Beware the rationing of care

More than four in five GPs expect the rationing of NHS care to increase in response to financial pressures, according to a poll conducted for the BBC in March of this year. And that matters, since they will be the ones having to do it: as the members of newly formed clinical commissioning groups, it is GPs who will be responsible at the local level for ensuring that NHS spending is kept within budget, in a context in which funds remain roughly flat and demand and costs continue to rise.

Of course, rationing health care – that is, denying patients potentially beneficial treatments because of limits to resources – is nothing new, and neither is it the sole preserve of the NHS in England. Governments and private health insurers the world over face the challenge of finite resources, and must make tough choices about what not to provide to patients.

Research suggests that we trust doctors far more than we trust politicians or civil servants, and we would rather have them make such spending decisions than be involved in making them ourselves. But the doctors themselves are not so sure. Clare Gerada, head of the Royal College of GPs, has raised concerns that ‘the pressure to make savings and be the financial managers of care is compromising the relationship between clinician and patient’. In her view, the GP’s first responsibility is to the patient in front of them, with the wider community having to take second place.

This call on GPs to play both clinician-champion of the individual patient in their consulting room, and the commissioner-guardian of public funds in the interest of the community at large, has the potential to leave them in something of a bind – the so-called ‘double-agent dilemma’.

Will our trust in clinicians lend local decisions on restrictions to treatments a new kind of legitimacy? Or will such decisions erode our trust in our local family doctor?

This is one of the issues that Professor Rudolf Klein and I explore in our new discussion paper, Thinking about rationing, published today. But when thinking through old debates and concepts on rationing in relation to the current NHS and the government’s reform programme, we realised that it is not just that there are new players on the scene. Rationing may be taking on novel forms – or at least, forms that we have not before recognised as examples of rationing. For while commissioners, working to tight budgets, have an interest in limiting patients’ access to particular interventions, once a patient has been referred for specialist care, one of the few ways in which hospitals can meet their own productivity targets is by reducing the cost-intensity of treating that patient.

Enter ‘efficiency savings’, which might include switching to cheaper drugs, equipment and diagnostic tests; placing limits on the number of follow-up appointments consultants can arrange and pushing clinical staff to order fewer tests or shorter courses of drugs; as well as cutting clinical and administrative staff numbers. We cannot assume that these changes necessarily damage patient care: if managed well, such changes may genuinely reduce costs without negatively affecting care, freeing up cash to be spent elsewhere. For example a reduction in nursing staff might follow from the closure of a service which is under-used and provided well at another hospital in the locality. But a cut to nursing staff might also signal a reduction in the ratio of staff to patients, which in turn leads to a decline in the quality of care patients might enjoy. As the Care Quality Commission's latest inquiry into dignity and nutrition for older patients in hospitals put it: ‘Having plenty of staff does not guarantee good care…but not having enough is a sure path to poor care’.

In the context of this and other damning reports on the quality of care received by some patients in some NHS hospitals, we need to be particularly alert to risks to care posed by efficiency programmes. If managed well, such programmes should make more resources available to invest in care, but if poor quality care is found to be a result of inadequate resources then it is surely an instance of ‘rationing by dilution’. Such cases must be made visible and subject to the same kind of public scrutiny and debate that we afford decisions on the funding of cancer drugs. And GPs as commissioners must be concerned, not just about whether or not they can refer a patient for treatment in the context of tight budgets, but also about what happens to the quality of that treatment as savings bite. This is now on their watch.

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Comments

#1158 Mark Cannon

This is a very important piece of work. You have raised an important point and one that is worthy of debate, if only because systemically there is a belief that rationing is inevitable and necessary. My studies do not lead me to conclude this. From what I have studied of the English NHS, rationing is symptom of plausible but wrongheaded beliefs about what works. There is a belief that a focus on costs reduces costs. In fact it increases them. Cost is in flow, end-to-end over time, but instead of being interested in economies of flow the system is focussed on economies of scale. By focussing on rationing and more sophisticated or targeted ways of doing it we are putting the screwdriver in the wrong place. Dealing with the Nicholson Challenge with more of the thinking that created it in the first place will not work. Building and tending to relationships end-to-end over time, understanding people in the context of how they live their life and removing all the paraphernalia that gets in the way of solving peoples problems (including things like Fair Access to Care and other such criteria) works better.

#1159 hank beerstecher
GP

The analysis on rationing is enlightening but concentrates entirely on the supply side. Concerns are raised about rationing because it will drive apart healthcare providers and patients by providing opposing incentives.

Patients have an incentive to acquire the most advanced care they can get. In the UK patients are not limited by incurring costs so we are in a tragedy of the commons situation.

With very few exceptions (Darzi walk in centres) providers are either paid on capitation basis or salaried. In a capitation system providers will earn more by limiting patient demand: i.e. putting up barriers to care or acquiescing to any patient request.

The only intervention ever proven to reduce healthcare usage is the introduction of co-pays or charges.

However in a fee-for-service healthcare system co-pays for patients clash with provider interest: patients are incentivised to use fewer resources but providers to increase interventions. Patients have notoriously poor judgement about the effectiveness or benefit that an intervention can bring so will reduce both the use of effective and ineffective interventions. Patients are missing out on care that could reduce the cost or need for future healthcare, and short-term savings through reduced demand are offset by increased long term or future costs.

Aligning patient and provider interests will thus only happen in a system where both providers and patients want to reduce healthcare use or the opposite where both patients and providers have incentives to increase healthcare usage. The latter will no doubt be an extremely high cost system.

With a few tweaks the UK healthcare system could be turned into the first healthcare system where patients' and providers' interests are aligned to concentrate on delivering only cost-effective care. Remove the fee-for-service pay structure for hospitals (PBR). Introduce co-pays for patients, the level of which can vary with the effectiveness of the intervention. Turn all non-capitation primary care into capitation-funded services.

#1160 martin rathfelder

Hank is wrong evidence is very clear that in shared decision making patients are less enthusiastic about high tech high cost intervention than doctors. Widespread copayment in the USA does not seem to have the desired effect.

#39738 cathi
nurse
health australia

This is a critical debate not just in the UK NHS but for healthcare systems worldwide. It is especially important in the Acute care setting where clinicians are increasingly competing on behalf of their patients for limited resources such as intensive care and high dependency beds or Operating Theatre time. As the population ages will the funds be available for the high standards of care we have come to expect ot will Ageism influence rationing?

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