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The Maynard Doctrine: How do you encourage a crab?

Professor Alan Maynard OBE reflects on the true crisis in NHS dentistry - PCTs' lack of teeth

Policymaking in Whitehall Village is like watching a crab traverse the beach: it is slow, and you despair of it ever getting there. As you think it is getting there, it is engulfed by a wave of nonsense which sets it back to from where it started.

This behaviour is epitomised by the Department of Health. Full of waffle about “quality”, “reducing costs” enhancing “productivity” and seeking the nirvana of “efficiency”, they are ambiguous in their use of terms and confused about the best process to achieve good outcomes.

Periodic bouts of panic about hygiene, mortality rates or some dodgy drug set back progress, as resources are dispersed by political fiat with often little regard to evidence or opportunity cost.

Apart from the lack of clarity in the terms used (e.g. “efficiency”), the problem is that policymakers are often naïve in terms of their understanding of basic economics.

We have spent decades lamenting and reiterating the failure of healthcare systems such as the NHS. Poor evaluation of cost-effectiveness of medical interventions; large unexplained and wasteful variations in clinical practice; medical errors; and a mad belief in that grossest of non sequiturs - that if you spend more on healthcare, you will automatically improve population health - have been reiterated regularly like pious chants to the Gods. Woe! we have failed Lord! (And we intend to do nothing about it; naturally).

A dry QIPP
But is the policy crab now heading in the right direction, and how can it be kept on course? The latest game in town is QIPP: quality, innovation, productivity and prevention.

This is a nice exercise in imprecision and waffle about networks, national programmes, capacity and capability, clinical leadership and clear narratives to mention. However, some of the underlined items in Comrade Nicholson’s “Dear Colleague” letter of August 10th (Gateway reference 12396).

Under all this nonsense, is the Department of Stealth edging towards the fashioning and use of better incentive systems to drive change? They need to do this, as previous policies of shifting the deckchairs on the Titanic have manifestly and unsurprisingly failed.

Hints of international despair
There are hints from policymakers across the developed world that, having invested in better information and audit and having pleaded for clinicians to change their fragmented and all too often evidence-free ways of treating patients, said policymakers are despairing. They have led the clinical horses to water, but failed to make them drink at the well of economics-based medicine (EBM) - i.e. cost-effective healthcare.

Bulldog dentures required
So with the IMF at the gate and the economy set to be sadly stagnant at best for the next five years, it is time for the piper (i.e. the purchaser) to call the tune and generate change.

’PCTs have all too little information about relative costs and activity, let alone outcomes’

At present, the NHS is designed to ensure that PCTs are toothless bulldogs. They can bark but they have few means of making providers alter their behaviour. GPs are insulated by contracts that government has decreed will be regulated with a “light touch”: just like the bankers who have now renderd millions unemployed.

PCTs have all too little information about relative costs and activity, let alone outcomes. Even if they were better-informed, they have few levers by which to engineer change. Primary care needs proper incentives, so that PCTs who are the guardians of patients and taxpayers, can protect them form the obvious inefficiencies of providers.

Hospitals, like GPs, are cocooned in their inefficiency. Managers all too rarely say ‘boo!’ to the clinical goose. Consequently, the geese ramble about in an unco-ordinated and inefficient way, which gives them a good life and patients a good wait! Foundation Trusts, the product of  former Trotskyite Alan Milburn (who fell out of love with Trotsky and into love with “competition” - a concept he knows nowt about!); have to be paid by PCTs for what they do. As they overtrade, they bankrupt PCTs.

PCTs can weep and wail, but they have to pay up by law and keep the hospitals in the all-too-inefficient style to which they are accustomed!

The Whitehall crab is now lurching towards giving PCTs some levers to combat the inefficiency of providers. Commissioning for Quality and Innovation (CQUIN) will enable them to cut tariffs if hospitals do not measure and manage standards of care better.

The Department of Stealth is lumbering towards empowering hospitals to cut hospital funding of “never” events. US Medicare started this policy in October 2008; and so (for example) if a patient is admitted with pneumonia and “acquires” a pressure sore, the hospital is reimbursed for care of the pneumonia but has to fund to care of the pressure sore out of its own funds. This American virus is spreading through Richmond House far too slowly; but will hit the hospitals as inevitably as H1N1.

All this has to be driven from the centre - and speedily. PCTs will be bankrupted too easily in the downturn unless they have the leverage to control GPs and consultants. As this armoury develops, we hope these noble tribes will be induced to “heal” themselves! Or is that asking too much?