Health CommitteeWritten evidence from Professor Alan Maynard (LTC 56)

Alan Maynard is a Professor of Health Economics, Department of Health Sciences and Hull-York Medical School, University of York. He was a Board member of York Hospitals NHS Foundation Trust from 1983–2010, and was Chairman from 1997–2010. He was appointed Lay Chair of NHS Vale of York Clinical Commissioning Group in 2012. He is a NHS patient with multiple morbidities, appreciating NHS long term care.

Current Policy Assertions

1. Patients with long term conditions could be “better managed” in the community with integrated pathways of care covering personal activity, primary care, local authority and NHS community support and hospitals.

2. Such care would offer better process quality, improved outcomes and the potential for cost savings.

Policy Problems

1. Commissioners are weak, compared to GP and hospital providers ie PCTs/CCGs are price and quality takers rather than price and quality makers. This problem is evident in both public-NHS and private health care systems ie private insurers also tend to be price and quality takers.

2. Successive “re-disorganisations” of the NHS since 1974 have failed to remedy this power inequality as evidenced by the following quote from the Francis report on Mid-Staffordshire (2013):

“Commissioners—not providers-should decide what they want to be provided. They need to take into account what can be provided, and for that purpose will have to consult clinicians both from potential providers and elsewhere, and to be willing to receive proposals, but in the end it is the commissioner whose discretion must prevail.”

3. Why are commissioners weak? The answers to this question are quite simple: incentives and fragmented care delivery systems in practically all public and private health care systems:

(i)The policy “ideal” is that investment in community care is a substitute for care in acute hospital settings. For this to be so, hospital capacity has to be reduced and resources saved transferred, perhaps with economy, to fund community service development of good quality.

(ii)Sadly this policy ideal may not achievable in many cases. Investment in community care may become a complement and not a substitute for secondary care. The consequence is that service quality for patients may be enhanced but costs also rise.

(iii)PCTs/CCGs/commissioners can only downsize hospital facilities by mutual agreement with providers. Hospital providers can resist, maintain referrals from GPs and garner income via the PbR system of payment for activity. GPs can be similarly resistant to change. They will resist having to increase care for patients previously treated in hospital unless they are paid. Thus CCGs like their PCT predecessors have little or no leverage on providers other than “moral suasion”.

4. An additional clinical problem is that guidelines and pathway advice are based on evidence from trials exploring the best way to manage single morbidities. Many of the patients with long term conditions have multiple morbidities. The best treatment for one morbidity may deleteriously affect the best treatment for another condition. As a consequence clinical co-ordination across specialties is essential and has to be resourced. Clinicians have to exercise judgements in collaboration with their colleagues involved in the treatment of multiple morbidities. Thus they may not always follow evidence based guidelines for particular conditions.

5. As emphasised for decades (eg Barbara Castle’s “Priorities in Health and Social Care” 1976), and nicely re-iterated in the 2013 Health Select Committee report on Public Expenditure in the NHS, health and social care production is fragmented into the silos of primary care, acute care (now commissioned by two organisations, specialist care by NHS-England, and non-specialist acute care by CCGs), social care (provided by local authorities (LAs), CCGs and the voluntary sector) and public health (also provided by LAs and CCGs). These silos are insulated by incentives which support the resources, power and income of providers rather than enhancing collaboration and exploitation of economies of scale to advantage the patient and the taxpayer. The policy advocacy of the Labour government in the 1970s is remarkably similar to that of the current administration (see Alan Maynard, “Funding health care in times of austerity: what goes around comes around”, Journal of Health Service Research and Policy, January 2013).

Four Inter-linked Questions

1. Where is the evidence that community care is cost effective?

2. Where is the evidence that that community care can be delivered as a substitute for hospital care, rather than as a complement which improves patient care and inflates expenditure?

3. Where is the evidence that hospital costs and employment can be taken out and transferred to fund community care?

4. With existing perverse incentives which sustain existing providers, in particular PbR for hospitals and the GP contract, what reforms are necessary? Eg would nurse led primary care be more cost effective?

In seeking answers to these questions, one result is “we need more research”! Ie an evidence base is absent despite expensive and extensive “innovation” over decades... There is a continuous storm of expensive local “innovation” to save money and improve patient care, often with particular focus on “community care”. However this activity is not support by evaluation which enhances the evidence base. As a consequence we do not know whether community care is a complement to specialist care or a substitute for it. The problem is exemplified in Professor Sarah Purdy’s review “Avoiding Hospital Admissions”, Kings Fund, 2010 where most of the policies reported are shown to have no evidence base.

Some Suggestions for Future Policy

1. Require providers and CCGs to register their plans nationally for changes in service delivery with reference to evidence sustaining change where it exists, and where it does not exist lodging their plans for scientific evaluation. Existing institutions such as the NHS Centre for Reviews and Dissemination should be an integral part of NHS investment activity rather than largely ignored by busy managers focused on a “quick fix”.

2. All reforms are social experiments (DT.Campbell, “Reforms as experiments” American Psychologist, 1969) and as such they should be evaluated to inform future policy choices. CCGs and providers, public and private, who fail to register innovations and evaluate them should be fined.

3. Train clinical and non-clinical managers in analytical methods so that they can access this knowledge and add to it by leading their teams in policy analysis. This requires radical reform of “leadership” training with emphasis on economics, other social sciences and trial design.

4. Incentivise further researchers supported by public funds to disseminate their work better by demonstrating the policy implications of their work. Oblige them to distribute clear and simple one page summaries of their work to NHS and Whitehall users eg the Health Select Committee.

5. Require all CCG and Hospital business cases to include details if any of the evidence base, and how investment will be evaluated. Relate success in complying with this requirement to promotion and salary increments and decrements.

6. Create a national capacity to inform health policy reform similar to that provided for medicine by the National Institute for Clinical Excellence.

7. Sanction limited radical structural experiments with evaluation eg the merger of hospitals with a co-terminous local CCG. Has 22 years of the purchaser-provider divide been efficient? There is no evidence to sustain it so radical experimentation with careful design and learning from Scottish, Welsh and New Zealand abandonment of the purchaser-provider divide may be informative.

Finally

Inertia fuelled by faith based rhetoric characterises many public and private institutions. Everywhere there is lip service to “evidence based” decision making and decision makers neglecting to translate words into practice.

Two physicians invented the term “scepticaemia” They defined it as “an uncommon generalised disorder of low infectivity. Medical school education is likely to confer lifelong immunity” P Skrabanek and J McCormick, Follies and Fallacies in Medicine, 1989).

In analysing the subject of long term conditions scepticaemia is essential. We must ask always where is the evidence, and where it is offered is it robust or optimistic advocacy?

9 May 2013