07-11-22 – NHS Resources and Patient Rights Flashcards
Learning outcomes
- Explain some of the reasons why the NHS has become overstretched, year on year
- Explain different strategies that could be used in NHS resource allocation, and describe their strengths & weaknesses
- Describe NICE and outline its role in technology appraisals and NHS rationing
- Outline the role of SMC and describe its involvement in NHS rationing
- Describe what a ‘QALY’ is, and its use in the decision-making process to purchase health care resources, and evaluate its strengths and weaknesses
- Give examples of controversial uses of the healthcare budget
When was the NHS setup?
What was its aim?
Why was the NHS thought to be ‘founded on a fallacy’?
- The NHS was Set up in 1948
- The aim had been to improve the health of the nation, and thus decrease the demand for healthcare (i.e. based on the premise that there is a finite amount of ill health)
- Why the NHS was though to be ‘founded on a fallacy’:
- “.. the NHS was founded on a fallacy: that there was a finite amount of ill-health in the population which, once removed, would result in the maintenance of health and the provision of healthcare becoming cheaper as the need for it dropped off. What has happened is that success in healthcare has resulted in people living longer potentially to be ill more often and therefore consume more resources”
What are some of the reasons the NHS is overstretched?
- Some of the reasons the NHS is overstretched:
1) Obesity – uses a lot of NHS resources and creates more complex cases
2) Population increase
3) Aging population – multi-morbidities difficult to treat
4) Inflation
What does rationing mean in the NHS?
What are 9 strategies for resource allocation?
- Rationing in the NHS does NOT mean that everyone gets the same fixed amount of resource
- Rationing instead refers to the discretionary allocation of scarce resources
- 9 strategies for resource allocation:
1) Equal access to treatment
2) Rationing according to clinical need
3) Maximising health gains (QALY)
4) Discriminating according to age – some intervention more effective in different ages
5) Taking individual responsibility for ill health into account e.g smoker, drinker
6) Rationing according to ability to pay
7) Singling out certain types of excluded treatment
8) Dilution of care
9) Random allocation
What 3 strategies of resource allocation do the NHS use?
What moral theories/pillars of medical ethics does each one deal with?
- 3 strategies of resource allocation do the NHS use:
1) Equal access to treatment
* Looks at justice – fairness in allocating scarce resources
* Also looks at deontology – equal access
* Deontology bases the morality of an action should be based on whether that action itself is right or wrong under a series of rules and principles, rather than based on the consequences of the action
2) Rationing according to clinical need
* Looks at non—maleficence and beneficence, as if we don’t treat, the patient can have a poorer outcome
3) Maximising health gains (QALY)
* Related to beneficence
* Also deals with consequentialism
* Consequentialism is a theory that says whether something is good or bad depends on its outcomes.
* An action that brings about more benefit than harm is good, while an action that causes more harm than benefit is not.
* The most famous version of this theory is utilitarianism - the greatest good for the greatest number of people
What is a QALY?
What is the moral theory related to QALYs?
How are QALYs measured? What is the equation for QALYs?
- QALY = quality adjusted life year
- The moral theory related to QALYs is consequentialism (utilitarianism)
- Ranking of QALYs:
- “.. It takes a year of healthy life expectancy to be worth 1, but regards a year of unhealthy life expectancy as worth less than 1.
- Its precise value is lower the worse the quality of life of the unhealthy person (which is what the quality adjusted bit is all about)” Williams 1985, cited H, S & H p202
- Equation for QALYs:
- Quality of life X life expectancy (before + after intervention, then compare each)
What makes a positive number of QALYs?
What means cost per QALY is low?
What equates to the overall welfare of the patient?
What are 3 problems with QALYs?
- Beneficial healthcare activity = positive number of QALYs
- Efficient healthcare activity = cost per QALY is low
- Quantity of resources used + Quality resources are providing = overall welfare of patient
- Essentially used to work out how beneficial/effective treatments being used are
- 3 Problems with QALYs:
1) What defines quality?
2) Are we only using healthcare to get back towards a QALY of 1?
3) Is it a just way of allocating resources?
What countries is NICE for?
What did NICE used to be known as?
What is the role of NICE?
What are 4 examples of guidance given for NICE?
- NICE (National Institute for Health and Care Excellence) is for England and Wales
- NICE used to be National Institute for Health & Clinical Excellence but social care came under their remit in 2013
- NICE produce evidence-based guidance and advice for health, public health and social care practitioners.
- 4 examples of guidance given for NICE:
1) Clinical guidelines
2) Technology appraisals
* Recommendations on the use of new and existing medicines and treatments within the NHS (clinical & economic evidence)
3) Public health
4) Interventional procedures
What are technology appraisals from NICE?
What are the 4 technology appraisal recommendations possible?
What is decision making in NICE like?
What are 3 criticisms of NICE?
- Technology appraisals from NICE are recommendations on the use of new and existing medicines and treatments within the NHS (clinical & economic evidence)
- 4 technology appraisal recommendations possible:
1) Recommended for use in NHS (if drug is effective and cost efficient)
2) Restricted use to certain categories of patients
3) Use confined to clinical trials
4) Should not be used in NHS
- Decision-making process in NICE is open & transparent
- 3 criticisms of NICE:
1) Status of guidelines ambiguous
* Guidelines can’t be completely comprehensive, which leads to (2
2) Implementation is variable
3) Topic selection is not random
* More attention towards certain drugs when other drugs would help more patients
* Largely due to limited resources
What is the Scottish Medicines Consortium (SMC)?
What is their aim?
What does it do?
What 5 ways does the SMC achieve this?
- The Scottish Medicines Consortium (SMC) is a national source of advice on the clinical and cost-effectiveness of all new medicines for NHS Scotland.
- Their aim is to ensure that people in Scotland have timely access to medicines that provide most benefit based on best available evidence
- The SMC evaluates whether the benefits of medication for patients may be considered an acceptable use of NHS resources
- 5 ways the SMC achieves this:
1) Comparison to current medication
2) Administration
3) Addition HCP time
4) Quality of Life
5) Downstream savings (complications form aging population avoided in the future
What are 3 possible outcomes for SMC medication review?
What happens when the SMC accepts a new medicine?
- 3 possible outcomes for SMC medication review:
1) Accepted
2) Accepted with restrictions
3) Not recommended - When SMC accepts a new medicine, NHS boards are expected to make it, or an equivalent SMC-accepted medicine, available
What are 6 investments where use of healthcare budget is debated?
- 6 investments where use of healthcare budget is debated:
1) Treatments to assist reproduction
2) Cosmetic surgery
3) Long-term nursing for elderly
4) Health education in schools
5) Provision of traffic-calming measures (fewer accidents help healthcare)
6) Reversal of sterilisation (as sterilisation is a voluntary procedure)
What are 4 examples of when incentives were used in healthcare?
What are 3 reasons why incentives in healthcare are deemed bad?
- 4 examples of when incentives were used in healthcare:
1) New mums paid £200 of shopping vouchers to breast feed” (12/11/13; updated 2017)
2) Incentives used in weight loss
3) Incentives used in smoking cessation
4) incentives used for patients with schizophrenia - BMJ paper (October 2013):
- 3 reasons why incentives in healthcare are deemed bad:
1) “Bribing patients is bad medicine” - Dr Margaret McCartney:
2) “We decrease the autonomy of the patient and contaminate our relationship with them” - Telegraph, 19/10/13)
3) Also have to debate if it’s the best use of NHS resources
