Are we wasting money on care that patients don’t want?

Comments: 5

The media have been highlighting waste and inefficiency in NHS procurement this week, prompted by a case in Cumbria where the NHS were paying up to four times the original price for specialist food products for coeliacs. At a time when clinical posts are being cut or held vacant, it is right to ask whether there is waste in the system that could be eliminated without a huge impact on patient care.

Could there be a much simpler solution towards making savings? What would happen if patients were fully informed about their care and treatment options? What if patients were asked what care they wanted?

The immediate reaction is that patients would demand more, more, more and bankrupt the NHS. But evidence suggests that, when fully informed about care and treatment, patients often want less intervention. In Patients’ preferences matter Professor Al Mulley, our first International Visiting Fellow, and colleagues present evidence in areas as diverse as benign prostate disease, abnormal bleeding from the uterus, coronary heart disease and back pain, where fully informed patients are less likely to choose surgery. Reassuringly, where the evidence was clear that surgery was beneficial, more patients were likely to choose it after having been supported to understand the evidence and weigh up risks and benefits. And yet in the UK, only half of patients say they were always involved in decisions.

Commissioning decisions are currently informed by assessments made by experts of need – at population level by public health specialists and at individual level by doctors. Clinical assumptions are made about the right level of treatment for the level of need in the population. And yet we observe huge variation in the rates of intervention that persist even after adjusting for need. In the absence of absolute markers for what constitutes appropriate levels of population provision for some procedures, some of the variation could reflect over – rather than under – provision of services. When patients are systematically given information and supported to make a decision about their treatment, the population intervention rates have been shown to be dramatically lower than even the bottom end of the distribution.

So what is the ‘right’ rate of intervention? How do we measure and capture information to inform these population level investment decisions in future?

Al Mulley and colleagues argue that the NHS must systematically measure decision quality, that is what patients know about the disease, the treatment options and possible outcomes. We already know that many people who would rather die at home end up in hospital, often subjected to intensive medical intervention in the hope of prolonging life. What if every person had an advance directive following a supported conversation about the quality of life implications of intensive treatment and resuscitation?

Clinical commissioning groups are being given responsibility for the NHS budget. They have a limited set of options to manage with less resources – either pay the providers of care less, ration care explicitly by refusing to pay for certain treatments, manage demand using clinical thresholds or allow waiting times to rise. None of these are very appealing.

There is another option. By making visible the fact that their patients are not fully aware of their choices and haven’t necessarily got the basic knowledge about their condition or the treatment options, clinicians can stop the silent misdiagnosis and create value for the NHS. The NHS needs to stop buying interventions and treatments that patients neither want nor need.

Comments

#1192 Andrew Harding
Researcher - professional practice development
Bournemouth University

It goes without saying that informed patients making responsible choices is something to aspire to - but is possible in reality?

Ian Greener cites a piece of research that suggests that 65% indicate a preference to make a treatment choice, but when diagnosed with cancer only 12% actually make a choice; when faced with a life or death decision, it would seems that in effect there is no choice.

I don't particularly like the word 'choice' in this context as I think it implies levels of autonomy that are often unrealistic.

I think what this suggests is, not that 'choice' is a bad thing (it's clearly not - although I prefer 'more involvement'!), but that not enough is known about where and under what circumstances/contexts choices of treatment are welcomed. A recent DoH doc on choice policies suggests this is an area of some ambiguity (pg. 29 - dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_134218.pdf)

I look forward to reading the paper - no doubt it's reccomendations for professional practice development will be significant.

#1193 Coeliac UK
Coeliac UK

Your post raises the important point that involving patients in what NHS services they use will not lead to an inexorable rise in demand. Indeed the opposite can happen. Ironically, in the case of gluten-free prescribing in Cumbria which prompted your post, that point has been proved.

The only treatment for coeliac disease, a serious autoimmune disease, is a lifelong strict gluten-free diet without which patients are at risk of osteoporosis, infertility and some gut cancers. But keeping to such a diet is very difficult as many independent research studies have shown and access to prescriptions is recommended by healthcare professional guidelines as an important way to keep such patients healthy.

We have worked over the last few years with pharmacists’ organisations to develop a scheme to supply gluten-free prescriptions which cuts the cost to the NHS. The scheme allows patients to deal direct with pharmacists where they can find out more about the products available on prescription and their cost. Since the introduction of the pharmacy supply scheme the cost per patient has been reduced from £420 to £315 per patient a year in Allerdale and from £418 to £252 in Copeland. Those involved believe that greater patient control and informed choice is driving at least some of this change

We are hoping that more areas take up the scheme and reap the financial benefits and you can read more about this scheme here coeliac.org.uk/Gluten-freesupplytoolkit

There would appear to be additional costs added to the prescribing of some products and they are of great concern to us – although this should not be happening in Cumbria now with the introduction of the new scheme. Agreement on the reasonable cost of products is made at a national level. We are aware that NHS commissioners have come across evidence of additional local charges being added to products and as a result are restricting access. The patient is losing out as a result.

We need better take up of the Cumbria scheme which allows the patient to take more control, reduces overall cost and gives all involved, from GPs and pharmacists to the patients, themselves greater satisfaction with the service

#1194 Mike Smith
Patients Association

The head of the NHS Confederation says that one in four people in an acute bed is not getting the care they require. They're awaiting an opportunity to be moved on and the staff are busy concentrating on those just in. Two thirds of all `acute' patients are over 65.

An acute bed costs £2300 per week. A local-authority-run care bed costs £700 per week. A shift of funds from the NHS to the L.A ( or a new joint responsibility organization) could satisfy the patients' needs in a care-centered establishment and the exchequer's needs at the same time. Discuss! Best regards Mike

#1195 mike stone

'Could there be a much simpler solution towards making savings? What would happen if patients were fully informed about their care and treatment options? What if patients were asked what care they wanted?'

There are issues, over whether or not patients will make choices. But the recent NCEPOD 'Time to Intervene ?' report about CPAs in hospitals, seems to suggest that clinicians were deliberately not discussing CPR with patients, and preventing patients from refusing CPR - the Chair of NCEPOD, a lawyer, in his Foreword suggested that such deliberate avoidance of asking for permission when a CPA could reasonably be a possibility, is perhaps illegal.

Especially where the benefits of treatment are small, and the invasiveness or length of the treatment is great, I think many patients might decline the treatment, if they were properly informed of the probable outcomes.

But, it has been observed that many clinicians are unhappy when discussing uncertainty - and being told 'you won't know until you have tried it' doesn't make it awfully easy, to assess the benefit of accepting a treatment, does it ?

#5546 Becky Allright
Commissioning Manager
Social Care

I find it a bit odd that people asked their opinion about their own healthcare options. I know it's not as simple as that, but my experience is that by providing opportunities for feedback, involvement and ownership of the process, this generates positive feedback for practitioners, commissioners as well as service users. This is known as "person centred" care.

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