There are major problems in attempting to ration drug use in the UK. These include the large indigenous pharmaceutical industry, the nature of funding of drugs within the NHS and the political sensitivities of rationing. Rationing of services within the NHS has therefore usually been implicit rather than explicit.

In relation to drug therapy, prescribing in primary care technically can only be rationed by encouraging the general practitioner (GP) to contain his or her own costs, effectively moving the difficult decisions to the GP. Direct incentives to GPs, in the form of incentive payments or by fundholding had some limited success in containing costs, largely by simple generic substitution.

Hospitals commonly try to transfer drug costs to the GP budget. While in part this is clinically appropriate, it can lead to tensions. The development of Local Health Groups, (Primary Care Groups in England) is likely to move responsibility for the rationing of services to these groups.

A proposal to introduce a national limited formulary in which drugs will be selected partly on the basis of an economic evaluation seems impractical, although similar ideas might be further developed.

The BMJ in February had an important message about waiting lists and priorities for different categories of patient on the lists. Doctors have long worried that the British government’s emphasis on the number of people on waiting lists, and the time they spend there, obscures the need to treat patients according to clinical urgency.

This concern has been voiced most recently in a report from the BMA, which warns that additional funds earmarked for reducing NHS waiting lists and waiting times will provide an incentive for operating on a large number of minor cases, leaving more urgent cases and potentially cost effective treatments to wait.

The BMA paper argues in favour of priority scoring systems, such as those developed for elective health care in New Zealand, Canada and Sweden. The success of such systems seems, however, to be mixed.

In the United Kingdom pilot experiments at Guy’s Hospital ranked the top 22 conditions on a general surgical waiting list according to their expected net quality adjusted life year (QALY) gain per unit of bed and theatre resource.

In Salisbury and Carmarthen patients were initially ranked according to points awarded based on the following criteria: rate of progress of disease, pain or distress, disability or dependence on others, loss of occupation, and time already waited.

Both approaches led to clustering of conditions, which posed difficulties for preparing balanced theatre lists. This problem has been overcome at Carmarthen through the introduction of a patient initial quotient to determine whether a patient should be placed on a waiting list, and an algorithm to reflect time waited, which has led to a more balanced case mix on prioritised waiting lists.

Back to top

Few randomised-controlled trials have looked at the value of clinical nurse specialists. One trial investigated the role of the specialist nurse for patients with stroke in the community and showed a small improvement in social activities for mildly disabled patients. A trial of the effects of a specialist nurse for terminally ill patients showed little difference in patient or family outcomes.

Evidence of nurse led interventions in heart failure is more positive. Nurses’ involvement in pre-discharge patient education and home visiting, has shown significant reductions in readmission rates and quality of life. Another nurse specialism with positive outcomes is anticoagulation management.

On current evidence it seems that specialist nurses are not likely to have a positive impact on outcomes if their role is essentially co-ordination of existing services, especially if such services are themselves of variable quality.