Reducing inequities in planned care: An Ethics Review for Integrated Care Boards

A summary of the review can be found below. You can read the full report here.

Strategies to reduce inequities in access to planned care: an Ethics Review for Integrated Care Boards - a summary

“In May 2022 the NHS Strategy Unit produced a report for the Midlands Decision Support Network, offering possible strategies that Integrated Care Boards (ICBs) could follow in trying to reduce inequities in access to planned care (which have been widening between different socioeconomic groups in recent years).  I was asked to provide an Ethics Review of this report; I was requested in particular to assess the material with an eye to consequentialist, rights-based and flourishing-based approaches to ethics.  In preparation I studied not only the report, but also the NHS Constitution; NHS targets and QALYs; a redacted draft version of the Ipsos report Prioritising the elective care waiting list in Coventry and Warwickshire: findings from a public deliberation; a legal review of the report by Hill Dickinson and Fraser Battye’s series of blogs on decision making for the Strategy Unit. 

After outlining the philosophical grounds for caring about fairness, and distinguishing ‘inequalities’ from ‘inequities’ in NHS usage, I consider the strategies proposed by the Strategy Unit for each stage of the care pathway: identification and referral to secondary care; pre-admission assessment and management; decision to treat; waiting list prioritisation; treatment accessibility. Although I do not find any of the strategies to be ethically unviable, I do have some caveats.  I find that many of the present difficulties and confusions surrounding decision making in the care pathway stem from ethical tensions within the NHS itself: its Constitution is largely – though not exclusively – rights-based, whereas both its targets and the QALYs it employs are mainly consequentialist.  I suggest that in some cases these tensions can be eased by adopting an approach based on the wellbeing or flourishing of both patients and providers, particularly in respect of waiting list prioritisation, shared decision making and decision coaches.  One of the issues in waiting list prioritisation, for example, which currently works against those in socioeconomically disadvantaged circumstances is that socioeconomic disadvantage is not a ‘protected characteristic’ in law - while one would hardly want to ‘protect’ disadvantage, the practical result is that wealthy but e.g. elderly patients take precedence in law over younger patients from disadvantaged backgrounds.  I argue that in some of these cases a wellbeing approach may offer a solution.  I also highlight strategies which are vulnerable to being gamed and suggest ways of protecting against this. 

I conclude by suggesting that the ethical complexities of the decision-making environment can be reduced if the focus is on process rather than on targets.  I recommend the application of a 5-stage process which involves mature acceptance of inevitable tensions and uncertainty; public consultation and consent; open and accurate reporting of data and careful monitoring; willingness to adapt in the face of unexpected new data.  If this process is followed with care, thoughtfulness and humility then decision makers can have confidence that ethically justifiable choices will be made, even if unwanted outcomes which could not reasonably have been foreseen mean that in the future an ICB wishes it had taken a different decision.”
Professor Angie Hobbs, Department of Philosophy