Feature / Right of access

Rationing of healthcare launched itself back into the media spotlight last month as the Royal National Institute of Blind People (RNIB) highlighted ‘arbitrary restrictions’ on access to cataract surgery and GPs called for their leaders to ‘expose the myth of rationing labelled as cost-effectiveness’.

Rationing is rarely out of the spotlight, but tighter finances tend to sharpen the focus on this highly charged subject. A string of GP motions at their annual local medical committees’ conference referenced service cutbacks and restrictions as part of local plans to cut costs. And the RNIB was guaranteed column inches when it reran last year’s survey on access to cataract surgery. Some 57% of PCTs had introduced restrictions, it claimed, that were ‘forcing thousands of people to live with serious and unnecessary sight loss’.

The restrictions were based on visual acuity thresholds and the RNIB said 70% of these PCTs had a ‘very restrictive policy that has little or no leeway for patients outside the visual acuity threshold’. It claimed that practice ranged from the North East of England, where people were given surgery as soon as the cataract affected their lives, to the South East, where some patients needed to ‘have visual acuity as low as the third line down on an eye chart’ before surgery was sanctioned.

Political response

Health minister Simon Burns gave the time-honoured political response. ‘If patients need treatment, they should get it when they want it and where they want it,’ he said. ‘If local health bodies stop patients from having cataract treatments on the basis of cost alone, we will take action against them.’

There was a similar reaction by health secretary Andrew Lansley last year in response to the Co-operation and Competition Panel report on patient choice. He announced bans on minimum waiting times and caps that did not take account of individual patients’ needs – describing them as ‘unfair measures’.

It is all hugely emotive stuff, particularly when analysed at the level of the individual, which explains why sensible discussions around rationing tend to polarise very quickly and rarely scratch beneath the surface.

But two reports this year from respected thinktanks have attempted to at least set out the key issues. The first was published in February by the Nuffield Trust. Rationing healthcare: is it time to set out more clearly what is funded by the NHS? draws on international experience in this area. And it assesses the advantages and disadvantages of the current system for determining which treatments are and are not funded by the NHS.

Some countries do try to explicitly describe the healthcare benefits that are paid for from public funds, either by listing those included or those excluded. But the report says the benefits packages often lack detail and so can only offer a guide to local clinical practice. They rarely set out ‘appropriateness’ criteria to indicate which patients should qualify for treatment.

While the Nuffield recognises the ‘superficial attraction’ of setting a national benefits package it concludes this would be unworkable for the NHS. It gives three reasons: it would not be practical because of cost and information requirements; given lack of information, rigid application would be inappropriate; and it would risk compromising the principle of solidarity on which the NHS relies.

But among its alternative proposals, the Nuffield calls on the NHS Commissioning Board to use NICE guidelines to produce a national list of the treatments that public money should not be spent on in the NHS unless there are exceptional circumstances. It suggests CCGs should be required to report publicly on progress in following this ‘do not do’ advice, explaining any exceptions.

This is already the acceptable face of local rationing. ‘We prefer to call it prioritisation, but yes, it is inevitable as we cannot afford to fund everything,’ says one finance leader of an emerging clinical commissioning group (CCG). ‘All commissioners operate a low-priority procedure list, which excludes procedures from routine NHS funding based on low evidence of efficacy (with a route for individual patient exceptions to be approved).’ But the key difference is that current arrangements are all based on local systems.

The lack of a national list of such activity was highlighted by the Audit Commission last year in its report on treatments of low clinical value. It is not a simple process. For some treatments there is more straightforward evidence that they are not clinically effective. But for others there is just a less conclusive lack of evidence of clinical effectiveness.

In total the commission estimated PCTs had collectively identified 250 different procedures with limited clinical value. Given the efforts already being undertaken locally, and the constant need to refine as new treatments appear and evidence emerges, a centrally compiled list – at least to provide a starting point for local policies –makes sense to some. This would not need to be a categorical ban on interventions but more of a warning to proceed with care.

But the sensitivity around the subject is clear. The Department of Health’s Right Care team has called for the phrase ‘procedures of limited clinical value’ to be dropped. It is seen as a barrier to clinical engagement. Instead the service should talk of ‘value-based or effective clinical commissioning’.

Earlier in the year the King’s Fund also published its take on rationing. Thinking about rationing is intended as a briefing paper to help inform current discussions. It underlines the fact that rationing has been a fact of life since the launch of the NHS, but acknowledges it is ‘certain to become an ever more dominant issue in the hard times ahead’.

To emphasise its point, it lists different types of rationing that can place, including rationing by: denial (refusal to fund); selection (funding only for particular patients); deterrence (putting obstacles in way); deflection (shunting patients off to other institutions); or dilution (where service remains but quality declines).

It is against the idea of a national menu of what not to provide. ‘As the experience of PCTs suggests, the savings tend to be marginal while the bureaucratic costs of dealing with “exceptional” cases can be large. Moreover, commissioners would almost certainly have to be selective in their use of the national menu to reflect local circumstances, so uniformity would still remain an illusory policy goal.’

However, it does argue for a national set of criteria to determine if any given patient should count as an ‘exception’. One CCG finance lead backs up this call, while dismissing national lists of NHS entitlements. ‘It might be more helpful to have a statement of what principles can be legitimately applied at local level to determine what is “not on the list”,’ she says. ‘The list changes and evolves constantly as evidence and financial constraints alter so I do not see how a national list would work.’

One PCT finance director says there is no sign that rationing is a major issue locally, but there are tell-tale signs that things could change.  ‘I’ve been in CCG meetings where GPs are challenging whether they need to fund NICE-approved guidance.’ While acknowledging that funding for NICE-approved drugs is a right within the NHS Constitution (see box), he says just asking the question shows a direction of travel. ‘In the past we’ve always absorbed this in prescribing budgets but maybe they want to invest in community services. It is embryonic at the moment but that’s the language starting to be used by GPs.’

Rationing is already being exhibited in more subtle ways. Commissioners in different areas may use different body mass index thresholds to trigger access to weight loss services. He suggests clinical commissioning is all about taking advantage of GPs’ inside track on local people. But in some aspects of local healthcare, rationing looks very like local choice.

King’s Fund director of policy Anna Dixon says the new commissioning system will by design lead to variation in local priorities. ‘That is exactly right, which is why these black and white decisions about what’s in and out are less helpful and sometimes a distraction from other decisions around clinical thresholds for when people become eligible for treatment. It is activity in this area that is likely to be of more interest to CCGs.’