The Maynard Doctrine: Teen pains - time for the prospects and challenges of real NHS reform
Professor Alan Maynard looks forward to the real reform conversations and challenges that will start once the Health Bill becomes law.
After an interminable debate about the NHS reform bill, it will be law in May. Not that that is very relevant: CCGs are already up and running in many places. The NCB is cutting and slashing (i.e. re-disorganising) so-called “bureaucracy” by creating five layers of management to control CCGs.
Oh, and we are still unclear about things such as ‘clinical senates’ will do, apart from taking doctors away from their patients so that they can witter and moan!
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As ever, the challenge is to keep the lumpenproletariat of medics away from management, and exploit the expertise of professional medical and non-medical managers.
Policy issues of importance
As the politicians inside Whitehall and in the professional bodies ‘reject’ the reforms and pose as champions of the NHS, it is important to focus on policy issues of importance.
QUALMs over QALYs
Here are a few issues that need our careful attention.
1) Quality, innovation, productivity and prevention (QIPP). Where is the clear definition of this programme? And where is the systematic collection of before-and-after data that proves it is working?
Can I suggest that clear definitions there are none that are other than vague sanctimonious avowals of good intentions?
David Flory of the Department of Health commissariat publishes quarterly reports of ‘success’ (the last one quietly published on December 23rd). These claim progress; but are these cost-cutting achievements anything other than financial games? Where is the evidence of innovation and productivity gains? Just how are these savings being deployed?
2) Clinical practice variations. Part of QIPP is the production of savings from reducing unwarranted clinical practice variations. How much can be saved, and how soon, by reducing variations? The New York Timesreported that “nearly half of lumpectomy patients who had a second operation may not have needed them”. Examples such as this require careful appraisal - and if true, indicate unacceptable waste and unnecessary patient distress.
Wennberg and his US Dartmouth College colleagues suggested in 2002 that if conservative, safe practices were adopted in US Medicare, 30-40 per cent savings are possible.
Others such as Cutler and Sheiner (1999) writing on ’The Geography of Medicare’ are more conservative, suggesting 15% savings possibilities in the US.
Whether such conservative approaches are accepted or not, the central issue is how do you reduce this waste and is it cost-effective to do so?
Answers to such questions are scarce! But faith-based statements aboud, feeding dubious arguments and data to the gullible.
3) Meanwhile down at the National Institute of Cost-Effectiveness (NICE), there is debate about discount rates in technology appraisals.
Recent Treasury-induced skulduggery had suggested differential discount rates for costs and benefits - i.e. 3.5% for costs and 1.5% for benefits. This would have made costs look smaller and benefits larger, thereby favouring big pharma.
Quel surpris! Hopefully the econ empire will strike back and NICE will move to say 3.5% for both costs and benefits. Watch this space!
4) Another threat to big pharma is the NICE cut-off rate, currently at £30,000 per quality-adjusted life year (QALY). Many new drugs do not produce many QALYs, instead offering QUALMs i.e. quality-adjusted life months! Research comparing PCT cut-off rates and those of NICE lead to the conclusion that £30,000 is very generous.
Perhaps the cut-off should be nearer half this: £15,000? If this emerges as a policy suggestion in the next year, we can anticipate a) a big pharma explosion, and b) political deviance!
5) Pay: with pay frozen for some years to come, the savings are considerable: this will no doubt be regarded as a major QIPP achievement. Incremental drift is still a problem, and stricter appraisal of doctors and all other staff should be used to avoid automatic progression.
Should there also be a policy of 'decrementalism' - i.e. moving folk down pay scales when their performance declines? In academe, you can observe folk retiring on the job: the same may happen in medicine. Let folk suffering from this condition retain their titles and have their pay reduced with suitable publicity, to induce change to repair reputations?
As the noise of conflict about the NHS reforms declines after May and we have to implement fundamental changes to ensure the future viability of the NHS, it is important to consider issues such as these.
After the profligacy of the noughties, the pain of the teen years will be considerable requiring radical changes in the ways healthcare is delivered, transparency assured and accountability improved.