An economist's perspective on the Francis report . . .
Following allegations of seriously substandard care, the Secretary of State for Health in England announced a public inquiry into the Mid Staffordshire NHS Foundation Trust to be chaired by Robert Francis (a lawyer). The “Francis report”, issued in February 2013, contains 290 recommendations meant to apply across the NHS, not just to one hospital. This, in turn, has given rise to heated debates about quality in the NHS and how best to ensure it.
OHE’s annual lecture in 2013, given by Prof Alan Maynard of the University of York, addressed quality issues from the perspective of an economist. Prof Maynard summarised his remarks as follows.
The legal perspective to NHS problems is epitomised by the Francis report. The regulation has failed, therefore we must regulate more. All too often such reports are un-evidenced, un-prioritised, un-costed and not implemented.
An economic approach to alleged quality, efficiency and expenditure difficulties faced by the NHS accepts that markets fail, governments fail and public and private health care organisations confront similar sources of inefficiency. The problems of clinical practice variations, over-diagnosis and patient safety are universal. They have defied the efforts of Royal Commissions, government structural “re-disorganisations” and public inquiries for decades.
The market for health care is complex due to ubiquitous agency relationships which render purchasers of care price and quality takers. Repeated efforts to enhance transparency by the collection and use of outcome data to performance manage clinicians have failed for hundreds of years. Such data has not been used to enhance professional senses of duty and trust and to incentivise efficient practice.
Perhaps it is time to adhere to Alan Williams’ maxim, “Be reasonable: do it my way”, when offering economic advice to NHS policy makers. Regulation has failed, but perhaps we can regulate less and regulate better. Use process and outcome data rigorously to identify clinical outliers and oblige them to “heal themselves”. Reinforce professional senses of duty and trust with non-financial incentives, and experiment and evaluate better pay for performance programmes. Current clinical efforts to enhance performance transparency are welcome and must be protected from reformers who still seek utopia through organisational reform.