Rationing health care is not and will never be a politically popular concept. And as some Clinical Commissioning Groups have been reported in the media as considering excluding certain treatments from their contracts with hospital providers it may prove unpopular with the public too.

For example, headlines include “CCG’s considering limiting IVF courses to three” and “Department of Health proposing to charge foreign nationals for emergency ambulance and casualty treatment and care.”

Whatever your views on this the fact is that as far back as 2000 the issue of NHS budgets was being seriously discussed particularly with regard to the eradication of overspends. The trouble is that, back then there was rivalry between GP Fund-holders and hospitals with regard to allocated money. GP Fund-holding Initiative practices were expected to agree service contracts with providers for a cash limited sum whilst hospitals regarded the money as ‘theirs’. This meant they spent and spent without any budget controls so whilst some practices ‘saved’ money, others overspent.

It’s a Lottery!

Although arguments about treatments like IVF, cosmetic surgery and treatments on religious grounds were raging in 2000, it’s a fact that little has been done because there has been no overall policy on this within the NHS. The health insurance system in the USA sets out a clear schedule for what treatments are available according to what is paid for. In the UK organisations like Den-Plan and Simply Health tell you what you will be refunded for. But in the NHS there is a wide variation in what treatments are available in different areas of the country. So now, in light of serious overspending in some areas, CCGs are considering what treatment and care options should be funded. So yes – we have a postcode, or more accurately, a CCG lottery!

GPs – the Budgeting Experts

So how can you solve this problem? GP Practices have been controlling their own budgets since 2004 and are generally very successful at it. This is because there is normally only one cheque book and one signatory to payments whereas NHS organisations have many different people who can approve and make payments. Some under-spend and some over-spend and there are many opportunities for waste.

I take the view that GP Practices survive because they are financially well managed and they can take a pat on the back for that. Because they understand the issue of finance, they run their practices and pay themselves, are they not ideally placed to guide CCGs in the control and management of expenditure in NHS contracted services? There may be criticism about how they use their money but almost without exception they manage to stay in the black.

How would YOU set a rationing policy?

Faced with a budget and potential over-spend problem, what criteria would you set for approving treatments and care in the NHS? There is a huge variation in what kind of treatments could be funded and the reasons for them, many of which will be personal to you. The criteria could range between –

• Ability to pay
• Asylum seeker or celebrity special considerations
• Economic migrant immediate treatment (not pre-existing conditions)
• Treatment and on-going community care costs
• Continuing cost of drugs
• Disability, life expectancy, life-extending potential.

There are too many more considerations to list here. Would personal preference influence your decision? What treatments would you exclude from NHS provision – breast implants, sports injuries? The debate is underway!