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The Maynard Doctrine: The new NHS virus - how to incentivise quality

Professor Alan Maynard considers the costs and benefits of new incentives for quality

After splurging billions of additional spending on the NHS, even the politicians have now begun to question the value for money of their generosity.

Since The NHS Plan in 2000, we have had two reports from the chair of the Northern Rock's remuneration and risk committees Sir Derek Wanless, and the musings of the St Mary’s surgeon Lord Ara Darzi. The views of both these gentlemen have further focused what academics asked from the outset i.e. is this expenditure shift a demonstrably efficient way of improving population health?

The initial focus of the Blair programme for the NHS was improving process. For instance, waiting times were successively driven down to hit the end 2008 target of a maximum wait of 18 weeks for elective surgery. What was the cost of this policy, and how much health gain did it produce for the population?

Waiting times for “urgent” cancers have been driven down. This policy depends on the skill of general practitioners in discriminating between urgent and not-so-urgent cancer cases. Research has show that GPs do not excel in this task with non-urgents being referred as urgents and urgents being designated as non-urgents and getting care too slowly.
Again the cost and health gains of this policy are unknown.

The large variations in clinical practice and knowledge of economies of scale (i.e. if surgeons specialise and do increased but often low volumes, they have lower mortality rates) led to the formulation of National Service Frameworks (NSFs). A good example of this is in cancer, where peripheral cancer units refer patients to regional cancer centres and each type of cancer is supposed to be dealt with by cancer care teams working to agreed national protocols. Again the cost of the NSFs is unknown, as are the population health gains arising from these ambitious and evidence-based policies.

The belief behind the Blair-Brown reforms was that spending more and doing more, particularly if informed by evidence, would be beneficial to patients. Such beliefs need to be evidenced. For instance: even if some patients are treated according to NSF protocols, the health gain may be marginal for advanced cancers, but the cost is considerable.

'Incentivised quality management is excellent in principle, but in practice no one has ever done this, and so the NHS is now entering a period of experimentation.'

The voices of 'doubting Thomases' have unhinged Whitehall village. Ministers are increasingly twitchy about whether they can defend what they have done. The Labour-Conservative consensus now is that there is an urgent need to demonstrate beneficial patient outcomes, and to use money to incentivise better process and outcome excellence. This new “policy virus” may have the potential to improve and harm patient care.

Incentivised quality management is excellent in principle, but in practice no one has ever done this, and so the NHS is now entering a period of experimentation. As with new drugs, there is always a risk that these reforms post Darzi will be costly with marginal health gains. Consequently evaluation of these experiments with taxpayer’s money on patients in the NHS is essential, but will no doubt be lacking especially given the current financial and fiscal crisis.

What are the Whitehall villagers contemplating? As part of “world class commissioning” there is a focus on “commissioning for quality and innovation”, known as CQUIN. This builds on the US Premier programme, now being replicated by the North West SHA, in which commissioners provide bonuses and penalties above the normal uplift in PbR tariffs for good and poor performing providers.

In these CQUIN-Premier type systems, the reward and penalty system is principally focused on processes rather than outcomes. Thus a commissioner might specify a process for a patient presenting with fractured neck of femur e.g. operate in 24 hours and use evidence-based treatment pathways. Achievement of the specified process might uplift PbR tariff by 1-2 per cent, and poor performance could lead to tariff reduction for the same poorly-performed procedure. Obviously, such narrow American-style process performance setting could be complemented with outcome measures e.g. the addition of patient reported outcome measures (PROMs).

'policy experimentation can damage patients’ health just as much as bad clinical practice and dangerous pharmaceuticals'

The US evidence base for Premier is incomplete - it is unclear whether hospital when pursuing these process targets lose focus on other non-incentivised procedures i.e. such programmes may have disguised opportunity costs. Experimentation is to be welcomed - but with the possibility of improving some care at the cost of poorer care for other patients, it is essential to move carefully and evaluate.

This is unlikely to happen. Ministers have contracted the quality and incentives virus, and may blunder where angels fear to tread! Questioning of the health gain of taxpayers' money is to be welcomed as long overdue, but policy experimentation can damage patients’ health just as much as bad clinical practice and dangerous pharmaceuticals.