‘Cosmetic boob jobs’ or evidence-based breast surgery: an interpretive policy analysis of the rationing of ‘low value’ treatments in the English National Health Service

BMC Health Services Research

Trisha Greenhalgh¹  Deborah Swinglehurst¹  Jill Russell¹ 

[1]Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK

关键词: Value based commissioning;    Low priority treatments;    Interpretive policy analysis;    Rationing;    Health care variation;    Breast surgery;    England;   

Others  :  1126308
DOI  :  10.1186/1472-6963-14-413

 received in 2014-04-10, accepted in 2014-09-11,  发布年份 2014

【 摘 要 】

Background

In England the National Health Service (NHS) is not allowed to impose ‘blanket bans’ on treatments, but local commissioners produce lists of ‘low value’ procedures that they will normally not fund. Breast surgery is one example. However, evidence suggests that some breast surgery is clinically effective, with significant health gain. National guidelines indicate the circumstances under which breast surgery should be made available on the NHS, but there is widespread variation in their implementation.

The purpose of this study was to explore the work practices of ‘individual funding request’ (IFR) panels, as they considered ‘one-off’ funding requests for breast surgery; examine how the notion of ‘value’ is dialogically constructed, and how decisions about who is deserving of NHS funding and who is not are accomplished in practice.

Methods

We undertook ethnographic exploration of three IFR panels. We extracted all (22) breast surgery cases considered by these panels from our data set and progressively focused on three case discussions, one from each panel, covering the three main breast procedures.

We undertook a microanalysis of the talk and texts arising from these cases, within a conceptual framework of interpretive policy analysis.

Results

Through an exploration of the symbolic artefacts (language, objects and acts) that are significant carriers of policy meaning, we identified the ways in which IFR panels create their own ‘interpretive communities’, within which deliberations about the funding of breast surgery are differently framed, and local decisions come to be justified. In particular, we demonstrated how each decision was contingent on [a] the evaluative accent given to certain words, [b] the work that documentary objects achieve in foregrounding particular concerns, and [c] the act of categorising. Meaning was constructed dialogically through local interaction and broader socio-cultural discourses about breasts and ‘cosmetic’ surgery.

Conclusion

Despite the appeal of calls to tackle ‘unwarranted variation’ in access to low priority treatments by ensuring uniformity of local guidelines and policies, our findings suggest that ultimately, given the contingent nature of practice, this is likely to remain an illusory policy goal. Our findings challenge the scientistic thinking underpinning mainstream health policy discourse.

【 授权许可】

   
2014 Russell et al.; licensee BioMed Central Ltd.

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