LOOKING ASKANCE ALAN MAYNARD

The medical royal colleges are venerable and powerful institutions, but are they really necessary?

The charters of the colleges focus on the protection of the patient and the provision of good-quality care by well-trained operatives rather than the quacks who threatened consumers as recently as the last century.

The focus of their work is postgraduate training, both in terms of controlling the content of skills acquisition and in examining attainment.A central part of this activity is their influence on the organisation and staffing of hospitals, which they regard as essential to regulate in order to create an appropriate learning environment.

These activities can be very threatening to trusts and their staff.

For instance, if a trust fails to meet the standards set by the college for training juniors, it can lose its accreditation and the junior staff essential for providing care.

What standards are used by the colleges in these circumstances? Are they evidence-based or evidence-free prejudices of college grandees?

The colleges are unaccountable for the costs they impose on the NHS.

Why is this tolerated ?

The dominance of the colleges' demands is self-evident throughout the NHS.The threat of loss of college training status can turn a trust's clinical and non-clinical management inside out at high cost and without clearly demonstrable gains to patients.

Patients may be delayed in accident and emergency departments so that juniors can run their eyes over them. In many cases these waits are unnecessary because nurse triage could get patients home more quickly.

Should trust managers tolerate unnecessary inconvenience to patients just to meet college demands for the training of young things?

Not only do the colleges facilitate the creation of outpatient and inpatient procedures of dubious benefit to the consumer, they also create a crescendo of incomplete advice about the design of hospitals.

They do this with great solemnity and partial reference to the evidence base.

Crudely, their argument is that we must have big hospitals as size guarantees quality. Is bigger always better?

The definition of 'better' in this area is survival as measured by 30-day mortality rates. If you live to day 31 you are a success, but if you die at day 29 you are a failure.This is a less than sophisticated measure of quality Managers and patients are interested not only in the length of survival but its quality - eg are patients moribund at discharge or can they waltz the night away?

Such questions cannot be answered by the existing evidence base, which is stuck with the limited, but useful, 30-day mortality measure of success.

The evidence base about volume and quality demonstrates that generalisation is dangerous.For some interventions greater activity appears to give better outcomes (eg treatment of abdominal aortic aneurysm), while for others the volume effect is absent (eg hip replacements).

Furthermore, with carefully constructed guidelines, careful monitoring of practice and modest volumes, many of the scale benefits can be achieved.That the colleges use this uneven and incomplete evidence base to demand wholesale reform of the structure of hospitals in the UK is irresponsible.

This is heightened when consideration of variables other than quality is considered.No hospital planner wants quality regardless of effects on cost and patient access.

Again the evidence base shows that costs fall for up to 200 beds and are then flat until 600 beds and then rise.

So the 'best' is 200 to 600 beds, a modest size for a hospital.

The evidence on access also warns against investing in large 'factories'.As facilities become more concentrated, the time and travel costs for patients and their carers increase.

It seems that such cost rises do not deter patients with acute disease (eg cancer) from continuing to consume care.However, for some treatment options, such as mammography, cervical cytology and alcohol advice, there is evidence of reduced use.

In effect, the concentration advocated by the colleges shifts costs to consumers and their carers.This type of outcome may be inconsistent with the efficient pursuit of equity goals, but these do not seem to have been highly ranked by the colleges in recent history.

Not only do the colleges generate hospital policy advocacy based on opinion, they also use this approach on manpower issues.For instance, one college president is advocating the creation of 'physician assistants'.This is despite evidence from the US that these people are complements, rather than substitutes, for doctors, and therefore cost-inflationary. Such folk are rarely confused by facts.

Given the amateur manner in which colleges apparently produce policy advice (essentially opinion collated over fine wine), together with the absence of audit and accountability, should the colleges be abolished and replaced by a government regulatory agency as in Sweden and Belgium?

The government should undertake a rigorous independent review of the colleges.This would be timely, as the Bristol report reveals to all the pathetic inadequacies of their governance. Equally, it would give the colleges the opportunity to demonstrate that their work is efficient.

If they failed, they should be thrown into the dustbin of history. If they succeeded, perhaps we would get a demonstrably more efficient means of producing quality healthcare.And if this was evidence-based, it would be great novelty for the NHS

REFERENCE

1 NHS Centre for Reviews and Dissemination.Hospital Volume and Health Care Outcomes, Costs and Patient Access.Effective Health Care 2. 6 December 1996.

Alan Maynard is professor of health economics at York University.