How clinical rationing works in practice: A case study of morbid obesity surgery

doi:10.1016/j.socscimed.2015.11.008

Social Science & Medicine

Volume 147, December 2015, Pages 288-295

https://doi.org/10.1016/j.socscimed.2015.11.008 Get rights and content

Highlights

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Clinicians use a range of rationing strategies to control access to UK healthcare.
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Outright denial of treatment was avoided wherever possible.
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Rationing by selection was most common, but most patients also had to wait for care.
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Patients were usually aware of rationing but this was rarely discussed by doctors.
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Existing rationing frameworks deal poorly with consultation level decision-making.

Abstract

Difficulties in setting healthcare priorities are encountered throughout the world. There is no agreement on the most appropriate principles or methods for healthcare rationing although there is some consensus that it should be undertaken as systematically and accountably as possible. Although some steps towards achieving accountability have been made at the macro and meso level, at the consultation level rationing remains implicit and poorly understood. Using morbid obesity surgery as a case study, we observed a series of UK National Health Service consultations where rationing was ongoing and conducted in-depth interviews with doctors and patients (2011–2014). A longitudinal approach was taken to research and in total 22 consultations were observed and 78 interviews were undertaken. Sampling was undertaken purposively and theoretically and analyses were undertaken thematically. Clinicians needed to prioritise 55 patients from 450 eligible referrals, but disagreed over the extent to which clinical and financial factors were the driving force behind decision-making. The most prominent rationing technique observed in consultations was rationing by selection, but examples of rationing by delay, by deterrence, and by deflection were also commonplace. Although all clinicians sought to avoid rationing by denial, only six of the 22 patients recruited to the research were known to have been treated at the end of the three-year period. Most clinicians sought to manage rationing implicitly, and only one explained the link between decision-making criteria and financial constraints on care availability. Although existing frameworks for categorising NHS rationing techniques were useful in identifying implicit strategies, in practice these techniques over-lapped substantially and we have proposed a simpler framework for analysing NHS rationing decisions at the consultation level, which includes just three categories – rationing by exclusion, rationing by deterrence, and rationing by delay.

Section snippets

Background

Difficulties in setting priorities for healthcare are encountered in countries of all income-levels (Sabik and Lie, 2008). In the context of ageing populations, a massive growth in chronic disease and constant improvements in healthcare technologies, the growing demand for healthcare stands in stark contrast to the finite funds available in an ongoing era of austerity. In the UK, healthcare is largely delivered through the monolithic, highly centralised National Health Service (NHS), of which

Methods

This research adopted a qualitative methodology, which is acknowledged to be especially powerful where the phenomenon of interest is an ongoing process, particularly where this occurs with in the context of ongoing social interaction (Kvale, 1996). We combined observations of clinical consultations where rationing issues were likely to be discussed with interviews with individual clinicians and patients so that both naturally occurring and more interpretive data could be accessed. Ethical

Results

11 professionals and 22 patients were recruited, and in total 78 interviews were undertaken and 22 consultations were recorded. Of the 11 professionals, seven were consultant endocrinologists, one was a consultant surgeon, and three were allied health professionals (supplementary information, Table 1 (INSERT LINK TO ONLINE FILE)). Aside from the surgeon, all worked within the Tier 3 weight management service. 17 patients were female and were aged between 21 and 63 (supplementary information,

Discussion

Clinicians in this study were faced with a prioritisation dilemma whereby there were only resources available to treat with weight reduction surgery approximately one in nine of patients seen in clinic. Although some clinicians argued that not all of these patients were suitable for surgery, all met the NICE guidelines for treatment and most had been referred by their GPs with an expectation that surgery was a potential treatment option. The majority of clinicians attempted to manage this

Acknowledgements

The study was supported by the National Institute for Health Research which provided funding for AOS's postdoctoral fellowship (PDF-2010-03-42). JLD was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol NHS Foundation Trust and an NIHR Senior Investigator award.

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A comparison of Extract 3 (in Figs. 3 and 7) with Extract 5 (in Figs. 5 and 9) illustrates that doctors are at least partially choosing among closing and opening the gate depending on whether patients have maintained their own responsibility as appropriate users of the healthcare system. Similar orientations to the patient's responsibility have been reported in rationing in emergency departments (Hillman 2014; Vassy 2001), and an obesity surgery clinic (Owen-Smith et al. 2015, 2017). Arguably, by tacitly sanctioning their patients' illness behavior through their reactions to resistance, DGM doctors contribute to the maintenance of the official institutional framework of the “free access” system.
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'There is no such thing as getting sick justly or unjustly' - A qualitative study of clinicians' beliefs on the relevance of personal responsibility as a basis for health prioritisation
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View full text

How clinical rationing works in practice: A case study of morbid obesity surgery

Highlights

Abstract

Section snippets

Background

Methods

Results

Discussion

Acknowledgements

Soc. Sci. & Med.

Soc. Sci. & Med.

The Painful Prescription

Saying no is no easy matter a qualitative study of competing concerns in rationing decisions in general practice

BMC Health Serv. Res.

Core services: pluralistic bargaining in New Zealand

Citizens, their agents and health care rationing: an exploratory study using qualitative methods

Health Econ.

Surgery for morbid obesity

Cochrane Database Syst. Rev.

Accountability for reasonableness: an update

Br. Med. J.

Moving forward on rationing: an economic view

Br. Med. J.

Rationing within the NHS should be explicit. The case for

Br. Med. J.

The Discovery of Grounded Theory: Strategies for Qualitative Research

International experiences with priority setting in healthcare

Med. Health Care Philos.

Reasonable Rationing: International Experiences of Priority-setting in Health Care

Physicians' responses to resource constraints

Archives Intern. Med.

Bedside rationing by health practitioners: a case study in a Ugandan hospital

Med. Decis. Mak.