Resource Allocation Flashcards
What impacts do scarce resources have on the work of doctors?
Healthcare expenditure is rising worldwide
Healthcare systems confront the problem of allocating limited healthcare resources in relation to competing demands
No country can keep up
How does demography affect resource allocation?
Population is ageing
An 85 year old patient costs the NHS 15x as much as a 5-14 year old
What is the role of technology in resource rationing?
New therapies e.g. cancer are often v expensive & generally expand the pool of candidates (e.g. broader indications, fewer side effects)
Don’t often cure but offer increased survival
Why does rationing have to take place in healthcare?
Resources are scarce
Demand greater than supply
So it is clear who benefits from public expenditure
So we are clear if spending is ‘worth it’
What are the 5 D’s of rationing in the NHS?
Deterrent - demands for healthcare are obstructed (e.g. prescriptions)
Delay - waiting lists
Deflection - GP’s deflect demand from secondary care (gatekeepers)
Dilution - Fewer tests, cheaper drugs
Denial - Range of services denied to patients (e.g. reversal of sterilisation)
What is explicit rationing?
priority-setting as care is limited
Institutional procedures used for the systematic allocation of resources within health care systems
Describe the aspects of explicit rationing
Based on defined rules of entitlement
Care is limited, decisions are explicit, as there are reasons behind them (made by CCGs)
Technical process - Assessments of efficacy & equity
Political process - Lay participation
What are the advantages of explicit rationing?
Transparent, accountable
Opportunity for debate
Use of evidence based practice
More opportunities for equity in decision-making
What are the disadvantages of explicit rationing?
Very complex Heterogeneity of patients & illness Patient & professional hostility Threat to clinical freedom Evidence of patient distress
What is implicit rationing?
The allocation of resources through individual clinical decisions without criteria for those decisions being explicit
(Care limited, neither the decisions nor bases for these decisions are clearly expressed)
Describe the aspects of implicit rationing
Before 1990, NHS relied on implicit rationing
Clinicians made decisions within overall budgetary constraints
Open to abuse
Decisions made on perceptions of “social deservingness”
What levels of rationing are there?
- How much allocation to NHS compared to other government priorities? e.g. education
- How much to allocate across sectors e.g. cancer
- How much to allocate to specific interventions within sectors e.g. end of life vs curative drugs
- How to allocate interventions between different patients in the same group
- How much to invest in each patient once an intervention has been initiated
Why was the National Institute for Health and Care Excellence (NICE) set up?
To ‘enable evidence of clinical & cost effectiveness to be integrated to inform a national judgement on the value of a treatment(s) relative to alternative uses of resource’
What is the function of NICE?
Provides guidance on whether treatments (new or existing) can be recommended for use in the NHS in England and Wales.
Appraises new drugs and devices: Clinical benefit, Costs
During appraisal NHS organisations make decisions on its use locally
Once national guidance is issued by NICE it replaces local recommendations and promotes equal access for patients across the country.
What happens to treatments that are/aren’t approved by NICE?
If expensive treatments are not approved, patients are effectively denied access to them
If approved, NHS organisations must fund treatments, sometimes with adverse consequences for other priorities
Occasional exceptional rulings, e.g. Herceptin in early stage breast cancer. Treatment has a large cost, impact on allocation of budget resources elsewhere.
