The Maynard Doctrine: Cut the horseshit: where’s the evidence?
Health economist Professor Alan Maynard wonder, not for the first time, why policymaking and management are still so often uninformed by evidence and evaluation.
The healthcare industry nationally and internationally is vast and expensive. Insurers and governments worldwide spend a lot of effort seeking to control expenditure growth, using rhetoric rather than evidence to improve the efficiency with which healthcare is delivered.
Everybody now believes in “integrated care”. The Americans are obsessed with focusing their reforms on “value”, i.e. improvements in the length and quality of life. All funders repeat the religiose cant that “prevention is better than cure”. There is agreement that primary care is “important” and should be funded properly.
These ideals permeate all public and private healthcare systems. In the case of the English NHS, they take the form of ill-digested newspaper columns, superficial TV news and current affairs diatribes and a flood of Department of Stealth initiatives and NHS England missives about plans, and ‘innovations’ galore. There is a ferment of advice and advocacy.
All this effort is characterised by a reluctance to use evidence and add to the knowledge base by high-quality evaluation. Earnest policymakers and daft politicians create floods of un-evidenced verbal diarrhoea.
This wastes societies’ resources, creating observable opportunity costs such as Lord Lansley’s barmy NHS reforms of 2012. Those reforms cost several billion pounds, thereby imposing avoidable mortality and morbidity on thousands of patients.
When well-intentioned policymakers and managers commit scarce resources to ‘improve’ the health service, the cry must be “where is the evidence?” Instead of believing in un-evidenced magic solutions, let’s confuse policymakers with facts.
Here are some popular policies which require much more careful evaluation.
1.) Primary care spending
NHS England has announced increased spending of over £2 billion in the next five years. GPs, according to a recent survey, are not overly disenchanted with their pay or administrative burdens but are thoroughly disenchanted with the quality of their working lives.
No wonder! Go and re-read the results of Symphony work in Somerset to see how many patients have multiple morbidities and associated complexity and high costs.
When I walk into my GP’s office with my multiple morbidities, he has to catch up with my latest events, diagnose what is bugging me now and treat me, all in 10 minutes! Quite a task - and the risk is either that corners are cut or that appointment times go to pot.
Hence GPs’ disillusionment with the pressures created by changing clinical needs of increasing numbers of patients who survive serious health events and proceed to make high demands on the NHS.
So, what to do with £2 billion plus from NHS England? More GPs, if they can be recruited from India and Poland, and slowly from UK medical schools, could reduce waiting lists and give more appointment time.
Be careful! If the supply of GPs is increased, will they detect increased need for hospital diagnostics and bed care? Supply creates its own demand, as there is significant un-met need in all healthcare systems: the disguised iceberg of illness.
But will increased supply of GPs always increase activity and costs? By how much? Where is the evidence?
So maybe fund more practice nurses instead or as well as GPs?
There is evidence, dating back to the 1970s, that nurses can substitute for maybe 50 to 70 per cent of a GP’s workload. But again, practice nurses can be economising substitutes for GPs, or complements to them who increase the quality and quantity of care. Will more expenditure on practice nurses increase the demand for hospital diagnostics and bed care?
The challenge for Sir Galahad Stevens is evidence-based design of efficient ways of investing in primary care. Whatever policies are selected, evaluation would surely be valuable?
However efficient evaluation of primary care funding is impossible, given the appalling lack of data about what transpires when GPs and practice nurses are busy caring for patients.
If Sir G is spending more on primary care, he and his merry fellow workers need to reduce our ignorance about what goes on in this ‘black box’.
2.) Competition and hospital mergers
Venerable academics such Carol Propper in England and Zack Cooper with work in England and the USA have shown that monopoly is associated with poorer outcomes and higher costs for patients. Competition challenges local monopoly, making it a better deal in some contexts for patients, insurers and the NHS.
However, part of current NHS policy rhetoric is the belief that hospitals should merge and form up into chains. Industrial economics indicates that takeovers and mergers often fail to produce the improved efficiency projected by their advocates.
Are NHS hospitals different? Where is the evidence?
One effect of mergers will be that the potential for competition will be reduced. Dear policymaker: how would you trade off the potential gains from mergers (if they exist) against the losses from reduced completion?
Time for some joined-up thinking, comrades!
3.) ‘Prevention is better than cure’
There have been some notable successes in prevention. The work of Sir Richard Doll over 50 years ago led to significant subsequent falls in smoking and the production of avoidable cancers and heart disease. The UK is now leading in its advocacy of e-cigarettes, on the basis of some evidence that they are less harmful than tobacco “cancer sticks”.
Excessive alcohol consumption continues to create ill health, particularly amongst pensioners. Scottish attempts to introduce minimum pricing is opposed by industry, and the EU has paused the policy because of completion rules. As with the tobacco industry, alcohol producers resist the erosion of their markets with highly effective lobbying of political institutions
Mortality from colorectal cancer has declined due to screening, complemented by improved treatments and the reduced incidence of the disease.
In the USA, where ‘poo screening’ reaches only 50 per cent of potential beneficiaries, death rates have fallen by over 45 per cent since the mid-1980s (Welch and Robertson, NEJM, April 2016).
But how should policymakers deal with excess salt and sugar in diets, and the consequent ill-effects on obesity, kidney disease and hypertension?
What are the likely costs and benefits of the proposed partial sugar taxation policy? Are these effects superior or worse than regulation of producers?
Will the Mars Corporation’s decision to put “health warnings” on some of their products result in loss of market share with few health gains, or lead to health-inducing emulation?
Sir Galahad’s Five-Year Forward View rightly advocates vigorous prevention policies. But politicians, lobbied by corporate interests, move as slowly as investment in evidence production.
4.) Integrated care
The fragmentation of primary and secondary healthcare and local authority social care has been highlighted as a problem for over four decades. Numerous NHS re-disorganisations have failed to bite the bullet of integrated care, in large part because of each sector’s reluctance to give up power and budgets to complementary competitors for public funding.
Recent investments in Vanguard projects and political initiatives such as the devolved, integrated Manchester (a Northern ‘poorhouse’?) are the latest manifestations of integration. Similar efforts are evident in the USA.
In both countries, there is investment in evidence, with US studies showing limited success. Given that the failures over decades of progress in developing efficient forms of integrated care, progress remains slow, with the need for healthy scepticism about the quantity and quality of evidence.
Beware the high priests of evidence-free policymaking! They dominate choices about the allocation of scarce resources amongst competing patients. Prepare to be challenged by academic researchers whose role, as Mary Beard noted in The Guardian recently, is to make everything more complex.
Simplicity is rarely the characteristic of healthcare reform. The healthcare market is very complex. Simple solutions rarely work.
The latest wheeze of vote-maximising politicians all too often wastes resources, thereby giving up potential health gains. Such behaviour is not only inefficient, it is immoral.
Politicians and managers should think before they spout un-evidenced drivel.