Alan Maynard

1. By
Alan Maynard
Email:akm3@york.ac.uk

2. outline
 Introductory issues
 Enduring problems
 Achievements
 Defending the achievements

3. Introductory issues: health
production
 The production of health: the primary
determinants of health are:
 Genetic endowment: Larkin
 Behaviour: parents again, income and
education
 Health care: repair industry costing £105
billion

4. What is health?
 “Health is a state of physical, mental and social well
being and not merely an absence of disease and
infirmity” WHO 1946
 1845 Lunacy Act required doctors to report regularly
whether their patients were:
1. Dead
2. Recovered
3. Relieved
4. Unrelieved
 Fines of £2 for failure to comply
 Little attempt to measure and manage systematically
patient outcomes: no measure of success!

5. The distinction between
outputs and outcomes
 An American health services researcher,
Donabedian, distinguished between:
1. Structure
2. Process
3. Outcome
 Policy obsessed by “redisorganisation”, and an
assumption of a link between that and processes
and outcomes
 What is “productivity”:a relation between inputs
and outputs, or a relationship between inputs and
outcomes?

6. Enduring problems
 Five related issues in all health care systems,
public and private, create waste and
inefficiency:
1. Uncertainty about whether health
care/medicine “works”
2. Persistent variation in clinical practice, and the
failure to deliver to patients what “works”
3. Patient safety
4. Reluctance to manage skill mix
5. Outcome measurement

8. „Flat of the Curve‟ Medicine?
Mark & Hlatky 2002, Fuchs 2004

9. What are the causes of uncertainty
about clinical effectiveness?
 Not so much a problem of inadequate
funding of R&D and clinical trials, more that
the quality of research is poor.
1. The problems of designing and reporting
clinical trials e.g. the problem of
“surrogate” end points, poor outcome
measurement and biased reporting.
2. What is the comparator?
3. What patient groups are included in the
trial?
4. How long do you run the trial? Vioxx case

10. Hogarth

11. The failure to manage
variations in England
 Priorities in Health and Personal Social Services
(1976) from the Department of Health advocated a
focus on day surgery and reducing length of stay.
The first article showing the day case surgery for
hernia repair was effective was in the Lancet in
1955 but there was little take up
 Much still needs to be done to follow this advice 30
years later e.g. the English NHS Innovation and
Improvement Institute
 Not just a NHS problem e.g. US Medicare and the
Dartmouth Atlas

12. Practice variations in the USA
 US Medicare per capita spending in 2000 was
$10,550 per enrolee in Manhattan and $4823 in
Portland, Oregon. Differences are due to volume
effects rather than illness differences, socio-
economic status or price of services.
 “Residents in high spending regions received 60%
more care but did not have lower mortality rates,
better functional status or higher satisfaction”
Fisher et al Annals in Internal Medicine(2003).
 Potential savings of 30% of total Medicare
expenditure if high spenders reduce expenditure
and provide the safe practices of conservative
treatment regions? (Fisher in NEJM, October, 2003)

13. Practice variations: why do
they persist?
 “the amount and cost of hospital treatment in a community
have more to do with the number of physicians there, their
medical specialties and the procedures they prefer than the
health of residents” Wennberg and Gittelsohn(1973 in the
journal Science)
 The English Darzi report (2008) “rediscovered” clinical
variation as major policy issue!
 Two policy issues:
1. Careful data analysis to identify outliers and to improve
average=mean performance
2. Use data analysis, benchmarking and improving average
performance by improving non-financial and financial
incentives

14. Patient safety: another
rediscovery!
 UK cases :Shipman, the Bristol case and
two gynaecologists (Ledward and Neale)
 Measuring error rates is difficult and the
evidence base is incomplete:
1. USA 3-5% of hospital admissions (Institute
of Medicine, 2000)
2. UK :two retrospective English studies of
case notes (Vincent et al, BMJ 2001, and
Sari et al (2006)) :10%
3. Australia: 16% (=10% if US criteria used)

15. Patient safety 2
 US rates of 3-5% from tow local surveys
means that:
1. Medical errors in hospitals kill 44,000-98,000
Americans each year
2. Errors kill more Americans than motor vehicle
accidents (43,458), or breast cancer (42,297)
or AIDS (16,516)
3. Medication errors alone kill nearly three times
more Americans than 9/11

16. Patient safety 3
 Types of errors
1. Medication: wrong drug, wrong dose
2. Surgery: wrong procedure
3. Infection control (Semmelweiss and Nightingale in
the 19th century) :what is the “cure” for poor
infection control?
 What is the efficient level of errors (it may not be
zero!).
 Where is the evidence base to inform efficient
investment in the “hygiene code”? E.g.
interventions to reduce central line infections,
C.Diff and MRSA, pressure sores etc?

17. Lessons from the 19th century

18. Patient safety
 The need to avoid “religious fervour” as seen in
the USA (www.ihi.org ) and at the World Health
Organisation
 In particular:
1. Identify which of the many competing safety
interventions are efficient i.e. improve patient
outcomes at least cost
2. Recognise that the efficient level of public
safety is not zero errors!

19. Skill mix
 Evidence from the Cochrane reviews that nurse
practitioners with full prescribing rights can act as
substitutes for GP (and patient like them better!)
 Evidence that assistant practitioners can replace
registered nurses
 Evidence that e.g.
1. Nurse anaesthetists can replace consultants
2. Nurse endoscopists are equally as proficient as
consultants
3. What else?
 But are they used as complements or substitutes!

20. Measurement of success i.e.
outcome measurement
 Mortality rates: use with caution!
1. Issues of small numbers
2. Issues around case mix adjustments
3. Use as screening device, not as a diagnostic
 Quality of life , pre and post treatment: patient
reported outcome measurement (PROMs):
reintroduce the 1845 Lunacy Act

21. Labour government
achievements: evidence
based medicine and policy
 The National Institute for Health and Clinical
Evidence (NICE). Many roles:
1. Evaluating the clinical and cost effectiveness of
new drugs (Technology Appraisal)
2. Producing clinical practice guidelines based on
clinical and cost effectiveness
3. Identifying what works in public health e.g.
minimum price for alcohol (and taxation of sugary
drinks?)
4. Improving the GP contract with evidence based
incentives (after investing nearly£1 billion in
incentives (quality outcomes framework(QOF)),
some of which are inefficient!)

22. And failures
 Continuous “redisorganisation” of structures
with no attempt to evaluate them e.g. 2006
merger of PCTs (see Select Committee report on
Commissioning, 2010)
 Introduction of interventions to help the
disadvantaged with little scientific evaluation of
effect e.g. “Head Start” (see the Select
Committee report on inequality, 2008)

23. Clinical practice variations
 Targets work: e.g. 18 week waiting time for elective
procedures, cancer targets and 4 hour waits in A&E
 But “advice” slow to take effect e.g.
1. NHS Institute for Innovation and Improvement
illustrates variation but how good is take up?
2. Poor management of the consultant contract: do
they do their sessions, how many do they treat in
their theatre sessions and what are their
outcomes: make national audits compulsory?
3. Need for greater transparency and accountability

24. Patient safety
 C.Difficile and MRSA: avoidable infections with
better hand hygiene and better antibiotic policy
 Beginning of benchmarking of rates of e.g. pressure
sores drug errors, wrong site surgery , falls and
items left in patients after surgery
 E.g. failure to give patients prescribed drugs in
hospital. The new “quality account” of UH
Birmingham benchmarked drug omissions for the
first quarter of 2009 and is now managing them
down. Omission rates on their website: 11% for
antibiotics and 20% for other drugs.
 To incentivise change should we “pay „em or flay
„em”? Are financial incentives the new “solution”!?

25. Potential risks of
incentivising change: pay for
performance (P4P)
 It is difficult to see if employees make the right decision
 e.g. the results of decisions may not be evident for years
 P4P attracts risk takers rather than those who want steady
employment
 Employees may manipulate the system
 e.g. “exemptions” in the GP-QOF
 P4P crowds out intrinsic rewards
 i.e. P4P rewards may drive out the natural inclination of
workers to do a good job
 Thus Akerlof and Kranton (2010) argue that “people want to
do a good job because they think they should and because it
is the right thing to do”
 In efficient firms the goals of workers and their
organisations are aligned.
 Comments on CQUIN - Maynard and Bloor, BMJ, February
2010

26. Skill mix
 Invest in workforce substantial in terms of numbers
and pay increases
 Innovatory practices but little evaluation
 Problems remain:
1. Enforcement of contracts e.g. Agenda for Change
2. Lack of focus on what savings can be made by
altering skill mix
3. Continued wide pa y differentials e.g. porters and
other ancillaries near NMW and no quid pro quo
for consultant pay increases

27. Measuring Patient Outcomes in the English
NHS
Procedure Condition-specific Generic
Primary Unilateral Hip Replacement Oxford Hip Score EQ5D
Primary Unilateral Knee Replacement Oxford Hip Score EQ5D
Groin Hernia Repair None EQ5D
Varicose Vein Procedures Aberdeen Varicose Vein EQ5D
Questionnaire
Plus a standard set of patient-specific questions in all cases
Source: DH Operating Framework, Guidance on the routine collection of patient-reported outcome measures, Department of Health 2007

28. Changes in health for five surgical procedures
from LSHTM pilot
Hip Knee Hernia Veins Cataract
Improve 358 (82.1% ) 329 (73.3% ) 203 (47.2% ) 148 (55.6% ) 150 (20.9% )
No change 21 (4.8% ) 45 (10.0% ) 127 (29.5% ) 72 (27.1% ) 335 (46.7% )
W orsen 18 (4.1% ) 34 (7.6% ) 71 (16.5% ) 34 (12.8% ) 190 (26.5% )
Mixed change 39 (8.9% ) 41 (9.1% ) 29 (6.7% ) 12 (4.5% ) 42 (5.9% )
Total 436 449 430 266 717
Source:
Using the EQ-5D as a performance measurement tool in the NHS Nancy Devlin a,
David Parkin a, and John Browne b. EuroQol Group Scientific Plenary, Baveno, Italy, 11-
13th September 2008.

29. Overview for Labour
achievements in health care
 Need to boast about and retain:
1. NICE: international excellence in analytical rigour
2. Targets
3. Focus on outcome measurement and management
 Can do better on
1. Evaluation of “redisorganisations”
2. Evaluation of “storm” of policy initiatives
3. Low pay
4. “Value for money”: variations in processes and
outcomes ignored too often.
5. Commissioning: weak exercise of purchasing power.
6. Nursing processes and quality

30. The future……..
 Budget squeeze with shift out of hospital financing
to primary and social care
 |massive Tory “redisorganisation” from April 2012
 PCTs gutted and replaced by GP consortia
 NHS Board with Regional Offices replacing SHAs
 Fate of targets and NICE uncertain, with the latter
threatened by industry
 Static pay: but maybe pay cuts above say £25000
and graduated?
 The challenge: measurement and management of
data and evidence rather than random “surgery”!