Last month a controversial proposal was made by Vale of York clinical commissioning group (CCG) to deny obese patients access to elective surgery for up to a year. The headlines were alarming and the approach felt wrong. The CCG defended its position by saying that it was “the best way of achieving maximum value from the limited resource available.” The suggestion is now under review in the wake of the outcry it caused, but is this a sign of the kind of care rationing we will increasingly start to see?
As the Carter review of productivity in hospitals explained at length, the NHS must make better use of scarce resources. There is a strong ethical rationale for doing so; money spent on the care of one patient is money unavailable for the care of another. At first glance, the Vale of York approach, in theory at least, aligns with Bentham’s ambition of seeking to achieve the greatest good for the greatest number of people. For commissioners, this may serve as a philosophical comfort blanket and an ethical basis upon which to base new rationing strategies. However, blanket bans, which delay access to potentially life changing surgery, represent a significant step change in the history of NHS resource allocation, and do not align with the principles of a value based healthcare system.
The concept of value here requires consideration of three key factors: the evidence in favour of the intervention, patient level criteria that may affect the outcome of the intervention, and the personal value that the patient places on the potential harms and benefits associated with the intervention. Therefore, policy must be amenable to personalisation.
Clinicians need guidance from commissioners about resource allocation, but they also need a degree of autonomy to make decisions about value—together with their patients. This involves discussing outcomes in the context of the individual patient, and identifying what matters most to them. This process of shared decision making can be complex and it requires an increased investment of time. However, it is undoubtedly a sharper tool for resource allocation, which endeavours to reduce wasteful interventions with poor outcomes, but still maintains “patient choice” at the heart of the decision making process.
For many obese patients, surgery will still be the right choice for them, despite the increased risk of complications. On the other hand, there are many areas of clinical practice where investment in time (rather than investigation or treatment) is a surer route to “less medicine” and better outcomes for patients.
A particularly pertinent example of this is the management of patients with prostate cancer. A study was recently published showing a 99% 10 year survival rate for men diagnosed with early prostate cancer, regardless of whether they opted for surgery, radiotherapy, or watchful waiting.
If we engaged in meaningful discussion with our patients about these outcomes, as well as the potential harms associated with intervention, a rational assumption would be that far fewer patients would opt for invasive, expensive treatments of questionable benefit. The idea of not treating cancer, however, does go against the grain, and it tends to take longer for patients to see the value of “doing nothing.” The quicker option that requires less shared understanding, and which is more familiar to both doctors and patients, is that of early intervention.
The theory that “doing nothing” takes more time is perhaps most apparent in general practice. The time pressures associated with a 10 minute appointment can force doctors to treat rather than counsel, and to investigate rather than reassure. This is not only wasteful but it also has several knock-on effects: namely, that it leads to the medicalisation of normal life experience, it perpetuates an inability to self-manage, and it drives demand in the form of reattendances. By shortchanging patients on time, this leads to wider inefficiencies in the system and poorer outcomes for patients.
Likewise, if we consider end of life care, there is a growing concern that we have overreached ourselves with the advent of modern medicine. State of the art kit and expensive drugs are quite the opposite of what is needed for a “good death.” If instead we committed the necessary time to have open and honest discussions with patients and their families about the futility of active treatment in the terminal phases of life, this would go a long way towards reducing the burden of treatment and improving end of life care.
However, with time being such a scarce commodity in the current healthcare environment, it is often the case that we carry on treating, and fail to prioritise shared decision making at the end of life. The situation is made worse by a system that rewards activity rather than personalised value. For example, there remains no quality and outcomes framework (QoF) measure for ensuring a “good death,” and no incentive payment attached to high quality discussions with dying patients and their families.
The commitment from the National Institute for Health and Care Excellence (NICE) and other arms lengths bodies to support shared decision making and embed it into all levels of practice comes as welcome news. Although this model requires the increased investment of time, it is likely to mitigate the culture of overdiagnosis and overtreatment that has spread into almost all realms of medicine. In a period of unprecedented financial challenge, it also has the potential to be an equitable tool for resource allocation. Shared decision making puts responsibility on doctors and patients to be the proponents of a value based healthcare system, and it may be the first step towards instilling a culture of stewardship among those who work in and use the NHS.
Rammya Mathew is a NIHR academic clinical fellow in general practice and a national medical director’s clinical fellow at the Royal College of Physicians, London.
James McGowan is a public health specialty registrar, NIHR academic clinical fellow at the University of Cambridge, and former national medical director’s clinical fellow at the National Institute for Health and Care Excellence (NICE).
Competing interests: None declared.