The Maynard Doctrine: QIPP - the sound of panic, or a belated vital sign of intelligent life?

Professor Alan Maynard OBE looks through the prism of QIPP at the NHS's task to avoid becoming heir to Royal Mail's strikes preceding privatisation. His solutions include a primary care-led A&E; turning the noun 'collaborator' into a positive; and the Kwik-Fit hospital.

QIPP: the policy announced in David Nicholson's August 2009 “need to know“ letter to Chief Executives as a follow-up to Ara Darzi's “Next Stage Review”: Quality Innovation Productivity and Prevention (or backing all horses in the hope that one will cross the finishing line!)

Quip: defined by the Oxford English Dictionary as “ a sharp or sarcastic remark”; a “clever or witty saying” or “a curious or odd action”.

Which of the two above definitions would you choose to describe QIPP?

In some ways, it is not a curious or odd action given the current state of the NHS. Ministers and civil servants seem increasingly depressed by the state of the NHS's finances. Comrade Nicholson mumbles at conferences about PbR being their most difficult 'problem' as they seek to free existing NHS funds to redeploy to meet increasing patient demands as the population ages and we all decline physically and mentally.

Welcome back, the two-part tariff
This concern about finance presumably means we will move back to two-part tariffs in 2010-11 - after only recently abandoning it. This back-track is to be accompanied by a journey into the unknown of 'normative prices'. Instead of fixing tariffs in relation to the average cost of a procedure, initially five conditions are to have 'best practice' tariffs.

Thus for instance for laproscopic cholestectomies, a target of 60% of these procedures have to be carried out as day cases. Tariffs will be paid for day case costs up to this level. So if (for instance) your hospital achieves only 15% as day cases, it will lose money on 45% of their workload (which is done as a more costly inpatient procedure).

In time, normative pricing may be used to drive further electives into day cases, and day cases into inpatient procedures.

All change, please
Those hospitals who are slow to change their local practices and herd clinicians into swift collaboration will become financially embarrassed.

Hopefully, when such institutions go bust, it will not be the managers alone who are targeted for the salt mines. Failure to shift clinical practices will be the product of clinicians’ behaviour. For once, we may hope that change-shy clinicians will accompany their management colleagues to the Gulag of fat pensions and jobs in other parts of the NHS.

However these policies are unlikely to be adequate to keep the books balanced in the short run. The return of block grants seems inevitable. This will help PCTs control their outlays and achieve balance but will mean providers - facing near-level budgets for the next half decade - will have to become much more efficient.

This means that phrases like 'lean', which is confused management code for efficient, will be trotted out by the faithful in consultancy firms throughout the land as they proffer advice to bemused NHS managers confronting the need to cut after a decade of spending like drunken sailors.

So QIPP is not an odd action, but an indicator of the sense of urgency (if not panic) in Whitehall Village.

But is QIPP a clever or witty saying? The word sounds good, and the policy seems to cover PbR, PROMs, CQUIN and every other policy announced since the creation of the NHS.

All the policy weapons are being called into action, even if they are mutually incompatible! Managers are obliged to not only do something but do lots of things, quickly! Thus if you as a manager are not doing everything, you have clearly failed.

For a hospital manager faced by flat funding for years, QIPP means it is time to get your finger out! Your survival will depend on changing your organisation radically.

The Kwik-Fit acute approach
In particular, patient flow has to be better managed and length of stay has to be reduced sharply. Patients who, for instance, have swollen legs and a suspected deep vein thrombosis (DVT) will not be put in a bed, but treated as an outpatient. Assessment facilities will be staffed by medical generalists trained to discharge safely and swiftly. GPs and nurse practitioners will screen A&E patients and, where safe, send them home rather than plant them in beds 'for observation'.

Hospitals have to become Kwik-Fit repair shops and ensure patients stay the minimum safe time possible, thereby shifting caring costs to individual patients, carers and other community facilities. If they fail to develop in this way, hospital access targets will be failed.

However, maybe QIPP is a sarcastic or witty saying indicative of the feeling that this is all impossible. Pessimists would argue that this agenda cannot be delivered with or without the help of Sooty and his magic wand. Why?

Because NHS management, both clinical and non-clinical, is incapable of engineering swiftly the changes that are needed. For instance: to reduce length of stay, most NHS hospitals need more generalist acute physicians. They have no money to hire new and additional staff. So can they persuade existing sub-specialists to abandon their specialism and become generalists? If not, will making surplus sub-specialists redundant be possible swiftly and cheaply?

Collaborators wanted to avoid being Consignia-ed to the dustbin of history
Managers will need to collaborate with all staff and outside agencies. Turf wars about who is in charge will destroy careers and institutions. They will need to collaborate - particularly with clinical leaders inside and outside hospitals, who will be the major agents of change.

Without such collaboration, we could have the NHS turn into the Post Office as operatives strive to maintain pay and conditions of employment no longer viable in the harsh world of the second decade of the 21 st century.

So QIPP is not a witty remark, but an attempted and increasingly desperate action to sustain the NHS. Supporters of this noble institution should wish Comrade Nicholson and his bunch of gangsters well, as they try to drive home changes obviously needed for decades but resisted by all-too-generous NHS funding and the restrictive practices of all-too-powerful elements of the workforce.