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Rationing decisions


12 January 2011

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One aspect of GP commissioning making
many doctors feel queasy is the prospect that they will have
to shoulder the blame for rationing care. Health Secretary
Andrew Lansley has made it clear that in the new world
of bottom-up decision-making, GPs will be accountable to
patients for the way they manage the commissioning budget.

Following the news that the National Institute for Health
and Clinical Excellence’s (NICE) role in drug funding is
to be scaled back and replaced by a system of value-based

One aspect of GP commissioning making
many doctors feel queasy is the prospect that they will have
to shoulder the blame for rationing care. Health Secretary
Andrew Lansley has made it clear that in the new world
of bottom-up decision-making, GPs will be accountable to
patients for the way they manage the commissioning budget.

Following the news that the National Institute for Health
and Clinical Excellence’s (NICE) role in drug funding is
to be scaled back and replaced by a system of value-based
pricing from 2014, it looks as though GP consortia may also
be also given the responsibility of deciding which drugs
should be made available to patients.

Dr Laurence Buckman, chair of the British Medical
Association’s (BMA) GPs’ Committee, says consortia will have
to make hard, cost-conscious decisions, which could mean
certain services or drugs will be available in one area and
not another. Critics have suggested that this could result in a
postcode lottery of care.

As practice boundaries are dissolved, Dr Buckman fea
rs
that patients may resort to a form of “health tourism”, where
they move from one area to another to get the medication or
treatment that one consortium approves and not another.
He is particularly uncomfortable with the notion that
consortia may have to make decisions about the availability
of drugs. At the moment he says there is not a great deal of
clarity about what value-based pricing will mean, but he is
adamant that GPs and consortia should not have to make
decisions about rationing drugs. He argues that the National
Commissioning Board should be given this role, although
such a proposal is not currently on the agenda.

As consortia take responsibility for rationing care,
Dr Buckman also wonders how long it will be before a
patient seeks a judicial review over a decision or sues a
commissioning group.

“GPs have always rationed care – through their prescribing
or referral decisions – but this kind of explicit rationing
hasn’t been as blunt as this before, and a lot of GPs are
understandably nervous,” he says. “They feel it could affect
the doctor-patient relationship at the most emotive margins.
For example, when a GP has to stare a patient in the face and
say, ‘you can’t have the drug you believe will stop you dying.’”

Negative press fears
Dr Clare Gerada, Chair of the Royal College of GPs
(RCGP), is particularly concerned that both media and
personal pressure from patients, currently directed towards
national organisations when cuts are made, could be
transferred to individual GPs who will not have the resources
to cope with it.

“The nightmare scenario could be the press camping
outside the GP’s surgery door, photographing him driving
away in his BMW because a patient has been unable to obtain
a drug that will give them an extra three months of life,”
she warns.

She worries that decisions about the drugs that are
prescribed in primary care could pale into insignificance
when consortia have to make choices about funding
expensive treatment in secondary care, such as for
immunosuppressant drugs that cost tens of thousands of
pounds. “It’s not just about whether GPs should prescribe
Benylin,” she says.

Consortia could end up caught between a rock and a
hard place, having to choose between funding a neonatal
cot versus an end-of-life palliative care service or a high-cost
psychotropic drug. “I will be clearly saying from the RCGP
that we are extremely anxious about GPs, and by implication
consortia, being put into the position of making these
decisions. I’m not sure this aspect of commissioning has been
entirely thought through,” says Dr Gerada.

Community and stakeholder engagement
But Dr Shane Gordon, co-lead of the GP Commissioning
Federation for the NHS Alliance, believes that doctors more
closely connected with their local communities will make
fairer and more logical decisions about which services should
or should not be provided.

In the next three years, the NHS will be required to
increase productivity by 20%. This will mean making more
efficient use of resources. “If we are able to treat more people
for the same amount of money because we are doing things
more efficiently then that isn’t rationing – that’s a very
sensible use of resources,” he argues.

It means consortia will have to take a closer look at whether certain procedures, which are of borderline value, should be
provided and other treatments should be restricted to only the people who would really benefit from them.

There are also likely to be even tougher decisions to be made about where an entire service should be provided, which could lead to changes at the local hospital, with mergers of services or closure of an A&E department.

“The real challenge will come if consortia have to make those changes in the face of public opposition. The trick will be to do it without blame. The only way I see that GPs can ensure they don’t end up as the bad guys is by engaging with local stakeholders such as hospital doctors, the public and politicians, who must be included in the decision-making process. To date, that’s not what many primary care trusts or strategic health authorities have been hugely successful at. It’s going to be the trickiest bit of the job, I suspect,” says Dr Gordon.

This argument is music to the ears of Dr Patricia Wilkie, President of the National Association for Patient Participation, who is lobbying for lay people to be involved in commissioning consortia. “GPs as a group are less likely to be blamed for rationing services if lay people are able to challenge decisions and ask questions,” she says. “They will also play a vital role in feeding information back to the public, who don’t know what things cost, about which treatments are to be purchased in their area and why.”

‘Equitable and transparent’
Dr Charles Alessi, executive member of the National
Association of Primary Care, and a GP at the Churchill
Medical Centre, Kingston-Upon Thames, says consortia will
not be alone in making these tough decisions, and checks
and balances will be made.

The actions of consortia will be performance-managed by
the National Commissioning Board. More critically, consortia
will be held to account and influenced by Health and
Wellbeing Boards – locally based organisations with public
health and local authority input. For example, if data show
there are a number of patients with rheumatoid arthritis in a
consortium’s local population, but there is a mismatch with
the amount of anti-TNF drugs being prescribed, questions
will be asked.

“I think the system will be more equitable and more
transparent,” says Dr Alessi. “It will not be perfect because I
don’t think we have a perfect way to manage anything. I hope
there will be more transparency and more process. Currently,
rationing is hidden and in future it is going to become more
explicit. There will be substantially more publicly available
information – not only about activity but also about outcomes
of treatments – than there is at the moment.”

The key emphasis of the white paper, says Dr Alessi, is that
commissioning will be about localism –– local communities
making decisions collegiately for their populations within
a framework that is evidence-based and within some broad
parameters.

“We already have a situation where drugs are available
in one hospital if a consultant thinks it’s a good idea to
prescribe them, but not in another because the PCT refuses
to fund them,” he says. “So I don’t think we will have anything
that is worse than what we have at present. My aspiration is to
ensure that the new system will be very much better.”

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