The Maynard Doctrine: The arrogant and the ignorant must be collaborative friends
Health economist Professor Alan Maynard explains why researchers ("the arrogant" *) and managers ("the ignorant" **) have to start to work together
The problem: ignorant managers and arrogant researchers
NHS managers offer us New Year messages advocating hospital closures to fund “care in the home”. Some of them vigorous advocate “telehealth” and “telecare”.
Locally, they are all reforming the processes and structures of healthcare delivery: where “reform” means they are experimenting on their patients by changing modes of healthcare delivery.
Sadly, all this innovation is rarely evaluated scientifically. All too often, these admirable folk are clueless when it comes to evaluating their earnest attempts to improve patient care.
In contrast to this ignorance, the research community tends to arrogance. They know how to evaluate the experiments that abound in the NHS locally and nationally. They have access to ring-fenced research funds worth hundreds of millions of pounds (e.g. NIHR).
Using esoteric research designs they publish learned papers in journal un-read by many of their peers, let alone NHS managers. These papers get them promotion and acclaim from their professional associations. They have few incentives to sell their findings to mere NHS managers, who might use them to improve patient care.
The arrogant and the ignorant march on in isolation. They ensure that new knowledge is poorly applied to improve the lot of patients and the taxpayer.
The managers of healthcare fail to articulate their needs for data analysis and modelling: they are pathetic consumers - or demanders - of knowledge.
The researchers fine-tune their research methods, gobble NHS data and feed it into their computers and arrogantly ignore the need to go forth and market the results of their endeavours to managers. They are pathetic providers - or suppliers - of knowledge.
With demanders (managers) and suppliers (researchers) working in isolation, it is unsurprising that much NHS “innovation” is evidence-free hogwash.
The market for evidence
The market for evidence is grossly inefficient.
How can the behaviour of both the demanders and the suppliers of evidence be better incentivised to produce better value for money?
Reforming the market for evidence use
1) The ignorant: managers and doctors
How many senior non-clinical executives in the NHS, be they at the Commissioning Board, NHS Trusts or PCT / CCG purchasers have an undergraduate degree, a masters’ qualification or (heaven forefend!!) a PhD in scientific method?
University qualifications are not essential - but they can be very useful. Sadly, these guys and gals are usually very able - but untrained in basic evaluative and interpretive skills.
The response of the Department of Health and the NHS is to offer these poor souls “leadership” training. All too often, this neglects training in health service research methods (HSR) and health economics (HE). Consider how much support the Kings Fund, the Health Foundation and other purveyors of “leadership skills” provide for training in health economics?
It is not just about managers. How much HSR-HE training is offered to the major decision-makers in the NHS: clinicians?
Medical school training consists of scores of GSE-type modules: “never mind the quality, feel the width” of this 'education'.
The General Medical Council recommends HSR-HE training. The latter (HE) is usually pathetic. Ask you friendly GP or consultant to name the cost of a drug, a blood test or a heart by-pass: if you get responses near 5% right, you have a remarkable practitioner in your sights.
Cost data is of course very limited, but revelation of such data in a comparative form may change the behaviour of doctors for the better! (Please evaluate, of course!).
The basic problem on the demand side of the evidence market - among both managers and doctors - is that the training they receive is determined by the ignorant, well-intentioned folk who have trained to be “leaders” (whatever that means), but were not given essential evaluative and scientific skills themselves.
This leads us into the current, pathetic circle of the ignorant determining the education of the ignorant - which is self-perpetuated! To the extent that there is any improvement, it is marginal and totally inadequate for a health service facing annihilation without evidence-based change in a period of severe austerity.
2) The arrogant: the suppliers of evidence
There is a multitude of very able researchers carrying out path-breaking work which illuminates the costs and benefits of national policy and NHS care. Researchers - like managers and doctors - are not deliberately perverse in failing to focus their work on NHS “needs” and the dissemination of their findings.
NHS managers are poor at articulating their needs for research, and even worse at prioritising such needs. With poor training, they find it difficult to design research questions and make researchers despair when they try!
They ask questions such as 'does XYZ work?': this provokes researcher questions such as 'compared to what? Over what time period? At what cost? (And by the by, it will take 3 years to answer your question at a cost of £100,000)'.
No wonder managers have recourse to faith-based policy, when tempted to waste hundreds of thousands on their unoriginal ultimate solution or ill-conceived innovation.
Researchers are focused on peer review success, publication in 'high-quality' journals that score highly in research assessment exercises and success in raising the next grant to fund their lifestyle. They are reluctant to be contaminated by the needs and often impossible time-horizons of NHS managers!
As a consequence, managers in their isolated institutions repeat the mistakes of colleagues who have either not evaluated the same policy and/ or not disseminated any results.
Some examples of this: how many local NHS service providers have put a GP in A&E; used telecare to better manage COPD, asthma and diabetes patients; and experimented with differing levels of nurse staffing and altered skill mix (e.g. replaced GPs with nurse practitioners)?
Go and look at the evidence for all these common policies - which have not always been thoroughly evaluated, but are in widespread use (start by using the Cochrane databases e.g. EPOC, and the NHS Centre for Reviews and Dissemination).
Managers and doctors continuously change practices, and thereby are experimenting on patients. This can be as dangerous for patient safety as poorly evaluated pharmaceuticals! Its opportunity cost deprives patients of care from which they could benefit.
3) What next, then?
The arrogant and the ignorant should be friends, instead of working in their separate “boxes” and failing to exploit the potential of better collaboration.
How can such collaboration be facilitated?
a) Reform leadership training throughout the life cycle of managers and doctors, especially for graduate-entry managers, so they have skills to distinguish twixt opinion-based bullshit and evidence of clinical and cost-effectiveness.
b) Reform medical school education to include more HSR and HE, as well as familiarity with the roles and working of NHS structures and the system’s history of “redisorganisation” as a solution to well-defined inefficiencies in service delivery.
c) Provide a mechanism by which all NIHR and research council researchers are required to send summaries of their results to NHS bodies and policy organisations such as the House of Commons Select Committee on Health, the National Audit Office and sister organisations in Scotland, Wales and Northern Ireland.
d) Require all HSR and HE researchers to register their activities in a publically accessible repository.
e) Require all NHS organisations to employ expertise to synthesise this research knowledge and facilitate its translation” into use in making policy choices.
f) Require all NHS proposal documents at hospital and CCG level to have both reviews of existing evidence and clear, funded plans to evaluate the success and failure of proposed innovation in rigorous ways.
g) Require researchers to love their NHS colleagues - and show this by marketing their findings energetically.
h) Require managers and doctors to love their research colleagues by recognising their skills and potential contributions to improving patient care.
i) Require NHS managers, clinical and non-clinical, to stop funding rubbish pseudo-research (and dodgy consultancy services not subject to rigours peer-review of design and reporting).
j) Evaluate such changes to ensure the arrogant become less arrogant and the ignorant become less ignorant - i.e. make them learn to complement each other’s skills better.
Happy 2013, and ensure you minimise your use of the dear old NHS in these frugal times.
* Arrogant is defined as “over-bearing, presumptuous, haughty"
** Ignorant is defined as “lacking knowledge, uninformed”