Pressure on NHS finances drives new wave of postcode rationing

BMJ 2017; 358 doi: (Published 04 July 2017) Cite this as: BMJ 2017;358:j3190

Re: Pressure on NHS finances drives new wave of postcode rationing

Dear Editor

We believe that the analysis of the data on individual funding applications needs reviewing because it is likely that prior approval processes and individual funding request (also referred to as exceptionality requests) have been conflated.

The list of the treatments and the numbers being dealt with suggest that data on prior approval schemes have been included in some CCG returns.

The individual funding request process is designed to consider whether or not a ‘service development for one patient’ is justifiable. The process should largely, but not exclusively, deal with the use of an existing treatment in an experimental clinical context outside of a clinical study.

A well-managed IFR process should demonstrate a low level of applications together with a high proportion of those passing the screen stage being approved at Panel, if there are sufficient funds to pay for them. The number of IFR applications should be low because the NHS currently allows clinicians considerable clinical freedom within what is normally commissioned.

Prior approval schemes enable commissioners to closely monitor activity or check that a patient meets the criteria for funding the treatment. Similar mechanisms exist in some hospital pharmacies for high cost or NICE approved drugs. One would therefore expect a prior approval application to be approved. With the advent of electronic systems such as blueteq the process has become fully automated which may explain an increase in the use of this tool.

These two processes therefore serve very different purposes.

It is understandable that clinicians, frustrated at being faced with explicit rationing and tightening criteria, may be driven to making more IFR applications but these are not appropriate, and commissioners should not be encouraging this or accepting them.

The error in the data does not negate the view that there is unwarranted variation in commissioners’ IFR processes - there undoubtedly is. The same can also be said for the variation in applications. But any assessment should be based on the correct data. If commissioners are also conflating the IFR and prior approval processes that would be of great concern but as we do not know how the FOI request was phrased it is not possible to judge.

The article suggests that the tight financial position is leading commissioners to further tighten commissioning criteria leading to more rationing. More rationing is needed. Baseline unmet need (which is considerable) + more need (ageing population, new treatments) and a slow growth in the budget will lead to more unmet need. In the absence of increased funding, efficiency savings and reducing waste cannot bridge the widening gap. If explicit rationing does not provide the means to balance the equation then implicit rationing will.

Post code variation, is a separate issue from the extent of unmet need (or rationing). Geographic variation is inevitable for many reasons not the least of which is that not all commissioners currently receive their allocated level of funding and the NHS Atlas of Variation illustrates huge variation in clinical practice. What has not been sufficiently agreed is what is considered warranted and what is unwarranted variation. Nor has there been sufficient debate about which services and treatments should be the priority for levelling up. Is it more important, for example, that there is equitable access to a number of treatments, such as high cost treatment which provides 3 months extension to life, or should A&E services be fully resourced and quality assured? In the presence of scarcity the answer cannot be that everything should be provided to the same level everywhere.

What is disappointing is that the discourse has not changed much in the last 2 decades. It has been suggested elsewhere that we should return to ‘elegantly muddling through’ which relies heavily on implicit rationing but this does not seem appropriate in an era when public services are expected to be open and accountable.

Competing interests: Both authors are Directors of Ethical Decision Making (EDM) Ltd.

17 July 2017
Daphne Austin
Public Health Physician
Dr Duncan Jenkins
Ethical Decision Making (EDM) Ltd
County House, St Mary’s Street, Worcester WR1 1HB