Rationing Flashcards
Give some reasons for the projected increase in demand for the NHS.
Demographics:
- double the amount of over 75yrs by 2031
- 60% of 65yrs+ have a long term condition
- increased incidence & prevalence of cancer
New technologies:
- new cancer therapies are expensive & broaden the pool of candidates
- new therapies increase survival time
- prophylactic drugs
What consequences of increased spending in the NHS have been demonstrated?
- 87% has gone on higher wages
- shorter waiting times, but unclear what value this has actually had
- slightly increased activity
- unclear whether quality & safety have improved
- unclear how much it would cost to produce any more improvements
- period of austerity
Why do priorities need to be set in healthcare?
Resources are scarce
Clear & explicit who benefits from public expenditure
Clear on what we want to achieve
What are the 5 D’s of rationing in the NHS?
DETERRENT = demands for healthcare are obstructed e.g. prescription & dental charges
DELAY = waiting lists
DEFLECTION = GPs deflect demand for secondary care (gatekeepers)
DILUTION = e.g. fewer tests, cheaper drugs
DENIAL = range of services denied to patients e.g. reversal of sterilisation, infertility treatment
What is implicit rationing?
Allocation of resources through individual clinical decisions without the criteria for these decisions being explicit
- patients believed care was offered/withheld on basis of clinical need
- can lead to inequalities & discrimination
- open to abuse; decisions based on perceptions of “social deservingness”
What is explicit rationing?
Use of institutionalised procedures for the systematic allocation of resources within the healthcare system.
- technical processes e.g. assessment of efficiency & equity
- political processes e.g. lay participation
- CCGs determine priorities
- problems in identifying criteria to govern decision-making processes
What are the advantages and disadvantages of explicit rationing?
ADVANTAGES:
- transparent & accountable
- opportunity for debate
- use of evidence-based practice
- more opportunities for equity in decision-making
DISADVANTAGES:
- very complex
- heterogeneity of patients & illnesses
- patient & professional hostility
- threat to clinical freedom
- evidence of patient distress
Who makes decision for what treatments and procedures become funded?
NICE provides “directions” (binding) on whether new or existing treatment can be recommended for use in NHS England & Wales
(judgement made on value of treatment relative to alternative uses of those resources)
Whilst a drug/device is being appraised by NICE, NHS organisations make decisions on its use locally. Once national guidance has been issued by NICE, it replaces the local recommendations and promotes equal access for patients across the country
If a treatment is approved, local NHS organisations MUST fund them (adverse consequences for other priorities)
What are Healthcare Resource Groups?
Standard groupings of clinically similar treatments which use common levels of healthcare resources, i.e. “units of currency”
Determines equitable reimbursement for care services delivered by providers
note: trust loses money on avoidable complications, and no payment for “never events”
What are examples of how the public view priorities in healthcare?
Majority think that everyone should have the health care they need, regardless of cost
Tend to value heroic interventions and particular patient groups e.g. babies
Preference for treating patients with dependents
Willingness to discriminate against those who were partially responsible for their illness
i.e. may be contrary to equity & equal access according to need, may go against cost-effectiveness
Define health economics.
Maximises social benefits subject to constraints imposed by resource ability
- net benefits
- evaluates services
- provides information to assist in the allocation of scarce resources in an efficient & equitable way
- recognises reality of fixed NHS resources and brings this to public attention
- exposes opportunity costs of new interventions
- enables consistency in investment decisions
- helps direct innovation into priority areas
What are the different components of health economics?
SCARCITY = need outstrips resources; prioritisation is inevitable
EFFICIENCY = getting the most out of limited resources
EQUITY = extent to which distribution of resources is fair
EFFECTIVENESS = extent to which an intervention produces desired outcomes
UTILITY = value an individual places on health state
OPPORTUNITY COST = once you have used a resource in one way, you no longer have it to use another way (measured as the value of the next best alternative use of those resources, the benefits foregone)
e.g. financial cost of hiring new psychiatric nurse = £20,000
opportunity cost of hiring new psychiatric nurse = 50 children requiring overnight observation
Contrast technical and allocative efficiency.
Technical efficiency = what is the most efficient way of meeting a need? e.g. should antenatal care be community-based or hospital-based
Allocative efficiency = choosing between many needs which need to be met
e.g. fund hip replacement surgery, or neonatal care?
Define economic evaluation.
Comparison of resource implications and benefits of alternative ways of delivering healthcare; competing programmes are evaluated in terms of costs and consequences (what is the best value for treatment?)
Based on assumptions (therefore use sensitivity analysis to check)
By costs of:
- healthcare services
- patient’s time
- care-giving
- illness
- borne by employers/other employees/rest of society
By consequence of:
- impact on health status (survival/quality of life)
- savings in other healthcare resources if patient’s health is improved
- improved productivity if patient/carers return to work earlier
Calculate consequences using discounting (present values of inputs and outcomes which accrue in the future)
Outline a cost minimisation analysis.
Outcomes assumed to be equivalent (therefore this analysis is not often relevant)
Focus on costs only
Use if there is good evidence on the effectiveness of the interventions and the interventions are equally effective.
e.g. if all prostheses for hip replacement improve mobility equally, then choose the cheapest one
Outline a cost effectiveness analysis.
Compare drugs & interventions which have a common health outcome
Cost/unit outcome e.g. for anti-hypertensives the cost per reduction of 5mmHg
If costs are greater for one treatment, but the benefits are also greater, you need to calculate how much extra benefit is obtained for the extra cost
Use when there is good evidence for the effectiveness of the interventions being compared, the interventions are not equally effective, the outcomes can not be valued in monetary terms, and the outcomes cannot be measured in quality-adjusted life years.
Outline a cost benefit analysis.
All costs & benefits valued in monetary terms (causes methodological difficulties)
Allows comparison with interventions outside healthcare
Use when there is good evidence for the effectiveness of the interventions, the interventions are not equally effective, and all the outcomes can be valued in monetary terms.
Outline a cost utility analysis.
Quality of health outcomes produced/foregone
Most frequently measured in quality-adjusted life years (QUALYs) = composite of survival and quality of life
Use when there is good evidence for the effectiveness of the interventions, the interventions are not equally effective, not all the outcomes can be measured in monetary terms, and all the outcomes can be measured as QUALYs
What is a QUALY? What are some alternatives to QUALYs?
Quality adjusted life year
1 year of perfect health = 1 QUALY
10yrs of 10% health = 1 QUALY
6 months of perfect health for 2 people = 1 QUALY
note: each year of healthy life is of equal value
Alternatives:
- health year equivalents (HYEs)
- saved-young-life equivalents (SAVEs)
- disability adjusted life years (DALYs)
note: NICE integrates QUALYs with the price of treatment using the incremental cost-effectiveness ration = change in costs in relation to the change in health status (cost per QUALY)
Give some examples of the criticisms of QUALYs.
- do not distribute resources according to need, but according to benefits gained per unit of cost
- calculation errors/problems
- may not embrace all dimensions of benefit; values expressed by experimental subjects may not be representative
- values embodied
- RCT evidence is not perfect
- NICE resented by patient groups, pharmaceutical companies, & CCGs which are forced to commission NICE-directed interventions (+ concerns about political interference)
Give an approximation of NHS England spending in 2013/2014.
£109.2bn (8.2% of GDP)
