In this article we consider the social, financial and ethical implications of the question. We examine the stance taken by other countries and healthcare systems and critically analyse them. We examine the arguments in relation to rationing of healthcare resources in the NHS and the factors that influence the decisions of what the public purse can afford and what it can’t.
Introduction - When the NHS was originally conceived, it was defined by the often quoted phrase that it should be free at the point of delivery to all the patients. A wonderful and revolutionary concept which, arguably, set the standard for the health delivery systems in many other countries throughout the world. As time has progressed, medicine has evolved and expanded with techniques and capabilities which were beyond the comprehension and original provision of the founding fathers of the service.
With this expansion has come the inevitable rise in public expectation that everything that is needed should be provided at no immediate cost to the recipient. Obviously, a moment’s reflection will show that everything that is provided does have to be paid for from some source, and this then leads the discussion on to the inevitable conflict of balance between provision for the public and the public’s willingness to pay.
This article looks at the specific issues relating to surgical funding. It is not a simple matter by any means as a great many other issues impinge upon it. There is the fundamental issue of absolute cost. Dependent on this are issues of rationing, availability of expertise and whether the fact that just because a particular procedure is technically possible and is available, should it be provided free? Research into new surgical techniques is expensive, but necessary for the public service to expand. Clearly it also needs to be paid for. Should the NHS then pick up the bill for that as well?
Methodology -We hope to be able to come to a rational decision by critically examining and evaluating the literature on the subject.
We can take some guidance and instruction from other countries who have re-structured their health service provision. Hadorn & Holmes (1997) produced several papers which analysed New Zealand’s restructuring in 1992. (Ashton 1993). There are several lessons that we can derive from this work. The significance of this paper in the context of our article, is that, after the restructuring (which had the stated aim of trying to provide greater accountability in the publicly funded health sector) a number of committees were appointed to analyse and report on the progress. One was charged with the task of developing a set of standardised criteria to assess the benefit of certain types of elective surgical procedures. These criteria look at the social and clinical factors which determine the eventual outcome together with the use of priority criteria to ensure fairness.
It is worthy of note that the NZ government allocated £57 million to “set the record straight” by removing surgical waiting lists. In the context of our particular considerations here, the paper looks at:
"kinds, and relative priorities, of public health services, personal health services, and disability services that should, in the committee's opinion, be publicly funded."
(Fraser et al. 1993). This is a very significant concept and it eventually refined the criteria to the following concept:
“It has……. defined eligibility for services in terms of clinical practice guidelines or explicit assessment criteria which depict the circumstances under which patients are likely to derive substantial health benefit from those services, bearing in mind competing claims on resources. Thus, for example, patients could reasonably expect to receive coronary bypass graft surgery at the taxpayer's expense if (and only if) their clinical circumstances were commensurate with a likelihood of substantial benefit from that procedure.”
This is an important point as it involves clinical practice guidelines which have been a progressive feature of the NHS for some years now and it explicitly defines eligibility for public funding as a function of the likelihood of deriving benefit. On the face of it, this may seem perfectly reasonable. It may seem less reasonable, of course, if you were the patient with an aggressively malignant tumour being told that you couldn’t have an operation which might just save or prolong your life, as it was likely that you probably would not derive benefit from it. (Dawes & Corrigan 1974)
The significance of this concept is that, in NZ, not only does your likelihood of deriving benefit determine your eligibility for surgery, but it also determines your priority on the waiting list. Those patients with the greatest likelihood of getting the greatest benefit will get the greatest priority.
This is a fundamentally utilitarian concept with the prime intention of deriving the maximum possible health gain from the most efficient use of available funds. (Tversky & Kahneman. 1996).
With regard to our considerations on funding, the committee also decided to take into consideration age, work status, whether patients were carers for others or threatened with unemployment or loss of independence together with time spent on the waiting list. (National Advisory Committee 1993)
The rest of the paper is taken up with discussing the finer points of these main elements so we will confine our consideration to what has been outlined in principal.
Having considered the precedents that have already been set by other countries, let us now consider the secondary issue that stems from the question “Should the NHS fund surgical procedures?”
If the NHS does not fund them, then presumably the assumption is that the patient will have to fund the operation on a private basis. On that immediate assumption we will consider a paper by Williams & Nicholl (1994). This paper is of relevance to us insofar as it provides us with a number of useful statistics which help to progress the argument further. The significant figures that we can take away from this is that over all of the private hospitals studied, only one in 20 patients was treated under the NHS contract and 90% of all surgical procedures were funded through private health insurance. It is also of significance that the paper observed that the independent sector, by a large, only does surgical procedures that require only minor degrees of technological support, the inference being that the bigger procedures ( and therefore probably more expensive ones), were done primarily in the NHS system. (Directory of independent hospitals and health services 1993.)
To continue the exploration further, the authors comment on the fact that the private hospitals operate significantly below their capacity because the number of people covered by private health insurance has stopped rising. (Laing 1993). The reason for this is clearly a matter of debate, as some may suggest that it is as a result of increasing confidence in the abilities of the NHS to treat surgical problems, others may point to the fact that people do not feel that they have free money to spend on health insurance any more.
The authors also allude to the fact that many NHS consultants feel a greater loyalty to their NHS Trusts which means that they are more likely to see patients within their NHS hospital rather than necessarily in the private hospital.
We have not really considered the issues of just how far can our current society afford the difference between what is possible and what is necessary? Most advocates of the NHS would agree that it should certainly cover the expenses involved in “what is necessary”. The differences become apparent when you start to consider “what is possible”.
On the face of it, most people would probably agree that the typical hip replacement is a matter of fairly uncontroversial agreement and that the NHS should fund it. Equally there would be general discontent with the suggestion that the NHS should fund the non-essential plastic surgery face-lift. This, then begs the question of just where do you draw the line? On the one hand you could have a system where every possible operation was funded. Clearly that would be both politically unacceptable as well as totally unaffordable ( and some would say morally wrong). The other extreme would be to say that no procedure would be funded from NHS funds. That view would also be politically unacceptable and of enormous detriment to the overall health of our nation. (Ryan et al 2005)).
A consensus has therefore to be reached, where the NHS funds those items which are considered medically necessary. It was for this reason that we purposely started this article with the consideration of the New Zealand system, which has essentially come to the same conclusion, but the difference being that they have spelt out in a number of publicly available documents their policy on priority and availability. This approximately equates with the NHS position of today with the obvious exception that the NHS does not have a “written constitution” in quite the same way.
The move towards the new NHS trust structure has placed a different emphasis on the ability, or indeed, need, for each trust to provide the same uniform quality of care across the whole clinical spectrum. Each Trust has the ability to determine and decide exactly how it feels that the money that it has been allocated should best be utilised in serving it’s particular community’s needs. This means that issues that we have already raised such as the provision of face-lifts on the NHS are no longer determined at central level, but at a local trust level. (Cave et al. 1993)
The emergence of bodies such as the National Institute for Clinical Excellence has relevance to our arguments insofar as it produces guidelines of expected practice or targets for each trust to aim for. This also helps the trusts to determine how they should priorities how they spend their money.
As time has progressed, the mood of patient empowerment has pervaded the NHS. (NHS Management Executive 1992). Patient pressure groups, and advisory and consultative committees are now commonly found, whereas even a decade ago, such thing would have been rare. (Secretaries of State for Health, Wales, Northern Ireland, and Scotland. 1989) The mood of public consultation has been addressed in an article by Ryan & Farrar (2000), who have looked at the issue of conjoint analysis.
This is a technique that allows for analysis of the patient’s (or community’s) preferences to be taken into account in the rationing and distribution of NHS funding at a local level. Issues such as local funding of various surgical procedures can therefore be decided at a level that is appropriate for that particular community. (Cleary P. 1999)
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