SURVEY – The third-party payer is bringing more complementary services into the coverage of care. With attractive offers, for some; the upcoming introduction of a bonus-malus system, denounce the others. Faced with the need for financing, the experts recommend defining a “solidarity” health basket. Countries are thinking about radical solutions.
If there is one debate that angers in the United Kingdom, it is that of the modulation of care according to the lifestyle of patients. To cope with a complicated budgetary situation, the National Health Service (NHS), the country’s national health system, is sometimes forced to ration the supply of care offered in certain regions.
The NHS is organized into regional committees, the CCGs, which since 2012 have been responsible for distributing health funding in the region. They enjoy a great deal of autonomy to arbitrate between the services they can offer. But this has sometimes led them to restrict access to certain treatments, and to limit the use of certain operations, for certain patients.
These decisions are often misunderstood by the local population, especially since there are until today no clear and harmonized rules to which the CCGs can refer to arbitrate the health services they are going to offer. “There is a lack of transparency in the decisions of the CCGs to limit access to certain treatments. »Explains Rebecca Gray of the King’s Fund, one of the largest think tanks in the country, specializing in public health.
And, according to her, this situation will not get better. NHS boss Simon Stevens estimates up to £ 30bn (€ 42bn) will be short by 2020 to meet the growing demand for care from the aging UK population. In this context, the debate on modulating care based on lifestyle criteria is therefore not about to disappear. A study carried out by the Health Service journal shows that 40% of CCGs could resort to practices of rationing of care based on hygiene criteria of life, during the year 2015.
Experimentation in Devon
Last November, as the electoral campaign approached, a CCG in southern England wanted to put in place an experimental plan to make up its 14.5 million pounds (20 million euros) deficit, by limiting the ‘access to certain care for smokers and obese people. In particular, they were refused certain routine operations, knee or hip.
For people with a body mass index (BMI) greater than 35, the condition for being able to benefit from this treatment would therefore have been to lose 5% of their weight, or to go back below 35. For smokers, it should have been shown that the smoking cessation had lasted for at least eight weeks. But in the face of criticism from doctors’ unions, as well as the government, the plan was withdrawn.
Dr Paynton of the Royal College for General Practitioners is one of the voices who have particularly spoken out against the measure. He believes that “the eligibility of a patient to receive a particular treatment must be taken on a case-by-case basis. It is not the role of CCGs to impose systematic restrictions on patients because of their lifestyle, for treatments that can potentially save them ”.
Medical arguments or discriminatory practices?
A fear shared with Tam Fry, of the British association “Forum for obesity”. According to him, “the idea of modulating care for obese people is almost a crime, an injustice in my eyes. We have an NHS which must offer free care to all who need it. “
But smokers and obese people are not the only ones affected by these debates. Infertile people have also been refused certain fertility treatments. NICE, the benchmark institution for health counseling, recommends that women under 40 who fail to conceive after two years are offered three opportunities for in vitro fertilization.
But a study carried out by the health think-tank, the Nutffield Trust, shows that in 80% of cases, only IVF is actually offered to women. Smokers and obese women are all the more concerned as they are less likely to have successful IVF. CCGs are therefore more reluctant to offer them this treatment.
Risk model
What do the British public think? Generally opposed to the idea of rationing of care, very attached to its NHS, the English seem rather in favor of measures that would make people pay for having risky behavior. In January, a poll carried out by the national Yougov institute, for the newspaper The Times, pointed out that around 6 out of 10 people considered it “reasonable to restrict access to certain care for people with unhealthy lifestyles”.
If we retain the hygiene of life as a criterion of arbitration, does this not call into question the very idea that all patients have the right to free health care, as stipulated in the founding charter of the NHS ? The risk: “obese people and smokers, by being refused certain operations, may no longer appeal to the NHS as much for other health problems” warns Tam Fry, of the forum for obesity. By calling into question the universality of the NHS, the modulation of care according to lifestyle would then risk penalizing the people who most need the support of health professionals in the country.
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