Health economist nonpareil Professor Alan Maynard considers how we might do something really radical, like focusing on how to make commissioning more efficient. And he seeks your input.

’The current “pause” will be used to sell the proposals, with much sucking-up to the professions and other lobbies, but no real changes in policy.’

The Coalition is likely to plough on with its reforms of the NHS. The current “pause” will be used to sell the proposals, with much sucking-up to the professions and other lobbies, but no real changes in policy.

The Lib Dems may hope for changes, but may not get little of substance, as a stubborn Secretary of State and Prime Minister trundle on, seeking their NHS nirvana.

A Parliamentary snooze
With Parliament sleeping through recesses and bank holidays, the Government will have some political peace until June - when we will be entertained by the House of Lords perusing the bill.

Will they prove they can be something other than a “toothless bulldog” when considering the NHS reforms? Watch this space!

It’s about incentives, not structures
The two central issues for reformers are surviving the funding parsimony and the need to improve efficiency by tackling practice variations and perverse incentives created by workforce contracts.

The latter is epitomised by the difficulties of removing deficient medical practitioners protected by BMA-inspired rules and government weaknesses that ensure jobs for life, regardless of proficiency

Regardless of what form of NHS structure is adopted, the central issue is how to enable purchasers to penalise inefficient providers and incentivise changes in their behaviour.

The rules to make commissioning work
Here are some rules for purchasers, regardless of whether they are PCTs or GP consortia. Their application requires some reform of existing restrictive practices inherent in the NHS - and also requires courage i.e. the power to pursue improved efficiency even when it ruffles the feathers of the “great and the good”.

For the large majority of medical practitioners, most of the rules that follow should be acceptable. They would enable their clinical firms and institutions to remove the few practitioners who inhibit change and reduce productivity. These are the folk who cause embarrassment to proficient and hard-working NHS staff and who, by their actions, deprive patients of care.

Rule 1: Don’t pay providers if they damage your patients.

If GPs do not carry routine screening and treatment of patients with chronic diseases, as they are incentivised to do with the expensive “quality and outcome framework (QOF)”, they should have their income cut - i.e. a negative QOF payment.

If GPs fail to file patient complaints with their commissioner and respond to such problems, they should be fined.

Already, hospitals can lose income for “never events”. Now is the time to strengthen these arrangements - and extend them to all public and private providers of primary, secondary and social care.

Rule 2: Pay for evidence-based practice (where evidence exists).
Traditionally, orthopaedic surgeons are rich, supplementing their NHS income with private practice. Is this wealth a product of “rent” produced by restrictive practices? How can it be reduced to free up resources for other services?

Purchasers should determine which prostheses should be used and ensure that buying in bulk reduces their cost. As well as using NICE guidance and information from hip registers here and in Scandinavia, every effort should be made to avoid disasters from poor prostheses (remember the 3M problem when hundreds of hips had to be re-done?) and poor clinical competence.

Hopefully, quite soon purchasers will have comparative patient reported outcome measurement data. The PROMs data may demonstrate differences in threshold decisions to operate and difference in “success” across practitioners. Purchasers should relish the idea of using these data to remove the few poor practitioners, and ensure only the proficient are contracted to work in the NHS.

Rule 3: Only contract with medical specialisms that have complete and timely audits.

The cardiac surgeons cleaned out their stable and publish comparative data for all their cutting comrades. Purchasers should announce that from some date quite soon, those practitioners not in audits will not be paid.

Those practitioners in audits who had not ensured that all their colleagues were in their specialty audits should be told their incomes would be cut by 5 per cent per year for each year of incomplete audit.

Rule 4: Do not pay for excess activity.

The two-part PbR tariff for emergency tariffs may inhibit growth in admissions. Many local initiatives in the NHS are examining how to reduce emergency referrals. Sadly, the evaluative design of these initiatives is not adding significantly to the evidence base, which Purdy (Kings Fund 2011) has shown to be poor.

The full tariff for elective procedures incentivises the reduction in threshold criteria for intervention. The potential role of PROMs data in illuminating this issue is considerable - if response rates to existing efforts can be improved.

One potential way to improve PROMs response rates is to hand data collection to GPs as part of the GP-QOF. These data are central to their commissioning role. If this proposal is too radical, hospitals should be incentivised by purchasers to collect PROMs data by fines for non-compliance.

Expenditure control inevitably means quantity control; even if PbR tariffs are progressively reduced as an evidence-free means of achieving “efficiency” targets (but maybe just cost reductions which affect quality?).

The mix of tariff and volume controls needed will be determined by the Coalition’s austerity plans.

These rules require purchasers to transform themselves from price, quantity and quality “takers” to price, quality and quantity “makers”. In other words, passive purchasing needs to be replaced by proactive purchasing.

This transformation is needed in all public and private commissioning or purchasing systems across the world. It can be best achieved by mobilising medical practitioners and their teams to discard myopic practices protected by indefensible employment contracts - and can ensure that as so many do, that patient care comes first.

Over to you, dear readers
Currently I am journeying up Mount Sinai, hoping that like Moses I can find another six rules to complete the Ten Commandments, this time for NHS and insurance purchasers.

I would welcome readers’ help in this endeavour. Please email me, via editorial AT healthpolicyinsight.com, marked ‘the missing commandments’!