I seem to remember in the early days that health economists made a
useful distinction between Evidence Based Medicine/interventions which
in fact increase pressure on limited resources and Cost-effective
Medicine /interventionswhich enabled us to rationalise rationing of
care and interventions which would improve health, but not enough or
for long enough to make it "worth doing".
From an honest professional perspective should those of us working at
the coalface not be talking honestly about "cost effectiveness" and
“rationing”, when we are restricting the use and availability of
interventions that deliver improvements in health; and “efficiency”
when were are improving the effectiveness or cost of interventions or
introducing better and/or cheaper interventions which
maintain/increase the number of positive outcomes.
Mike Hughes
On Tue, Aug 2, 2011 at 1:44 PM, Mike Simpkin <[log in to unmask]> wrote:
> Ash writes that "At no point has the clinician explained to the patient that
> 'it is no use operating on your early cataract now, because the healthgain
> is very minimal/marginal, so let's wait a little while longer until your
> cataract progresses to blah blah blah'."
>
> Perhaps someone could explain to a non-economist the extent to which health
> gain is a clinical or an economic concept. I remember that in the later days
> of the last Tory government's "Health of the Nation" health gain was used to
> rationalise expenditure reductions including broader issues of public health
> and health inequality where interventions were regarded as insufficiently
> evidenced.
>
> I know this is just a rapid email debate with dialogue not necessarily to be
> taken literally but what does "it's no use" mean? - that the operation won't
> work? that the risks of the operation outweigh the potential benefits? that
> early cataract removal may increase the chance of repetition? that although
> the patient is experiencing sufficient difficulties with their sight to have
> sought referral, that they won't notice sufficient improvement? If money
> were no object (e.g. chez Liz Jones) are there clinical or ethical reasons
> why the patient should not have a cataract removal earlier rather than
> later? or is it really (and genuinely) the case that for the collective
> good, resources need to be concentrated on those whose sight has reached a
> certain level of deterioration?
>
> Where does patient choice fit in? If choice is always seen at an level of
> an individual case, then the patient is often in difficulties - last year my
> partner was referred for knee stuff and possible arthroscopy (another
> procedure in the news) through a PCT contract with a non NHS provider. The
> consultant investigated carefully and said that he could not guarantee that
> the procedure would produce an improvement, but it might - there was also a
> small risk of degradation. He left the choice to her. Probably a poor health
> gain scenario. Should the choice have been made available? What difference
> would charging have made? Was the consultant gaming? Should the patient
> take an offer now, because rationing might make it unavailable later?
> Presumably these are all questions that are health economy's bread and
> butter.
>
> What about collective choice? To have the PCT always painted as the baddy
> as in Ash's scenario means that there has been insufficient public
> engagement in this type of decision making - hardly surprising these days
> because PCT engagement and involvement staff have been among the first to
> go. But people do understand about priorities - they are prepared to wait
> where there is a rational and comprehensible justification (pure cost is not
> usually good enough) though not when they suspect queue jumping, other sorts
> of inequity or sheer inefficiency. We don't necessarily have to go as far
> as the old Oregon route to facilitate better understanding of the issues at
> stake.
>
> Rationalisations and reconfigurations have always been difficult to
> disentangle, with a perpetual suspicion that the loss of a facility (whether
> always valued or only when it is threatened) is a loss to the service as a
> whole. One of the iniquities of Lansley's combination of HSC Bill and
> "efficiency savings" plus cuts (as Rudolf Klein pointed out on this list a
> week or so ago) is that the ability to debate these issues properly at local
> level has been severely damaged, making it even more difficult to
> distinguish between service improvements and financial shenanigans to secure
> a 'balanced budget'. Reductions in commissioning are covered up "to reduce
> patient anxiety". It's not surprising that people think they smell a rat -
> and GP consortia or embryonic clinical commissioning groups need to beware.
>
> Mike Simpkin
|