The public’s view of which treatments should be available on the NHS

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NHS England’s favoured future funding option suggests that nearly three-quarters of the £30 billion funding-needs gap that will exist by 2020/21 is to be filled by increased productivity. Even if the ‘down payment’ pledges of extra money for the NHS from the three main political parties eventually swell to meet the £8 billion NHS England are asking for by 2020/21, the productivity challenge remains substantial.

Being more productive does not just involve producing more of the same for each health care pound to meet growing demands. It also means improving the quality of the product – for example, not just more hip replacements, but hip replacements with reduced recovery times, using hips that last longer and produce bigger improvements in patients’ self-assessed health status.

In short, improving productivity means generating greater value for patients. This, in essence, is at the heart of the difficult task – not only for the new productivity challenge over the next few years, but for NICE too: making better use of the resources it is given means the NHS providing better quality (or more effective) care at the lowest cost.

In practice of course, identifying what’s cost effective is difficult, and requires significant investment in generating the right technical data and, importantly, judgements about what constitutes good value for money. But no matter how tricky it is to amass the evidence needed to identify the costs and benefits of a treatment, it is hard to disagree with the principle that both costs and effects of treatments need to be weighed in order to make decisions about improving value for money and productivity.

Or so you might have thought. For a majority of the public however, this is not a principle they hold.

In the 2012 British Social Attitudes survey we asked the public what treatments should be available on the NHS – asking them to select one of three general criteria that could decide this:

  • all treatments regardless of cost or whether they provide proven health benefits
  • only those that provide proven benefits, but regardless of cost
  • only those that provide proven health benefits and good value for money.

You might ask why people would choose the first or second criteria. But as figure 1 shows, four out of ten of those surveyed stated that while treatments should have proven benefits, cost should not be considered as part of a decision about what treatments the NHS should provide. And (all logically minded individuals look away now) for three out of ten, not only was cost irrelevant, but so too was whether treatments even had any proven benefits.

Figure 1: Which treatments should be available on the NHS? Views from the public

Which treatments should be available on the NHS? Views from the public

Data source: NatCen 2013

The remainder of those surveyed picked the final answer; treatments provided by the NHS should have proven benefits and be good value for money.

Even allowing for some potential misunderstanding about the question and the answer options (though there is extensive testing of BSA questions), these attitudes are pretty surprising. Or are they? As a patient, how sanguine would you be to be told that although a treatment had proven health benefits you couldn’t have it because it cost too much for the benefits it could provide?

Perhaps rather than bemoan the illogicality of the public’s views, these results should remind us of the need to help the public understand about the inevitable need to weigh the costs and benefits of the services and treatments the NHS provides – and not only in times of financial famine. Such evaluations are unavoidable regardless of how health care is funded, whether collectively from taxation or social insurance or from private means. The alternative can be measured, not just in wasted money, but the health benefits that money could have bought.

This may be a hard (and to many, a harsh) message to convey. But as the financial squeeze continues public support (and understanding) of the need for the NHS to tackle increasingly difficult choices about prioritising spending, will become ever more important.

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Andres Freiberg

Community Health,
east Kent NHS
Comment date
19 December 2014
yes. interesting results but tricky interpretation. surely the public cares about effectiveness more than cost or science altogether. But since we cannot promise all services to everybody, perhaps explaining opportunity cost better would have changed the answers?


Consultant Neonatologist & Prof. of Perinatal Health,
Comment date
18 December 2014
There are multiple factors that impact on the choices of people when answering a survey like this including the quality of the question and the context.

It is important to understand that 'without proven benefit' isn't the same as 'proven to be of no benefit' or 'proven to be harmful'. It is our job in healthcare and in research to move modalities/interventions from the first category to the 2nd or 3rd. How much of funded research in this country is spent on this?

Moreover, going back to your hip replacement example, productivity from that perspective on a systemic level, also involves preventing hip disease or delaying its progression and more importantly using 'shared decision making tools' appropriately which suggest that the number of people choosing hip replacement will fall significantly in particular situations.

With regard to the funding gap, money alone will not solve the problems. The amount of money that has been thrown at ED waiting times over the years has not ensured that this 'wicked problem' goes away. Some money is required for transformation but more importantly we require COLLABORATION at system level. Collaboration is the INNOVATION of today. The Dalton review has highlighted some exciting possibilities in this regard.

Last, but not the least, the first step in informing the public is to stop all misinformation. With a few months to the election, your guess is as good as mine...Which public body is charged with informing the public about the NHS tearing at the seams?

John Kapp

Social Enterprise Copmplementary Therapy Company
Comment date
18 December 2014
Complementary and Alternative Medicine (CAM) is an alternative health service (AHS) which tests the cost effectiveness of drug-free treatments all the time (millions of times each day) and is the cause of health inequalities - the rich can and do invest their own money in cost-effective CAM, so live 9 years longer, and 18 years more without suffering long term conditions. CAM (such as yoga classes) is basically education of how to look after your own health. Prince Charles addressed the WHO annual meeting in May 2006 calling for the best of CAM to be integrated into the NHS, and he was right. I am campaigning for NICE-recommended Mindfulness Based Cognitive Therapy (MBCT) 8 week courses to be mass commissioned and mass provided to improve mental health and reduce inequalities, see paperw on section 9 of www,, and have developed a licencing system for provision in Brighton and Hove. This could save £7 per £1 invested.

Michael Crawford

Comment date
18 December 2014
So 31% of the population when asked "cold" support Loord Saatchi's point of view.

I wonder how many of the 28% who said "Proven effective and good value for money" would join the 41% who only insist on efficacy or the 31% Saatchi tendency when the question is put: "Your diagnosis is rhubarbitis which can only be treated with an expensive drug; 2 out of 5 people who have had it so far said thy felt much better apart from the rash it caused. Do you want to receive it?"

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