Resource Allocation Flashcards
Why is healthcare becoming more expensive?
Demography
- Aging population
- Aged people cost more
Technology
- New treatments and technologies cost more
- Often don’t cure but increase survival
Why do we set priorities in healthcare?
Resources are scarce
So that it is clear and explicit who benefits from public expenditure
To be clear about whether spending is ‘worth it’
What are the 5 Ds of rationing in the NHS
Deterrent - Demands for healthcare are obstructed Delay - Waiting lists Deflection - GPs deflect demand from secondary care Dilution - e.g. fewer tests, cheaper drugs Denial - Range of services denied to patients
What are the two forms of rationing? (when difficult decisions are needed)
Explicit rationing
- Based on defined rules of entitlement
Implicit rationing
- Care is limited, but neither the decisions, nor the bases
for those decisions, are clearly expressed
Explain what is meant by implicit rationing.
Implicit rationing is the allocation of resources through individual clinical decisions without the criteria for those decisions being explicit.
Before 1990s reforms, NHS relied mainly on implicit rationing
Clinicians made decisions within overall budgetary constraints
Patients believed care was offered (or withheld) on basis of clinical need.
- It can lead to inequities and discrimination
- Open to abuse
- Decisions based on perceptions of “social
deservingness” - Doctors appear increasingly unwilling to do it.
(Despite its limitations, at the point of service it is more sensitive to the complexity of medical decisions)
Explain what is meant by explicit rationing.
Explicit health care rationing or priority-setting is the use of institutional procedures for the systematic allocation of resources within health care system.
Care is limited and the decisions are explicit, as is the reasoning behind those decisions
Technical processes
- e.g. assessments of efficiency and equity
Political processes
- e.g. lay participation
What are the advantages and disadvantages of explicit rationing?
ADVANTAGES
Transparent, accountable
Opportunity for debate
Use of EBP
More opportunities for equity in decision-making
DISADVANTAGES
Very complex
Heterogeneity of patients and illness
Patients and professional hostility
Threat to clinical freedom
Evidence of patient distress
Give some examples of the different levels of rationing there is in the current health service.
- How much to allocate to NHS compared to other government priorities e.g. education?
- How much to allocate across sectors e.g. mental health, cancer?
- How much to allocate to specific interventions within sectors e.g. end of life drugs with curative intent?
- How to allocate interventions between different patients in same group e.g. which patients with advanced cancer should be treated?
- How much to invest in each patient once an intervention has been initiated e.g. how long should cholesterol be lowered in treated patients?
How does NICE fit into resource allocation in the NHS?
National Institute for Health and Care Excellence
Set up to “enable evidence of clinical and cost effectiveness to be integrated to inform a national judgement on the value of treatment(s) relative to alternative uses of resources”
Provides guidance on whether treatments (new or existing) can be recommended for use in the NHS in England and Wales.
In 2002 NICE recommendations changed from ‘guidance’ to ‘directions’ and became binding
Nice has a particularly controversial role in relation to expensive treatments
- If not approved, patients are effectively denied access
to them.
- If approved, local NHS organisations must fund them,
sometimes with adverse effects for other priorities.
How does the process of NICE recommendations work?
NICE is asked to appraise significant new drugs and devices to “help make sure that effective and cost effective products are made available to patients quickly and to minimise variations in the availability of treatments”
While a drug or device is being appraised by NICE, NHS organisations make decisions on its use locally, using their usual arrangements.
Once national guidance has been issued by NICE, it replaces local recommendations and promotes equal access for patients across the country.
What are tariffs in relation to the NHS?
Tariffs: Payment by results
Healthcare Resource Groups (HRGs) - standard groupings of clinically similar treatments which use common levels of healthcare resource
HRGs are a ‘unit of currency’ determining an (imperfectly measured) equitable reimbursement for care services delivered by providers
When a hospital treats a patient, the diagnosis and treatment are recorded and coded, the HRG assigned and a tariff paid
- E.g. caesarean birth has higher tariff than normal birth.
How do tariffs promote quality and efficiency?
Efficient trusts can make a profit, but inefficient trusts can lose money - incentive to become more efficient over time
Can make profit by doing things for less than the tariff
If avoidable complications occur, trust can lose money
‘Never events’ - no payment
Why not let the public decide?
Consultation very problematic
Resistance to inevitability of rationing
Majority think everyone should have the healthcare they need regardless of cost
Tend to value heroic interventions and particular patient groups, e.g. babies/children over the elderly
Preference for treating patients with dependents
A willingness to discriminate against those who were partially responsible for illness (e.g. drinking)
Public priority may be contrary to spirit of equity and equal access according to need
Public priorities may go against cost effectiveness data
