How fear of rationing hinders efforts to reduce low-value care
By Judith Garber
The National Health Service (NHS), the United Kingdom’s government-run health care provider, is taking much-needed steps to curb the use of unnecessary and harmful services. However, a recent article in The Guardian painting these proposed policies as “rationing” may threaten the NHS’s anti-overuse efforts.
There are many aspects of this piece that are unbalanced and poorly framed, so I want to go through each health care myth one by one.
1. Reducing access to unproven health care services is “rationing.”
Denis Campbell, health policy editor of The Guardian and author of the piece, warns readers that the NHS’s “sweeping” changes would constitute a “major escalation of NHS rationing.” Throughout the piece, Campbell lists tests and procedures that would become more difficult to get under the proposed policy, without citing or mentioning the vast quantities of research showing that these services don’t work.
Here are a few of the tests and treatments that Campbell mourns will not be available to patients:
- Imaging for low-back pain. Low-back pain is one of the most common reasons Americans seek medical treatment, but but there is little doctors can do to help. Acute back pain usually improves on its own over time, and for chronic back pain, exercise and non-drug therapies are recommended over medication or invasive treatments. Having x-rays, CT scans, or MRIs for non-specific low-back pain without indicators of a more serious condition has not been shown to benefit patients, and the incidental findings from these tests can lead to a harmful cascade of treatment. This is why many American medical societies recommend not ordering imaging tests for non-specific low-back pain.
- Hernia repair surgery. For patients with minimally symptomatic inguinal hernias, undergoing a period of “watchful waiting” for two years has shown to be as effective in reducing symptoms, while avoiding the substantial risks of surgery. This is why some medical specialty societies recommend watchful waiting for appropriate patients rather than jumping into surgery.
- Knee arthroscopy. This surgical procedure for osteoarthritis has been shown many times to not improve outcomes more than placebo. The procedure also exposes patients (mostly older patients) to avoidable harm such as infection, nerve damage, chronic pain, and post-surgery opioid use.
- Prostate-specific antigen (PSA) test. As we’ve written many times, certain types of cancer screening expose many more patients to false alarms and overtreatment than saves lives. The PSA test specifically has been criticized by clinicians for having a high false positive rate and subjecting patients to unnecessary treatment that affects their quality of life. This is why the US Preventive Services Task Force recommends not routinely screening men for prostate cancer, but instead having a discussion about the benefits and harms of screening first.
It would have been fairly easy for Campbell to include links to Choosing Wisely and other sources that show the lack of evidence for the tests and procedures he lists in the piece. Instead he frames them as common-sense services, ignoring the fact that they provide little benefit and often lead to harm. Why not get “an xray on [your] sore back?” he writes. Why limit screening for “prostate cancer – the commonest form of cancer in men”? When you disregard the evidence, every health service seems necessary.
2. All tests and treatments that are used regularly must be necessary
Campbell warns multiple times in this piece (even in the headline) that the NHS is cutting “everyday” tests and procedures. He writes that among the procedures being reduced are “some of which have been used routinely for decades.”
However, just because a lot of people receive a health care service does not mean it works. Millions of people take vitamins and supplements with no proven benefit. Over decades, hundreds of millions of dollars were spent on giving stents to patients with stable cardiac disease, despite a lack of evidence that it saves lives or even reduces pain compared to placebo. A BMJ study of thousands of “everyday” medical treatments found evidence of benefit for only 40% of them.
New tests and medical devices are often approved without robust evidence that they work. Worldwide, we are starting to see the considerable patient harm caused by clinicians adopting medical devices with no proof of effectiveness. Using the logic, “We’ve always done this, so we have to keep doing it,” is nonsensical in most cases, but especially in medicine.
3. Reducing low-value care is only about money
Campbell describes the proposed NHS policies purely as a cost-cutting effort, with barely any acknowledgement of the fact that these services have proven ineffective. One source in the piece asserted that decisions about coverage should be be “based on the best available evidence and not cost-cutting.”
The framing of the NHS decision as only financial misses the point, which is that these services are useless and harmful. If the medical community understands that certain health care services have no value, why would the NHS want to keep paying for them? Campbell makes it sound as though the NHS is taking something away from patients, but in reality it will be giving back some of patients’ tax dollars that currently are used to fund ineffective treatments.
To put it a different way: if every day you gave a doctor $100 to bless you with a “magic stone,” wouldn’t you want to stop paying for that once you figured out it was bogus? Not paying for the magic stone isn’t “reducing access” to health care, it’s just common sense.
The NHS is trying to do right by patients by reducing the use of low-value tests and procedures. The media coverage of this effort should not attempt to undermine it by provoking fear of rationing, but instead explain why reducing overuse will benefit patients’ health (and yes, their pocketbooks too).