Why is rationing inevitable in healthcare?
- Ageing population - more LTCs
- Technology - new therapies expensive
- Many drugs don’t cure but improve survival
- Consumerism
- Demand > supply
- Recent big increases in spending on wages, shorter waiting times
What are the 5 Ds of rationing?
- Deterrent - charges
- Delay - waiting lists
- Deflection - GPs deflect from hospitals, referral, gatekeeping
- Dilution - fewer tests, cheaper drugs
- Denial - range of services denied
What are the two types of rationing?
Explicit and Implicit
What are the problems with letting patients decide what to ration?
- No regard for cost
- Tend to value heroic interventions and particular groups
- Preference for treating those with dependents
- Discrimination against those responsible for their illness
- Not equitable
- Some level of consultation needed for legitimacy
What is explicit rationing?
What is technical and political process?
- The use of institutional processes for the systematic allocation of resources within healthcare systems
- Based on rules of entitlement
- Care is limited, but the decisions and reasoning are explicit from CCGs
Technical process - assessment of efficiency and equity
Political process - lay participation
What are advantages of explicit rationing?
- Transparent and accountable
- Opportunity for debate
- Evidence based practice
- Equitable
What are disadvantages of explicit rationing?
- Complex
- Heterogeniety of patients and illness
- Patient and professional hostility to rationing
- Threat to clinical freedom
What is implicit rationing?
- Care is limited
- The allocation of resources through individual clinical decisions without the criteria for those decisions being explicit
- Can lead to inequalities and discrimination
- More sensitive to complexity of medical decisions and needs and practices of patients
What does NICE stand for?
National Institute for Health and Care Excellence
What is the role of NICE?
Enables evidence of clinical and cost effectiveness to be integrated to inform national clinical judgement on value of treatments relative to alternative use of medicines
Appraise new drugs and devices - available to patients quickly
Minimise variations in availability
National guidance replaces local recommendations
Why can NICE guidance replacing local recommendations be controversial?
May deny access to expensive treatments
If approve, NHS organisations have to fund treatments - can affect other priorities
What is a Healthcare Resource Group?
Standard groupings of clinically similar treatments which use common levels of healthcare resources
Reflect and average cost for a patient spell
Diagnosis and treatment are recorded for a patient, determines which HRG they are assigned to and which tariff is paid
How do tariffs incentivise efficiency?
Can make a profit for doing things for less than paid by the tariff
Avoidable complications such as never events - no payment
What are 5 concepts of health economics?
- Scarcity: needs > resources
- Efficiency
- Equity
- Effectiveness
- Utility
What is an opportunity cost?
- Once you have used a resource in one way, you no longer have it to use in another way
- Measured in benefits foregone = the benefits you lose not being able to do the next best alternative
- Benefits should outweigh the opportunity cost
What is technical efficiency?
The most efficient way of meeting a need
E.g. community vs hospital based
What is allocative efficiency?
Choosing between the many needs to be met
What is economic evaluation?
The comparison of resource implications and benefits of alternative ways to deliver healthcare Compare resources (inputs) and benefits (outputs)
What are some problems with economic evaluation?
Based on some assumptions - sensitivity analysis to check effects
Some health benefits not felt for years
What are the 4 main types of economic evaluation?
- Cost minimisation analysis
- Cost effectiveness analysis
- Cost benefit analysis
- Cost utility analysis
Describe cost minimisation analysis
Assumes all outcomes are equivalent, so choose the cheapest one
Outcomes are rarely equivalent
Descibre cost effectiveness analysis
Comparison of drugs with a common health outcome e.g. reduce BP
Compared in terms of cost per unit outcome
If costs are higher for one treatment, but benefits are too, need to weigh up if its worth the extra cost
Describe cost benefit analysis
All inputs and outputs valued in monetary terms
Allows comparisons with interventions outside healthcare
Methodology is difficult to put monetary value on non-monetary things
Describe cost utility analysis
Type of cost effectiveness analysis
Focuses on quality of health outcomes produced or foregone - most frequently used measure is the QALY - compare in cost per QALY terms
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1: Quality and safety25
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2: Methods and evidence19
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3: Inequalities in health19
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4: Lay beliefs, health promotion34
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5: Chronic illness and patient related outcomes42
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6: Screening34
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7: NHS structure and management18
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8: Resource allocation30
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9: Patient evaluations and complementary therapies34
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10: The Medical Profession31
