Rationing in the NHS
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39218.599109.80 (Published 24 May 2007) Cite this as: BMJ 2007;334:1068
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Robert Royce dramatically overstates his case.
Yes there are many treatments where no consensus exists, but there
are a disturbingly large number where the evidence is solid but medical
practice is decades behind (tonsillectomy is one of those). The reason is
not that consistent standards can't be encouraged or enforced, it's that
too many managers and doctors start with the assumption that individual
medical judgement is supreme in the face of all the statistical evidence.
His point that health is not like manufacturing because it can't be
automated is just wrong. The key to improvement is manufacturing (and any
other area of human endeavor) is a diligent committment to continuous
improvement. This comes from recording the different ways things are done,
measuring the results and analysing which things work best. This technique
can work well in Medicine (Atul Gawande describes how american military
surgeons halved the battlefield death rate in one of the chapters of his
book "Better: a surgeon's notes on performance") but is rarely applied. My
point is that medical practice is far too variable (this observation
applies as much to death rates as to efficiency).
My view of waste is not an economist's: it is a patient's. Highly
variable medical practice overtreats some and undertreats others. In the
current system the patient may get neither what they want nor what they
need. Neither the medics nor their bosses ought to accept that.
Competing interests:
None declared
Competing interests: No competing interests
Stephen Black's argument that rationing would not be necessary if the
NHS stopped wasting the money it is given "on futile and harmful activity"
presupposes that there is a consensus as to what falls into these
categories. Unfortunately, for the most part, this is not the case. If it
were, his solution would have already been adopted. The fact that it has
not should be a clue to the inconvenient flaw in Mr Black's 'cunning
plan'.
Essentially the problem is that health care is as much a social
construct as it is a series of science based clinical interventions
(arguably much more so). The clue rests in the word 'care'. Humans tend to
be big on 'futile' and 'harmful' activity -as defined by utilitarians and
health economists.
The nature of the problem can be illustrated in the example Mr Black
gives -tonsillectomy. It is not true that this intervention is 'almost
universally thought to be useless' by either those demanding it (mostly
parents of children with recurrent throat infections, those referring
(GP's), or performing the operation (surgeons).They may well all be wrong
in that view, but should Primary Care Trust's (PCT's) decide tomorrow to
impose a general ban on paying for tonsillectomies you can be sure of
three things:
1. It would be considered as an example of NHS rationing by the
public.
2. Many clinicians would denounce it as not in patient’s interests.
3. Because of 1&2 it would be political dynamite.
Mr Black's also asks why the health service isn't performing like
manufacturing industry? The key difference is the limited scope for
automation. Health care is highly labour intensive, and all such services
(where labour is well organised -in the sense of trade unionism) tend to
be relatively expensive. His example of car manufacturing does however
throw up an interesting side point. There are lots of different types of
cars, with lots of features and hence one can say that given that the
ostensible purpose of a car is a means of transport most of the above fall
into the 'wasteful' category. The answer lies in what is perceived as
being of 'value'...which as already noted often represents a significant
departure from that of the cold eyed economist.
Competing interests:
None declared
Competing interests: No competing interests
Klein is correct when he states that the current reconfiguration and
commissioning of services based upon local needs is becoming clogged up by
policy and practice processes. Feasibility, rather than improved quality
of service delivered, too often drives reconfiguration or the perceived
need for change. Quality and not feasibility must drive change, which
should be cost effective for the National Health Service. All decision
making processes should be devoid of optimism bias or conflicts of
interest, matters which are unfortunately not stringently safeguarded
against in the current rapid pace of change.
Competing interests:
None declared
Competing interests: No competing interests
I completely agree with Stephen Black. Before we decide to change
anything else in the NHS we must acknowledge the data to which Stephen
black refers. The productivity gains that potentially exist in the NHS are
huge. Admittedly this data has not been very visible or clearly packaged
but it is all there within the archives of the website for the NHS
institute for innovation and improvement and at www.steyn.org.
There is another issue however - what lies at the heart of the
productivity gains will be designing clinical systems around the 'work' as
opposed to making the work fit around the 'workers' - which is how
clinical systems have evolved to date. This will immediately challenges
hierachies, professional boundaries, working patterns, clinician autonomy
etc..
As an optimistic I hope that absence of the this aspect from the
debate simply represents ignorance - so we should welcome stephen blacks
attempt to open our eyes - part of me worries however that exposing the
knowledge may be the easier part!
Competing interests:
None declared
Competing interests: No competing interests
Stephen Black, as always, provides a thought-provoking perspective..
Of course there is no Iron Law that states that healthcare costs MUST
increase. The unfounded law of Induction whereby turkeys come to assume
that every day they will be fed, is proved wrong at Christmas.. We
should abandon false inductive reasoning, and spell out plan based on a
theory of healthcare costs and productivity.
Stephen suggests that there is at least ten years worth of efficiency
savings available if we stop doing useless things and avoid waste. He
cites the car-market as an example of increasing cost-effectiveness, which
is fair enough if we isolate that aspect only ( Customers ration
themselves according to what they will afford, whilst other problems
remain or increase). But we in th NHS have had at least ten years of
systematically squeezing the extra value out of healthcare spending by
'management measures' -national monopoly purchasing, queueing, then
marketisation, purchaser/provider split, then 'flagship' foundations,
performance targets, etc. What have we missed ?
I would suggest that the essential missing item is a clear and direct
relationship of value to price.
For example, doctors have for years performed hip replacements, or
prescribed cancer-relief, or stroke-preventers, according to how effective
they were, without direct regard to cost, or cost-effectiveness. A
burgeoning ( and often self-defeating) apparat to enforce cost-management
was deemed necessary, using various rewards and punishments.
As a system analyst and managemnt consultant, perhaps Stephen might
agree that there is scope for mimicking his car production example. A
paying 'customer' ( eg: the local elected Authority, or an NHS drug
purchaser ), with direct responsibility for stumping up the money, might
simply set the price of what it means to purchase (eg. the TARIFF),
according to the value it attaches to the intervention (motor car)..
inviting a variety of providers ( public, charitable or private ), and
then simply refuses to pay any of them a penny more for the service than
it deems worthwhile. Such a proposal , of course, will only match the car
sales model, if unnecessary bureaucracy is suffocated out of the system.
Competing interests:
GP, taxpayer, and potential patient
Competing interests: No competing interests
The frequent debates about the need to ration access to healthcare
are driven by two key assumptions: one is that need for healthcare is
constantly increasing; the other is that there is no way to deliver more
without spending more (this is often combined with the belief that the
unit-cost of healthcare provision inevitably rises over time). Most of the
debate seems to just accept these as self-evident truths carved in stone.
But they are not as obvious as they seem. In England it has often
been assumed that waiting lists act as a form of rationing but the handful
of specialties where waiting lists have been mostly eliminated have found
that underlying growth is often lower (if not much lower) than expected.
There is certainly some cause to question the inevitability of demand
growth.
But the more important assumption--that spending increasing amounts
is the only way to satisfy demand--is even less reliable. There are
several reasons for questioning this. It assumes that productivity
improvement (achieving more with the same spend) has little to offer. Yet
in other areas of human endeavour we get higher quality, more safety at
the same time as lower costs (today's cars, for example, last longer, have
far more technology in them and are safer than they were two decades ago
yet they cost 40% less).
More importantly internal analysis of how PCTs spend money suggests a
degree of variability in health activity that is probably an order of
magnitude greater than any variation in need would suggest. Rudolf Klein
suggest that in the past the NHS had no incentives to maximise activity,
but the evidence of Provider Induced Demand looks just as strong as it
does in the USA where the Dartmouth Atlas Project (www.dartmouthatlas.org)
estimates that 30% of Public health spending is wasted on futile or
harmful activity. An example of this in England is that the number of
hospital beds (per head) is more strongly correlated with intervention
rates for elective activity than most of the key demographic factors that
are supposed to drive need. Many PCTs are still spending heaviliy on
treatments almost universally thought to be uselss (eg tonsilectomy).
The degree of inconsistency in intervention rates suggests that there
is a great deal of scope to save money by driving towards more consistent
clinical standards. In other words the big issue is not rationing, but
stopping all the wasteful spending that is either unneeded by or
positively harmful to patients.
Big ideas such as an independent NHS board, voluntary top-up fees or
compulsory insurance (all suggested as solutions to the inevitability of
rationing) all seem to miss the point as none seem likley to address
productivity or wasted spending in the current system. If we did a better
job of not wasting the money we have now, it would be a couple of decades
at least before we would need to worry about rationing again.
Competing interests:
None declared
Competing interests: No competing interests
Doubts remain
I fear I have not overstated my case. At the risk of repetition, and
using tonsillectomy as an example, the issue is NOT the evidence -although
if it is as clear cut as claimed it is not clear why hundreds of ENT
surgeons aren’t being referred to the General Medical Council (GMC) for
performing useless operations? The central issue is how our society would
view an attempt to reduce this and other ‘useless and futile’
interventions that would result in a claimed reduction of health
expenditure by 30%?
Returning to Klein’s article perhaps we can agree that should such
decisions be made that they are best done nationally. Surely a National
Health Service funded by general taxation, cannot allow people in one part
of the country to receive an intervention deemed ‘inappropriate’ by
commissioners in another part? Interestingly such variation would be less
likely in an insurance based system as any dispute on cover allows the
insured person ultimate recourse to contract law and the courts would take
a dim view of a variation based only on the geographical location of the
subscriber.
Finally, whilst continuous improvement can reduce costs it is not a
magic bullet. Firstly the limited economies available to labour intensive
services remain. Think of hairdressers, plumbers and electricians. The
only labour intensive industries that have low costs pay their workers
very little.-hardly a position that applies to the NHS. Moreover there are
many examples of continuous improvement in health care over time but it
does not necessarily follow that such improvements will also be cheaper.
Competing interests:
None declared
Competing interests: No competing interests