Guest Blog by Ben Tyler – Reflections on a GP and Commissioning Placement – Week 4

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Last week I discussed how I think consulting the public earlier in the decision process would help the NHS in saving money.


This week I’m taking a slightly different tack. In my opinion, some decisions need to be made by those with the relevant training to fully understand the benefits and consequences of them.


When practicing for medical school interviews I got posed with a question regarding an ethical scenario similar. It was along the lines of ‘should £X be spent to give one person 50 more years of life, or one thousand people 10 more years of life’. The interviewers weren’t after a right answer, but wanted to see how you thought through the problem and got to the answer.


Local commissioning groups are now looking at different conditions they may limit service access to, to save money. How do you decide which conditions to treat? How do you come to that decision? Utilitarianism is an ethical theory that says the best moral action is that which produces the greatest good, for the benefit of the majority. Is this the best way to proceed?


A recent discussion at the CCG surrounding access to elective surgery intrigued me. A high BMI and smoking both can effect how successful the intervention is. Therefore should patients be required to lose weight or stop smoking before they are put on the waiting list? If an obese patient has a knee replacement, it will last less time than if a healthy weighted person has one. Therefore should the obese patient be made to lose weight before the operation? But then if their knee is painful how can they exercise to aid weight loss? A similar scenario could be drawn up with smoking.


Each case is different and therefore it is hard to use a blanket value. E.g. two people may have a similar BMI but one may be more muscular than another. So then should individual surgeons make the choice whether they operate or not? But then each surgeon may make a slightly different decision. How is this fair?


When the NHS is trying to save money, at such a rate, in my opinion it is nearly impossible to do this in a fair way. There are going to be winners and losers. Each individual case can nearly always be argued in either way.


It reminds me of a Radiolab podcast I listened to called ‘Playing God’. It spoke about triage and how with a limited resource, how do you decide who receives it first. Essentially, how do you decide which life is worth more. Albeit the current situation isn’t quite that serious, but how do you decide if one person deserves an intervention, and another one doesn’t?


There is no right or wrong answer, but perhaps those in the best position to make those decisions are the relevant medical professionals? Those that carry out the interventions and conduct follow up know when it is successful, and how much of a difference it makes. The doctors that see patients with certain conditions are in the best position to understand what will happen if access to interventions for these are limited. It makes sense that these are the people that should shoulder this responsibility.


Similar to the conclusion the podcast came to; I think it is unfair for clinicians on the ground to make the decision based solely on their clinical opinion. Emotions can come into play and pressure from patients could sway decisions. Someone in less clinical need but more emotional about the intervention could be awarded it instead of someone in more need.


Pathways must be drawn up, acknowledging the local demographic, for clinicians to follow. This means that clinicians are responsible for their decisions collectively.


Maybe the general population, with no conflicts of interest, could help work through the more controversial pathways. A group of non-clinicians could debate amongst themselves which interventions or conditions to limit access to, after the pros and cons had been discussed by clinicians.


There may be patient backlash about some decisions made, but I think this is the fairest way of coming to conclusions – making decisions with relevant clinical professionals working in tandem with a group of the non-bias public. Although controversial cases may appear in the press and on social media, in my opinion this is the fairest way of limiting treatment to save finance, which unfortunately needs to happen.


This blog is by Ben Tyler, 4th year Medical Student at Sheffield University


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