The media have been highlighting waste and inefficiency in NHS procurement this week, prompted by a case in Cumbria where the NHS were paying up to four times the original price for specialist food products for coeliacs. At a time when clinical posts are being cut or held vacant, it is right to ask whether there is waste in the system that could be eliminated without a huge impact on patient care.
Could there be a much simpler solution towards making savings? What would happen if patients were fully informed about their care and treatment options? What if patients were asked what care they wanted?
The immediate reaction is that patients would demand more, more, more and bankrupt the NHS. But evidence suggests that, when fully informed about care and treatment, patients often want less intervention. In Patients’ preferences matter professor Al Mulley, our first International Visiting Fellow, and colleagues present evidence in areas as diverse as benign prostate disease, abnormal bleeding from the uterus, coronary heart disease and back pain, where fully informed patients are less likely to choose surgery. Reassuringly, where the evidence was clear that surgery was beneficial, more patients were likely to choose it after having been supported to understand the evidence and weigh up risks and benefits. And yet in the UK, only half of patients say they were always involved in decisions.
Commissioning decisions are currently informed by assessments made by experts of need – at population level by public health specialists and at individual level by doctors. Clinical assumptions are made about the right level of treatment for the level of need in the population. And yet we observe huge variation in the rates of intervention that persist even after adjusting for need. In the absence of absolute markers for what constitutes appropriate levels of population provision for some procedures, some of the variation could reflect over – rather than under – provision of services. When patients are systematically given information and supported to make a decision about their treatment, the population intervention rates have been shown to be dramatically lower than even the bottom end of the distribution.
So what is the ‘right’ rate of intervention? How do we measure and capture information to inform these population level investment decisions in future?
Al Mulley and colleagues argue that the NHS must systematically measure decision quality, that is what patients know about the disease, the treatment options and possible outcomes. We already know that many people who would rather die at home end up in hospital, often subjected to intensive medical intervention in the hope of prolonging life. What if every person had an advance directive following a supported conversation about the quality of life implications of intensive treatment and resuscitation?
Clinical commissioning groups are being given responsibility for the NHS budget. They have a limited set of options to manage with less resources – either pay the providers of care less, ration care explicitly by refusing to pay for certain treatments, manage demand using clinical thresholds or allow waiting times to rise. None of these are very appealing.
There is another option. By making visible the fact that their patients are not fully aware of their choices and haven’t necessarily got the basic knowledge about their condition or the treatment options, clinicians can stop the silent misdiagnosis and create value for the NHS. The NHS needs to stop buying interventions and treatments that patients neither want nor need.
- Read our new paper: Patients’ preferences matter: Stop the silent misdiagnosis