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Rationing decisions

Rationing decisions

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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 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.
'A lot of GPs are understandably nervous and feel this could affect the doctor-patient relationship at the most emotive margins'
As practice boundaries are dissolved, Dr Buckman fears 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.'"
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.
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 per cent. 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."
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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