maintain their salary.
Average tenure of chief executives is 18 months. Instead of addressing why the financial dyke is leaking, managers are motivated to adopt a short-terms perspective rather than a long-term strategy: sack a few nurses to cover the deficit, and worry about patient care quality later!
Following the un-costed, un-prioritised and un-evidence report on the Mid-Staffordshire hospital, quality has been added to managers agendas in a much more vigorous manner. This has led to NICE adopting Atkin’s research from the USA which asserts that more nurses mean higher quality/ lower death rates: (Always? No diminishing returns? Regardless of nursing efficiency?)
Hiring more nurses means increased expenditure, thus jeopardising financial balance.
The remarkable thing about NHS managers is that they stoically follow instructions. They and their organisations, like the NHS Confederation and the trade unions for nurses and doctors, do not stand up and emphasise that every vote-seeking evidence-free ministerial whim has an opportunity cost.
Instead, they let Labour’s Mr Milibean say all will be well and we will save £100 million by cutting bureaucracy if we vote for them.
The Conservatives’ Comrade Hunt asserts that quality and new technology will save money and enable the NHS to survive with level funding until 2020.
Why do clinical and non-clinical managers not say loudly and consistently that such policies are evidence-free delusions?
With the election looming, perhaps we should set up a Wheeze-Counter that scores the political parties in relation to the number of daft ideas they put forward.
Thinking and doing outside the box
Here are a few things that might work. Perhaps we should try these instead?
a) Exploit NHS administrative data to demonstrate variations in activity and outcome of all GPs and consultants. Use this data in appraisals with 360-degree assessment of practitioners and their clinical and non-clinical managers.
b) Use this transparency to encourage professional bodies to exploit reputational incentives that improve average performance and reduce well-established variations in activity, processes and patient outcomes.
c) Address NHS management weaknesses in data analysis and reputational performance management by exploiting thousands of academics in local universities. Academics are now performance-managed in part by measures of their impact on policy; their survival is dependent on their being demonstrably useful to managers and policymakers.
d) Reform NHS leadership training to focus on data analysis and the exploitation of evidence bases such as Cochrane. Make recruitment and promotion of managers dependent on demonstration of such skills. Without these skills, collaboration with academics may be still-born.
e) Reduce Whitehall preference for financial incentives as motivators of change. The letter approaches - CQUIN, QOF, QIPP - and other policies have been shown to be of limited, often short-term effects. Furthermore, they require comparative performance data as a precursor. Focus on this data and exploit reputational incentives, before wasting millions of pounds on financial incentive systems.
f) Be constructively critical of political-vote maximising wheezes, with critical appraisal of 2015 election proposals that demonstrate failure to adhere to the maxim: In God We Trust: All Others Bring Data