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NHS rationing should not be driven by cost NHS rationing should not be driven by cost
(7 months later)
Rationing to some extent has existed within the NHS for years now; for instance, for cosmetic procedures, alternative therapies and IVF. This makes financial sense at a time when the burden of ill health continues to rise.Rationing to some extent has existed within the NHS for years now; for instance, for cosmetic procedures, alternative therapies and IVF. This makes financial sense at a time when the burden of ill health continues to rise.
Over recent years, however, increasing financial constraints have been dictating even basic "necessary" treatments. Currently, procedures such as cataract surgery and hip or knee replacements are not performed unless there are significant symptoms. Scorecards used to decide if patients have significant symptoms include immobility, rather than just pain. Eye tests for cataracts would have to confirm that the condition affects quality of life. Yet corrective procedures often significantly improve patients' lives.Over recent years, however, increasing financial constraints have been dictating even basic "necessary" treatments. Currently, procedures such as cataract surgery and hip or knee replacements are not performed unless there are significant symptoms. Scorecards used to decide if patients have significant symptoms include immobility, rather than just pain. Eye tests for cataracts would have to confirm that the condition affects quality of life. Yet corrective procedures often significantly improve patients' lives.
Unlike many other countries, GPs in the UK have always acted as gatekeepers to secondary care services. But over-zealous gatekeeping has been socially undesirable, even if there was a sound clinical reasoning behind every decision to refer a patient, or not. The goalposts are changed yearly, so a patient now has to be more disabled for a knee replacement or surgery to relieve carpal tunnel syndrome. Often, arbitrary non-evidence-based thresholds are used and handed down to GPs.Unlike many other countries, GPs in the UK have always acted as gatekeepers to secondary care services. But over-zealous gatekeeping has been socially undesirable, even if there was a sound clinical reasoning behind every decision to refer a patient, or not. The goalposts are changed yearly, so a patient now has to be more disabled for a knee replacement or surgery to relieve carpal tunnel syndrome. Often, arbitrary non-evidence-based thresholds are used and handed down to GPs.
John Lashley (not his real name) was a fit 69-year-old who lived alone. He was a caretaker at the local high school for most of his working life and, until recently, volunteered at a Salvation Army centre. His vision gradually deteriorated, due to bilateral cataracts, until he felt unable to continue volunteering and became housebound. But he did not meet the referral criteria for cataract surgery.John Lashley (not his real name) was a fit 69-year-old who lived alone. He was a caretaker at the local high school for most of his working life and, until recently, volunteered at a Salvation Army centre. His vision gradually deteriorated, due to bilateral cataracts, until he felt unable to continue volunteering and became housebound. But he did not meet the referral criteria for cataract surgery.
Over the course of a year he became increasingly confused and his vision deteriorated further. I was finally able to refer him for cataract surgery but under a general anaesthetic (with its own inherent risks and a longer hospital stay), as it was felt that he would be too agitated under local anaesthetic for the surgery to be performed safely.Over the course of a year he became increasingly confused and his vision deteriorated further. I was finally able to refer him for cataract surgery but under a general anaesthetic (with its own inherent risks and a longer hospital stay), as it was felt that he would be too agitated under local anaesthetic for the surgery to be performed safely.
Post-operatively, Lashley was unable to manage at home and, aged 70, was placed in a nursing home. Had the surgery been carried out earlier, he would not be in a home, at a cost to taxpayers, and would probably still be volunteering in his local community.Post-operatively, Lashley was unable to manage at home and, aged 70, was placed in a nursing home. Had the surgery been carried out earlier, he would not be in a home, at a cost to taxpayers, and would probably still be volunteering in his local community.
It is challenging to provide sound clinical care that is both evidence-based and cost-effective. There are no easy answers when the NHS is expected to save £20bn. There is certainly waste within the NHS, stemming from equipment, drugs and missed appointments. Prescribing budgets form a big chunk of spending costs.It is challenging to provide sound clinical care that is both evidence-based and cost-effective. There are no easy answers when the NHS is expected to save £20bn. There is certainly waste within the NHS, stemming from equipment, drugs and missed appointments. Prescribing budgets form a big chunk of spending costs.
We are getting better at tackling the use of multiple medications by patients and non-compliance with medications, but we still have a long way to go. Many diabetic patients aim for good glucose control and need to perform fingerprick testing several times a day, yet most of the testing strips they must use are expensive for prescribers.We are getting better at tackling the use of multiple medications by patients and non-compliance with medications, but we still have a long way to go. Many diabetic patients aim for good glucose control and need to perform fingerprick testing several times a day, yet most of the testing strips they must use are expensive for prescribers.
Previously, under primary care trusts, and now under clinical commissioning groups, we have been expected to stick to our prescribing budgets, though it is unclear what the penalties of overspend are likely to be. But rationing items such as strips is a false economy, since there are profound long-term financial costs of poor diabetic control. These include poor cardiovascular health, kidney failure and peripheral vascular disease, which can all lead to amputations.Previously, under primary care trusts, and now under clinical commissioning groups, we have been expected to stick to our prescribing budgets, though it is unclear what the penalties of overspend are likely to be. But rationing items such as strips is a false economy, since there are profound long-term financial costs of poor diabetic control. These include poor cardiovascular health, kidney failure and peripheral vascular disease, which can all lead to amputations.
Rationing of services should not be driven by financial constraints but by clinical need. But it is often short-term cost-cutting, as in the case of Lashley, with no long-term benefits.Rationing of services should not be driven by financial constraints but by clinical need. But it is often short-term cost-cutting, as in the case of Lashley, with no long-term benefits.
Certainly, any incentives offered by budget-holders to limit access to secondary care should be regulated and fed back into improving patient services. But it remains completely unethical to impose blanket bans on many treatments or to cap the number of people who can receive such treatments, as is currently happening.Certainly, any incentives offered by budget-holders to limit access to secondary care should be regulated and fed back into improving patient services. But it remains completely unethical to impose blanket bans on many treatments or to cap the number of people who can receive such treatments, as is currently happening.
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