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The Maynard Doctrine: Faith-based policymaking: dear God, when will it end?

Professor Alan Maynard OBE suggests that reforms to improve and incentivise commissioning should be based on evidence. What is not going to help is a faith-based cut-and-paste from Holland.

There is universal concern over - if not condemnation of - the quality of ‘commissioning’ in healthcare.

Whether you appraise the private healthcare sector and its track record in protecting their customers from inefficiency, poor quality care and premium inflation, or whether you review the track record of NHS commissioners, the conclusion is the same: they have failed to protect patients, taxpayers and insurance payers.

Given this deplorable record of public and private sector inefficiency, for some the solution is to improve performance through ‘competition’ and ‘privatisation’. What do these words mean? What are the implications for the NHS?

Ends, means and justifications
The religious advocates of competition often forget that it is a means to an end; not an end in itself. Thus in judging whether competition works, it is essential to identify and rank the goals of healthcare reform.

Only by doing this can you evaluate whether the reform of competition has worked.

What do we want healthcare systems to do?
The three most commonly cited objectives of healthcare systems are:
- ease of access to care which does not bankrupt you (equity);
- the delivery to patients which is right, at the right time and at least cost (efficiency); and
- staying within budget (expenditure control).

The correct question for policymakers to address is this. Does competition improve a performance of a system - public or private - in relation to those three goals?

The affirmative evidence is very thin. In the US, the local form of competition has inflated healthcare expenditure to over 16% of GDP (and a per capita spend in excess of double that in the UK). The provision of care is inefficient, with large variations in clinical practice and major concerns about quality and safety.

As for equity of access to care, President Obama is seeking to improve access for 35 of the 46 million Americans who lack insurance.

The rhetoric of competition
Competition has been part of the rhetoric of successive governments for several decades. The purchaser-provider split was designed to create opportunities for price-and-quality-making PCTs to focus on variations in practice and to increase efficiency by driving inefficient providers to deliver more uniform, evidence-based and efficient care through competitive tendering and privatisation.

Sadly, PCTs and the Health Authorities before them have proved unequal to this task, preferring to be conservative bank clerks and price-takers, anxious not to ruffle the feathers of often-deficient providers.

The reformers now agree that commissioning has to be revolutionised to reduce provider inefficiency and enable the NHS to survive the recession. But how can this be done when the public and private sectors can offer only models that have failed?

The managed care optimists.
The optimists are beginning to focus on the advocacy of the “managed care” model, which appears to have failed in the USA and has been redesigned and partially introduced in the Netherlands. These advocates argue that the Dutch model of managed care has been carefully designed and implemented, and will work.

Hope springs eternal. This position brings to mind the argument of the novelist GK Chesterton, who asserted that Christianity had not failed because it had not been tried properly in the preceding 2000 years! So with the Dutch model, the argument seems to be one more tweak and nirvana will be achieved.

In the Netherlands, health care is provided by public and private organisations that are highly regulated by government.

The Dutch have focused on the careful implementation of managed care on the demand side - i.e. funding only. They have created a market in which citizens can sign up with competing insurers. The insurers get a risk-adjusted, publicly-funded premium for each person who joins their fund.

The NHS analogy would be compacting PCTs into say 40 insurers who then compete for patients. An individual and a family could sign up with any of these competing PCT-insurers. So a Geordie could insurer herself with the Devon and Cornwall PCT-Insurer.

The insurers would compete for members by, hopefully, imposing hard contracts on providers. These contracts would oblige providers to be more efficient, thereby giving good value for money to members.

Evidence required
Where is the evidence that this alteration in organisational structure would improve efficiency and equity? What has been the cost of re-configuring the Dutch insurance market to produce some managed competition in funding?

The Dutch have designed a fascinating system, but inefficiency and expenditure control remain major problems.

'We need changes in commissioning to be supported not merely by rhetoric and faith, but by improved incentives and evidence. The English track record on evaluating organisational reform is limited and poor'

What evidence is there to expect these insurers will be more active and effective commissioners than has gone before? The Dutch response is that time will tell, and the advocates of reform remain optimistic that such a model can be emulated internationally and produce significant benefits.

A more pessimistic response is that, as ever, reformers need the assistance of Sooty to wave his magic wand and transform failure into success. We need changes in commissioning to be supported not merely by rhetoric and faith, but by improved incentives and evidence. The English track record on evaluating organisational reform is limited and poor.

It is difficult to reduce the flow of faith-based policy proposals for the reform of the NHS. We have to be careful in considering often simple solutions to complex problems!

With policymakers worldwide seeking the Holy Grail of efficient commissioning, the vendors of snake oil are required to evidence why and how their seductive liquors will suddenly work this time around - having failed last time around.