The papers are full of disturbing reports about patients being denied new drugs through their local NHS, and campaigning organisations calling for universal access to treatments. What many people refer to as the 'post-code lottery'.
But the reality is that primary care trusts (PCTs) have a limited pot of money to provide all the health services for their local community. And people that work in PCTs constantly have to take difficult moral and ethical spending decisions .
The challenges that face primary care trusts are similar to those faced by a typical family or organisation. Only in the NHS, these decisions are even more challenging and pointed because at the end are people's lives. Not just in terms of life or death, but also the ability for people to be able to live in their own homes or improve their health and well-being.
At times it is easy to perceive that the challenges about how best to spend NHS money in a cash-limited environment only affect the UK, because traditionally we have had lower than average spending on health in the this country. In fact, the same moral and ethical debates about how to prioritise the needs of one group of patients against another happen in some of the countries that spend the most on their healthcare systems. In a recent Commonwealth Report comparing developed health services, the NHS came out top for equity.
In the United States, where they have made rationing relatively simple and based it on ability to pay, some states have tried to address the difficulties about where to invest public health money. In Oregon, for example, all the cities in the state got involved in trying to prioritise spending priorities. The problem was that the hidden services, such as those for drugs and alcohol treatment, were given a much lower priority - even though the returns for society in investing in these services can be huge.
The focus of attention on the kind of issues that doctors, nurses and managers in PCTs face every day is heightened when expensive drugs like Herceptin are in the news. And because these drugs are for cancer patients, the debate is even more emotive. But the reality is that PCTs are regularly having to balance spending money on expensive drugs like Herceptin and expensive treatments such as IVF, against others that might not get as much media attention but are still vitally important, like substance misuse or mental health services.
So when the media focuses strongly on drugs like Herceptin, how should a PCT decide how much money to spend on areas like drug abuse? It is known that 'chaotic' drug users are not just destructive for families, but also contribute to 40-50 per cent of crime. Investing resources in drug treatment is not only beneficial to patients, it also benefits the wider community even though this particular client group might not be very 'media friendly'.
There is a similar balancing act when considering the needs of potential IVF patients against the needs of mental health users, in the knowledge that 40 per cent of the population will have a mental health problem at some point in their life and there are very few advocates prepared to stand up and shout for mental health sufferers.
There are no simple answers to these complex, moral and emotional questions. But they are decisions that PCTs make every day. And quite understandably, patient groups will continue to champion the needs of those they represent. All points of view and patient needs are important. But the PCT has to make the judgement of Solomon about how they balance their demands with the needs of the wider community.
The difficulties in prioritising spending decisions are compounded by pressures of rising expectations and an ageing population. PCTs need to work with the public, doctors and nurses and local government to ensure that there is true ownership of the decisions. They must also make sure the range of services they provide are not only effective, but also efficient because every penny wasted is a penny that cannot be spent meeting patients' needs.
There isn't a right answer, but the challenge for the PCT is to deliver the best it can for patients whilst meeting these competing demands. This is why high quality management and detailed data on the communities' needs are so essential, in order to help nurses, doctors and the public to reach decisions about the right way forward.
The NHS Confederation believe that politicians, the public and the NHS urgently need to engage in an honest discussion about the reality of so-called 'post-code prescribing' of health services across the country. This is why the NHS Confederation will be hosting a debate in November to discuss this issue. For more information, see www.nhsconfed.org/confidence
Dr Gill Morgan DBE
Chief Executive
NHS Confederation
Whitehall and Westminster World - 12th September 2006
