NHS will soon have to specify what care is and what isn’t freely available, GPs say

The NHS needs to think carefully about what will and what won’t be funded as budgets contract, the Nuffield Trust concludes in a new report. It rules out producing a national list of treatments and procedures as too challenging a task and one that, even if successful, would inhibit local autonomy and be vulnerable to political lobbying.

But if a national list of NHS treatments is ruled out, how can an undefined offering be managed? Most (85%) of the GPs in England who responded to a survey carried out for the Nuffield Trust to coincide with the report agreed that the financial challenge will eventually force the NHS to set out more clearly what care is, or is not, freely available. Only half believe that the NHS will be able to achieve enough efficiency savings in the next five years to avoid having to cut back on services. A representative sample of 821 GPs in England was surveyed.

The Nuffield Trust’s answer to the problem relies heavily on evidence, financial incentives, and “nudging.” It calls for a set of principles to be established and enshrined in the NHS Constitution that would underpin decisions about resources and services. The NHS Commissioning Board and the National Institute for Health and Clinical Excellence (NICE) should together establish a set of care standards and also a list of treatments on which money should not be spent. These standards should then be reflected in the NHS tariff, ensuring that hospitals and other providers would be paid in a way that upholds an NHS services package that is affordable, clinically effective, and cost effective.

Any services funded outside this set would have to be reported publicly, and clinical commissioning groups would be obliged to make their decision making transparent—two steps that would “nudge” commissioners and providers towards what would become a de facto NHS package. Patients should also be nudged through information to make the “right” decisions.

The report’s careful tiptoe through the problems of NHS rationing was done in advance of a debate on the subject held at the Royal College of Surgeons on 23 February. Although participants were not told of the report’s conclusions, the debate reflected exactly the same struggle between the desire for greater certainty and the realities of political life.

Julian Le Grand, professor of social policy at the London School of Economics, said that there were four ways of deciding what not to fund: “The first two are bad, and the other two are bad.”

The first was to cut out trivial treatments, but this was difficult. As a non-executive member of the board of what is now North Bristol NHS Trust he had to help decide whether to eliminate breast reduction surgery. He would have said that this was a trivial operation until the board was shown slides of the degree of deformity and heard stories of the jeers and abuse that women (and men) endured. “So it wasn’t trivial. What is trivial to an outsider may be a hole in the quality of life to others.”

The second approach was to exclude patients who had brought their afflictions upon themselves: would be suicides, for example, who had destroyed their livers with a paracetamol overdose. “But there you get into difficult questions. Should you include cyclists, skiers, those who abuse drink?”

The third approach, to compare the relative effectiveness of treatments as a rationing tool, was harder to argue against, but effectiveness is not always easy to define. The fourth, cost effectiveness, was better, and NICE was already there to help. Treatments could be rationed simply by dropping NICE’s value for money threshold from £30 000 (€35 000; $48 000) per quality adjusted life year (QALY) to £20 000.

“So maybe that’s what we should be doing,” he said. “But it would cause huge political difficulties. I think we just basically have to muddle through.”

Others agreed that giving a stronger mandate to NICE made sense but also emphasised the need to carry the public along. Clare Gerada, chairwoman of the Royal College of General Practitioners, said that only politicians could ration. “Doctors can help, but politicians make the big decisions,” she said. The Guardian columnist Polly Toynbee said that explicit rationing would require an enormous amount of public consultation and would then only nibble round the edges. Whenever a hard case emerged there would be problems. She believed, however, that more power to NICE would be a start.

Judith Smith, head of policy at the Nuffield Trust, warned that constrained budgets and greater local decision making could lead to more variation of care. “The current system for deciding what is in and out of the NHS ‘offer’ is far from ideal,” she said.

“That’s why,” she added, “the NHS Commissioning Board should work closely with clinical commissioning groups to ensure they are not deviating from national guidelines about what to fund and what not to fund, unless there are good reasons for doing so, and that any decisions made locally are subject to proper public scrutiny.”