“The rationing process in the NHS is messy,” said the King’s Fund. On this I think we can agree. Just look at what is happening with IVF services to understand the messiness with commissioning and the rationing of health services.
Croydon’s clinical commissioning group (CCG) has decided to save over £800 000 a year by no longer funding IVF. This is despite 77% of people consulted opposing the decision. Meanwhile, across Scotland three cycles of IVF are provided on the NHS, ending local variation. Over the border in England, 80% of CCGs fail to commission three cycles, despite this being the official guidance from the National Institute for Health and Care Excellence (NICE), while in Northern Ireland and Wales one and two cycles are offered, respectively.
The King’s Fund argues that some rationing is inevitable, but we must avoid the “fudges” seen with commissioning IVF. Whose job is it then to sort messes like these out?
It is not NICE doing the rationing; they recommend that women under the age of 40 years, who have not conceived after two years of regular unprotected intercourse, should be offered three full cycles of IVF. Individual CCGs decide to ration services through stricter criteria, thus introducing local variation and postcode lotteries. CCGs therefore decide what to fund based on local needs—hopefully following proper consideration of the evidence, national priorities, and NICE guidance.
How and what CCGs ration is also informed, to some extent, by how their predecessors (the primary care trusts (PCTs)) reduced spending on low value clinical treatments. A 2011 Audit Commission briefing identified Croydon PCT as a forerunner in identifying low value treatments. The “Croydon List,” as it became known, included procedures where cost effective alternatives should be tried first, interventions with a small benefit or risk balance done in mild cases, and cosmetic or ineffective procedures. PCTs identified some 250 different procedures with limited clinical value, but no single, nationwide list was collated.
Identifying low value interventions became part of the remit of the NHS Right Care Programme, yet they advocate using NICE guidance. Consequently, CCGs develop their own approaches, often incorporating the Croydon List of low priority treatments.
Stopping low value interventions in the NHS must be a good thing; but IVF doesn’t meet the Croydon criteria and wasn’t on their list. IVF remains an easy target and it is likely that many CCGs will follow Croydon’s lead as they try to save money.
Once CCGs refuse to pay then market forces become the dominant factor in accessing healthcare. Leaving rationing to the market, however, is deeply troubling on many levels: in America, many individuals go without health insurance, without prescriptions, forego preventive care, and often wait when sick because they cannot afford the market cost of healthcare.
If we want to bring an end to postcode variation, remove market forces, and reduce irrational rationing, we need to boost funding. We also need to be more open and explicit, as a national health service, as to what we will fund, what we won’t fund, and what evidence we will use to stop low value interventions.
Carl Heneghan is professor of EBM at the University of Oxford, director of CEBM, and a GP.
His research interests span chronic diseases, diagnostics, use of new technologies, and investigative work with The BMJ on drugs and devices that you might stumble across in the media. He is also a founder of the alltrials.net campaign.
Competing interests: Carl Heneghan jointly runs the Evidence Live conference with The BMJ and is a founder of the AllTrials campaign. He has received expenses and payments for his media work. He has received expenses from the World Health Organization (WHO) and the US FDA, and holds grant funding from the NIHR, the National School of Primary Care Research, the Wellcome Trust, and the WHO. He has published previously on IVF ‘Add-on treatments’ in the BMJ.