Rationing

If rationing is to be defined as the setting of priorities and managing of resources, it has no meaningful relevance to policy makers, managers, and clinicians alike. The word has such associated negative and emotive connotations that it should itself be severely rationed.

Some brief background as how I got involved with anti-rationing. When the conservative government introduced their 1991 NHS reforms, I welcomed the policy as the NHS needed and indeed still needs reform. I especially welcomed the introduction of general practice-based budgets, as clinicians if they wish to challenge and reshape care must have at least some accountable budgetary responsibilities. GP Fund Holding was an integral part of the reforms, the policy intent for them to be micro ‘purchasers’ of care to offer a challenge to NHS macro purchasing. For many of us we accepted the policy and all it entailed as we wanted budgetary responsibility, but our predominant driving force as providers was clinical resource management, not contractual purchasing. (The term commissioning subsequently replaced the term purchasing although in my opinion neither have been particularly effective).

It was as a clinical manager I researched information on effective and ineffective care, discovering the Anti Rationing Group based at Cardiff University. Their premise was rationing was the delay or denial to effective or appropriate healthcare. That definition thus included both clinical interventions and how clinical care was organised. Their further premise was any other form of resource management was not rationing. I still subscribe to both definitions informed by my working experience of clinical resource management.

In general practice incentivised by budget holding, encouraged inter partner comparative audit with an exigent concentration on prescribing activity and hospital referral that beneficially informed further educational needs. Access to such as musculo-skeletal physiotherapy further reduced referrals, as did implementing long term conditions case management, with significant service shifts consequent on a detailed focus on multi morbidity and chronic mental illness. The resource benefit of the attendant shortened lengths of inpatient stay enabled by the case manager visiting our patients, and the reduction in hospital admissions, accrued entirely to the hospital. Inpatient activity was out with our budget but at least our patients had reduced incarceration. Working closely with hospital clinical staff led to an improved service offer, not least from lessening duplicated effort. Much of what was achieved at practice level led to me originating the Primary Care Home which in turn led to the introduction of Primary Care Networks. There is good potential for list based primary care to have a major impact. General practice not uniquely, varies greatly in its ambition and Primary Care Networks small enough to be local, yet large enough for be of strategic value offers advancement.

My interest was now whetted beyond general practice and learnt much from USA academics of managed care. David Eddy who for instance in the 1980s found no random controlled for glaucoma treatment over 70 years. Al Mulley and both Wennberg’s majoring on unwarranted clinical variations and clinical decision making. And in the UK, Muir Gray describing outpatient care as a relic of 19th century medicine. Some facts may now have changed since my research on hospital activity, but two thirds of outpatient care was and is spent on patients follow up, much inappropriate. Too often patients were admitted unnecessarily early pre operation, large variation in lengths of inpatient stay with counter intuitively, more variation from planned admissions than urgent admissions. Clinically too many years elapsed before childhood tonsillectomy, adenoidectomy, glue ear treatment and dental fillings were realised as often of little value.

It seems we need to be more circumspect on the definition of rationing as surely it should not encompass ineffective or inappropriate care. Mulley defined warranted variation as only if patient involvement. The benefits of clinical resource management on quality and finances are explicit and provides a link between our rationing discussion and the future discussion on NHS finances. The previous NHS CEO Simon Stevens bequeathed the current NHS architecture to enhance integrated resource management. Will it be utilised? The NHS self-evidently needs more resources, the service part of the deal is to use those resources optimally. An essential culture is for clinicians to accept non adversarial questioning of their work, many are reluctant. Resource management is not only for government and managers.