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Flashcards in Session 8 - Resource allocation Deck (36):

Give two factors which outline the inevitability of rationing



How does demography change increase healthcare costs?

Ageing population, old people cost more


How does technology changing increase cost of healthcare

New technologies expensive, expand pool of candidates. Don't cure but offer increased survival.


What are the 5ds of rationing in the NHS

o Deterrent
 Demands for healthcare are obstructed (e.g. prescriptions)
o Delay
 Waiting lists
o Deflection
 GP’s deflect demand from secondary care (gatekeepers)
o Dilution
 Fewer tests, cheaper drugs
o Denial
 Range of services denied to patients (e.g. reversal of sterilisation)


What is explicit rationing?

Explicit health care rationing or priority-setting is the use of institutional procedures for the systematic allocation of resources within health care systems


Who maekes explicit rationing decisions?

Clinical Commisioning Groups


What is explicit rationing based on?

Defined rules of entitlement


Give four advantages of explicit rationing

- Transparent, accountable
- Opportunity for debate
- Use of evidence based practice
- More opportunities for equity in decision- making


Give five disadvantages of explicit rationing

Very complex
Heterogeneity of patients and illness
Patient and professional hostility
Threat to clinical freedom
Evidence of patient distress


What is implicit rationing?

Implicit rationing is the allocation of resources through individual clinical decisions without criteria for those decisions being explicit


What are two disadvantages of implicit rationing?

 Open to abuse
 Decisions made on perceptions of “social deservingness”


Give five levels or rationing

1. How much allocation to NHS compared to other government priorities
o E.g. education, defence
2. How much to allocate across sectors
o E.g. mental health, cancer
3. How much to allocate to specific interventions within sectors
o E.g. end of life drugs versus drugs with curative intent
4. How to allocate interventions between different patients in the same group
o E.g. which patients with advanced cancer should be treated?
5. How much to invest in each patient once an intervention has been initiated
o E.g. how long should cholesterol be lowered in treated patients?


Why was the national insitute for health and care excellence set up?

Set up to ‘enable evidence of clinical and cost effectiveness to be integrated to inform a national judgement on the value of a treatment(s) relative to alternative uses of resources’.


What does NICE do?

o NICE provides guidance on whether treatments (new or existing) can be recommended for use in the NHS in England and Wales.


How does NICE appraise drugs?

 Clinical benefit
 Costs


Give a negative result of NICE disapproving a treatment?

Patient denied access to them


Give a negative result of NICE approving treatment

NHS organisations must fund treatments, with adverse consequences


What is a tariff?

o Payment by Results
o When a hospital treats a patients, diagnosis and treatment are recorded
 Information decides which HRG the patient is assigned to and therefore which tariff is paid
 E.g. caesarean birth has a higher tariff than normal birth


What do tariffs do?

 Incentive to become more efficient over time
 If avoidable complications occur, trusts may lose money
 ‘Never-Event’ – no payment for in-hospital maternal death from haemorrhage after elective caesarean section


What is scarcity of resource?

Need outstrips resources. Prioritisation is inevitable.


What is efficiency of resource?

 Getting the most out of limited resources.


What is equity of resourceS?

 The extent to which distribution of resources is fair.


What is effectiveness of reources?

 The extent to which an intervention produces desired outcomes.


What is utility of resoucres?

 The value an individual places on a health state.


What is an opportunity cost?

 Once you have used a resource in one way, you no longer have it to use in another way.


Give four different methods of comparing cost benefit

Cost minimisation analysis
Cost effectiverness analysis
Cost benefit analysis
Cost utility analysis


What is cost minimisation analyiss?

 Outcomes assumed to be equivalent, e.g. all hip prostheses improve mobility equally, so choose the cheapest one.
 Not often relevant as outcomes are rarely equivalent


What is cost effectiveness analysis?

 Used to compare drugs or interventions which have a common health outcome
 E.g. blood pressure in terms of cost per reduction of 5mm/Hg
 Is extra benefit worth extra cost?


What is cost benefit analysis?

3. Cost benefit analysis
 All inputs and outputs valued in monetary terms
 “How much would you pay to have your hip replaced?


What is cost utility analysis?

 Quality of health comes produced or foregone


What is a QALY?

Quality adjusted life year
o Uses a single index incorporating quality and quantity of life
o 1 perfect year of health = 1 QUALY
o Assumes that 1 year in perfect health is equal to 10 years with a quality of life of 10% of perfect health.


How is QALY measured?

Using a generic HR QoL instrument - EQ-5D


How does NICE assess cost-effectiveness?

By integrating Qualy score with price of treatment using incremental cost effectiveness ratio


How are cost per QUALY figures used?

o < £20k per QUALY technology normally approved
o £20k - £30k judgements take account of
 Degree of uncertainty
 If change in HRQoL is adequately captured in the QUALY
 Innovation that adds demonstrable and distinctive benefits not captured in the QUALY
o > £30k per QUALY technology needs an ‘increasingly stronger case’


Give four criticisms of QUALYs

o Do not distribute resources according to need, but according to the benefits gained per unit of cost
o Technical problems with their calculations
o QUALYs may not embrace all dimensions of benefit; values expressed by experimental subjects may not be representative of the population
o Controversy about the values they embody


Why was the national insitute for health and care excellence set up?

Set up to ‘enable evidence of clinical and cost effectiveness to be integrated to inform a national judgement on the value of a treatment(s) relative to alternative uses of resources’.