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Is it a GP's job to ration treatment?

The Tories are right to believe GPs are ideally placed to assess local needs and they would be trusted by the public to make rationing decisions, says Dr Paul Charlson. But Dr Caroline Chill argues that asking GPs to ration treatments would damage the doctor-patient relationship and leave practices vulnerable to legal challenge

The Tories are right to believe GPs are ideally placed to assess local needs and they would be trusted by the public to make rationing decisions, says Dr Paul Charlson. But Dr Caroline Chill argues that asking GPs to ration treatments would damage the doctor-patient relationship and leave practices vulnerable to legal challenge

The NHS faces hard times, with its growth in spending set to slow to a halt within two years. Firm commissioning decisions - a polite term for rationing - will become increasingly important as the recession bites over the next few years.

There are at least three tiers of rationing: national schemes, local schemes and individual discretion. Doctors are ambivalent about rationing treatments by assessment of research evidence. Do we prefer to be given the freedom to make decisions with broad leeway or to work to explicit rules laid down by health managers? Nobody really wants to get their hands dirty, but someone has to.

Politicians can play their part by ensuring that national rationing is explicit. Core NHS services must become clearly defined and resourced. But beyond this, resources should be allocated for commissioning decisions based on the needs of the local population.

Conservative shadow health secretary Andrew Lansley believes GPs are the best people to make decisions on rationing of treatments. For this to happen, GPs must step up to the plate and become active in making commissioning decisions at a local level. There are several reasons for this.

First, GPs are trusted individuals. The public would rather hear that a group of experienced GPs had made a rationing decision than that a group of managers had.

Second, GPs are more likely to adhere to decisions if they feel they have had a part in the process. Third, GPs are uniquely placed to know what is needed, particularly if aided by accurate information - although this is often lacking at present.

Last, GPs say clinical freedoms are being eroded and this is of course true. But by becoming actively involved in decision-making at a local level they can at least do something about that.

With practice-based commissioning, PCTs hold the purse strings and GPs do not have real budgets or the ability to reinvest savings. Under a Conservative government this would change. It would be like 'super fundholding', with groups of GPs making commissioning (or rationing) decisions on behalf of patients in areas such as the prescribing budget.

There are pitfalls, but at least it recognises that GPs are best placed to understand local health needs and co-ordinate care of chronic conditions.

Super fundholding

Under such a scheme, a major issue for commissioning groups would be how to manage outlying practices that were not using budgets as effectively as others. And with limited resources, rationing decisions would have to be made and adhered to, which would be uncomfortable when faced with a patient who was going to be denied treatment.

But in reality every doctor makes decisions about patients' treatments that take into account a variety of factors, including the cost of treatment compared with the perceived benefit. This causes a certain amount of unresolved tension but is fine provided doctors act in the patients' best interests.

The opportunity to ration treatment at individual level should be managed carefully as the risk for GPs is that they will lose patients' trust if they are found to be making decisions based on cost.

To make local decisions effectively, GPs will need greatly enhanced information on the effectiveness and cost of treatments. This is an immense undertaking and needs to be introduced slowly. Those GPs taking part need to be properly trained and supported to allow them time to perform these important tasks effectively.

If we have a Conservative government in 2010, it will be up to GPs to take up the gauntlet and be proactive in their commissioning. They may at last find they can make a difference for the benefit of their patients.

Dr Paul Charlson is a GP in Brough, East Yorkshire, and chair of the Conservative Medical Society

On Tuesday 27 January, shadow health secretary Andrew Lansley spoke to an audience of doctors at BMA House and outlined how the Conservative party would manage the NHS if it were elected. This included strengthening of practice-based commissioning and the belief that GPs are the best-placed people to ration treatments.

I welcome the Conservatives' confidence in GPs' ability to commission excellent services for patients, but I think making us responsible for rationing would be a great mistake. It would damage the value of GPs to their patients and the health service as a whole, by undermining the trust patients place in us. GPs are often both providers and commissioners of services.

Rationing, as opposed to gatekeeping, would create perverse incentives and leave us caught between satisfying the wants of the practice population and meeting the needs of society as a whole.

I see my GP role primarily as a family doctor providing good medical care to my patients and acting as their advocate while making cost-effective use of resources.

I balance the needs of individuals with the needs of my local population. I try to reduce health inequalities. My patients trust me to do my best for them and to offer them good, safe and unbiased advice about the most appropriate treatment.

When I regretfully tell Mrs Pudgy that the NHS will not fund the liposuction she wants and offer to refer her to the local 'flabby thigh' diet and exercise classes, she isn't happy but she does understand. She also knows she won't get NHS liposuction from any other GP practice.

If she thought it was within my power to give her what she wanted but I chose not to, the doctor-patient relationship could be irreparably damaged. How can I deliver effective terminal care to her dying father if I am the one who made the decision to deny him life-extending new drugs? How can I support the family in their bereavement when they feel I bear some responsibility for his early death?

GPs are great at providing and managing services and are well-placed to commission too. When given the resources, we are good at managing our budgets and delivering improved outcomes. We even have a stab at managing demand, but overall we want to do the best we can for our patients.

Choice agenda

We have delivered on the choice agenda. A Conservative government would ask us to decide not only how that choice should be limited but also which treatments to deny. GPs will be reluctant to ration in the increasingly market-driven NHS as patients will choose those GPs who ration less.

Rationing is difficult. It should be evidence-based and publicly supported and is one of the reasons NICE was formed. NICE has the remit, knowledge and resources to weigh the evidence for the cost-effectiveness of treatment and is in a position to look at the needs of the whole population. Despite this, its decisions have been successfully challenged.

If GPs had to make such decisions at a local level, they would be much less robust and more open to challenge and litigation. Postcode lotteries would be exacerbated. Health inequalities would increase as more affluent and educated patients demanded more at the expense of the vulnerable.

So if I am not prepared to ration, who should? We should start a public debate and allow the electorate a say. Rationing decisions should be open and explicit. Being the final arbiters of rationing is not compatible with maintaining a healthy doctor-patient relationship. We should recommend, advise and treat, which is what we are trained to do. Politicians should listen to that advice and take responsibility for the final decisions, which is what they are elected to do.

Dr Caroline Chill is a GP in Merton, south-west London, who attended the BMA event

No Yes Is it a GP's job to ration treatment?

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