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The Maynard Doctrine: Saving money to save the NHS

Professor Alan Maynard OBE looks at the upward drivers on healthcare demand, and predicts some patterns of probable NHS behaviour in response

The fate of healthcare funding and the NHS is unclear. Despite the rhetoric of decades, there is little evidence that community care is cheaper or more efficient. With patient demand for care continuing to increase, community care may be no solution.

The usual explanations of increased patient demand are technology, an ageing society and patient expectations. Let’s review each of these.

Worthy innovation?
Firstly technology, where the argument seems to be that the inventiveness of big pharma and the medical profession is “automatically” increasing the demand for funding by 0.5 to 1.0 per cent annually.

This approach assumes that the inventiveness of entrepreneurs is worthy of funding!

Is it? Technology appraisal as practiced by the National Institute for Health and Clinical Excellence (NICE) is inflationary, with much of the “guidance” mandating NHS use of marginally cost-effective interventions. Sometimes, and perhaps most times, these NICE induced investments of inferior cost-effectiveness to other options the PCTs would prefer to fund if NICE “guidance” wasn’t mandatory.

Not only is NICE inefficient and inflationary, it is also a price taker - i.e. instead of being able to negotiate prices with Big Pharma, it has to accept the exorbitant prices they set.

Thus NICE guidance and its use of PCT funds is a means of subsidising the pharmaceutical industry to deliver inefficient therapies to NHS patients. If politicians were not so keen to protect these inefficient capitalists, the inflationary pressure produced by technological change could be reduced.

This would make the delivery of care to the ageing population less expensive. However, the international success of keeping citizens alive for longer will continue to be inflationary for healthcare systems.

Morbidity – less compressed than might be hoped
The hoped-for compression of morbidity in successive cohorts of the elderly seems reluctant to manifest itself to any significant extent. Thus people are living longer, with needs for ongoing routine repairs such as hip and knee replacements and support for chronic diseases such as diabetes, stroke, cancer and heart disease, where survival times are slowly improving.

A challenge for those interested in the moderation of the inflationary pressures arising from the ageing of the population is to reduce clinical practice variations. However, it remains unclear whether reducing this variation would increase funding pressure or mitigate it.

Whilst Darzi asserted that improved “quality” would reduce costs, as with variations mitigation, we lack evidence. Only with very careful management of variation reduction can managers be assured that squeezing out these inefficiencies does not produce other inefficiencies, to protect the incomes and employment of those guzzling from the healthcare trough!

Thus the elderly are always with us, and in increasing numbers. Furthermore these “baby boomers” have considerable but very unequal access to resources. Perhaps part of “reducing the deficit” will involve more means testing of benefits to the elderly such as “free” prescriptions and “free” bus passes?

The elderly - and indeed the rest of the population - have high expectations about the capacity of healthcare to give them longer and better-quality lives. However, the major determinant of health - apart from the genetic endowment offered by birth - is behaviour.

Prevention and its problems
The case for spending less on the NHS and more on prevention is overwhelming at the level of principle. However, the problem is that the evidence base for such interventions is even worse than for investing in healthcare.

There seems to be evidence that investing in the early years is most efficient - that kids have to be caught young if adverse behaviours are not to become embedded and difficult (if not impossible) to mitigate in later life.

This requires both marginal change and political courage: both attributes forever in short supply in Whitehall Village!

Marginal change is needed, so that we can learn more by careful evaluation of interventions. Political courage is needed because any investment in behaviour modification is inevitably paternalistic, with overtones of “we know best, and we need to save you from your sad and bad behaviours!”

Furthermore, such paternalism will be resisted by industries, as behaviour change will affect their profits. So what would they not like to see?

Well, let’s say we were to enforce a minimum price per unit of alcohol (as is proposed in Scotland); tax highly-processed sugary foods and beverages to save the young from the perils of obesity; and imprison the former and saintly footballer Gary Lineker for his promotional activities for potato crisps. All of these sound fun; would improve population health; and would certainly provoke industries and the libertarian right.

The change checklist: what to expect and hope for next
So is the NHS doomed? It is doomed to have another crisis of “rationing”, where harsh choices about access to care are inevitable. To hit elective surgery targets, expect treatment thresholds to be raised so that more citizens are left in avoidable pain and discomfort, whilst “targets” are hit!

Expect reduced outpatient levels. Expect change! Expect that management will finally have to work with professionals, so that featherbedding is reduced and taxpayers get better value for money.

Hope that wisdom and evidence can be used to sustain the NHS and keep it available to all, with minimal user charges.

Recognise that this hope can only be fulfilled if all concerned are prepared for radical change in working practices and the ways in which we treat patients.