Less is more? Examining attempts to tackle overuse in health care

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the University of Birmingham

“These are clearly welcome developments, especially as they promise to alleviate a long-standing system imbalance between investment in the new, on the one hand, and disinvestment in the old, on the other. However, if such initiatives are judged by the extent to which they bring about actual changes to practice then so far it has to be said that progress has been slow. To say the very least, ‘do not do’ lists of this kind are insufficient in and of themselves as a means of bringing about change”

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The Academy of Medical Royal Colleges has recently drawn up a list of some 40 health care practices that it considers could be discontinued without significant harm to patients. These include, for example, various medicines for those nearing end of life, a host of unnecessary scans and x-rays, inappropriate use of practices such as blood transfusion, and so on. As well as reducing harm and improving patient experience, the Academy argues that tackling these over-uses of health care could save up to £2billion a year in unnecessary expenditure.

This is not the first initiative of its kind, and the ‘Choosing Wisely’ campaign, which originated in the US, has attracted worldwide attention as a means of tackling waste and over-medication in health care. The NHS Right Care programme is promoting similar activities closer to home.

These are clearly welcome developments, especially as they promise to alleviate a long-standing system imbalance between investment in the new, on the one hand, and disinvestment in the old, on the other. However, if such initiatives are judged by the extent to which they bring about actual changes to practice then so far it has to be said that progress has been slow. To say the very least, ‘do not do’ lists of this kind are insufficient in and of themselves as a means of bringing about change.

There are multiple possible reasons for this, and these are all in some way related to the resistance generated by any attempt to remove or replace health care. For example, the concept of ‘loss aversion’ can help to explain why patients often attach greater importance to avoiding losses than they do to gaining benefits - for example, by switching to superior treatments. Somewhat ironically, stakeholders such as specialist professional societies have been found to support established practices where evidence appears to indicate withdrawal or replacement.

Recent research at the Health Services Management Centre, University of Birmingham, analyses what happens when attempts are made to remove or replace health care, including in more ambitious programmes of service and organisational change. Early findings suggest that no blue-print exists and that outcomes, especially of more ambitious programmes, are hard to predict.  However, it is clear that guidelines and lists do not negate the need for a thorough understanding of context in terms of systems and relationships. What’s more there is a pervasive suspicion among patients and services users that proposed changes are informed by the need to cut costs and, in the context of a hugely cash-strapped NHS, this suspicion is not entirely unfounded.

As a recent conference hosted by the University of Birmingham amply demonstrated, the challenges of setting limits on health care is something of a ‘wicked issue’, requiring insights from across disciplines such as medicine, economics, sociology and others. Whether we are seeking to encourage professionals and patients to examine their own assumptions and expectations, or to enable a genuinely open dialogue with citizens about health care rationing, we can expect to encounter highly entrenched beliefs and behaviours. Lists will be just one of the tools required to help us along the way.

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