Growing financial pressure on the NHS is exposing a lack of legitimacy in the way many decisions about rationing healthcare in England are made, according to the Nuffield Trust.
In a briefing aimed at current and prospective MPs, the think tank’s Chief Executive Nigel Edwards argues that some rationing is inevitable in any health system. However, he states that we must do better at avoiding ‘fudges’ when it comes to making decisions about which drugs and treatments should be funded by the NHS, whether these are made at a local level through commissioning policies, or at a national level through policies like the Cancer Drugs Fund.
The rationing process in the NHS is messy. Policymakers, commissioners and clinicians have muddled through and have made a series of compromises and trade-offs.
Nigel Edwards, Chief Executive at the Nuffield Trust and lead author
Mr Edwards also warns policymakers and commissioners not to overestimate the ability of rationing approaches to reduce NHS expenditure.
A separate Nuffield Trust survey of 100 health and social care leaders, also published today, finds that over a third of respondents felt that the current approach to rationing healthcare was unfair and 7 in 10 said that the Cancer Drugs Fund should be wound up.
Nigel Edwards said:
“The rationing process in the NHS is messy. Policymakers, commissioners and clinicians have muddled through and have made a series of compromises and trade-offs. This has resulted in reduced access to treatments in some areas for reasons that have not been made clear and it has led to cancer drugs receiving priority over other treatments at a national level.
“This approach worked while there was money in the system. But as funding pressures grow, the messiness of these compromises becomes rather harder to defend. Part of the problem is that there is no easy alternative to muddling through. This leads to decisions of questionable legitimacy like throwing large amounts of money at individual conditions, or commissioners having to use clinical criteria as a mechanism to make savings. We must do better at avoiding the worst of these kinds of fudges in future.”
The Nuffield Trust briefing Rationing in the NHS argues that despite the lack of public support for rationing decisions, there is room to improve the level of transparency in the system. It suggests a greater use of public consultation and better communication about local commissioning decisions. The briefing commends the approach of the National Institute for Health and Care Excellence (NICE) in appraising new technologies but acknowledges this comes at a cost. It says that NICE should be given responsibility for decisions about expensive cancer drugs currently considered under the Cancer Drugs Fund.
The survey of the Nuffield Trust’s health and social care leaders is the third of four being conducted in the run-up to the election. It polls leaders’ views on rationing in the NHS, finding that:
- More than a third (36.7%) of respondents felt that the current approach to rationing is unfair – in the words of one panel member: “it is too opaque to us as health care professionals – let alone patients, families and the general public”. However, more respondents (43%) said it was fair.
- 59% said that the Cancer Drugs Fund should be wound up and responsibility handed to NICE, and 11% said the Fund should be wound up and responsibility handed to another body – one panel member described the drugs it pays for as “all about hope and nothing to do with evidence”.
- Almost seven in ten (68%) think that people should get the same package of NHS services no matter where they live. However, more than half (52%) think treatments and services should be locally tailored, illustrating the difficulty of resolving some of the policy challenges around rationing.
- Financial pressures are seen as the biggest restrictor of clinically effective care.
The Nuffield Trust’s briefing lays out the ways in which the English NHS rations care, looking at the mixture of local and national processes used to determine which treatments are funded by the NHS. These include:
- Appraisals and guidelines from NICE, the body responsible for deciding what medication and treatments should be available on the NHS;
- Rationing decisions by local CCGs, the doctor-led bodies responsible for planning and purchasing healthcare locally;
- The Cancer Drugs Fund, set to spend £340 million next year on buying cancer drugs not routinely available on the NHS.
The briefing and survey are published ahead of a debate on the ‘postcode lottery’ in healthcare, held in partnership with the Royal College of Surgeons. Speakers include Ben Page of ipsos MORI; former health minister Lord Warner; Dr David Jenner of NEW Devon CCG; and Professor Karol Sikora of the University of Buckingham.
Notes to editors
- The Nuffield Trust’s briefing ‘Rationing in the NHS’ is the second in a series of policy briefings on the issues and challenges the Nuffield Trust believes are critical to the longer‑term success of the health and social care system, and which any new administration following the election will need to consider. The first briefing from the series examined the state of general practice.
- The survey of health and social care leaders is the third in a series of surveys conducted by the Nuffield Trust in the run up to the General Election.
- Between 24 November and 19 December 2014, the Nuffield Trust asked the panel a series of questions about out of hospital care. 80 of the 100 leaders responded.
- The Nuffield Trust/ RCS debate on the ‘postcode lottery’ in healthcare will take place on Thursday 19 February 2015 at the Royal College of Surgeons. Further information can be found here: http://www.nuffieldtrust.org.uk/talks/postcode-lottery-justified