Bookmarkers beware: Bookmarks to pages other than the home page may not work after we change our server in April Editor's Choice | This Week in BMJ | Press releases BMJ No 7129 Volume 316 Editorial Saturday 7 February 1998 Rationing health care A logical solution to an inconsistent triad Albert Weale The basic principle of the NHS is simply that comprehensive, high quality medical care should be available to all citizens on the basis of professionally judged medical need without financial barriers to access. In seeking to enact this principle, the NHS is not alone. The same aspiration is to be found in nearly all economically developed societies outside the United States. Yet, in the face of increasing healthcare costs this basic principle threatens to become what logicians call an inconsistent triad; a collection of propositions, any two of which are compatible with each another but which, when viewed together in a threesome, form a contradiction. Perhaps we can have only a comprehensive service of high quality, but not one available to all. Or a comprehensive service freely available to all, but not of high quality. Or a high quality service freely available to all, but not comprehensive. Each of these three possibilities defines a characteristic position in the modern debate about healthcare costs and organisation. High quality comprehensive care that is not freely available to all is, of course, the solution to the dilemma adopted by the United States. This is a poor solution. It is not simply the uncivilised way in which the healthcare needs of citizens are ignored, with up to 20% of Americans uninsured or underinsured and with non-existent primary care services for the poor. It is also that, even for those who are insured, the consequence of the search for ever more prestigious health care is a mutually defeating game of spiralling costs and defensive medicine. American analysts reply with their own arguments, asserting that the NHS buys its comprehensiveness and free availability at the cost of quality. This is the essence of what may be termed the "Brookings" characterisation of the NHS, after the famous Washington think tank. Its reports have argued that the NHS serves patients badly, with too few diagnostic tests, too much waiting, not enough screening, and an unwillingness to use expensive treatments.(1,2) All too often this argument conjures up wartime stereotypes of a phlegmatic island race bearing their misfortunes with fortitude. More seriously, it commits the fallacy of assuming that good medicine is always interventionist medicine. It is not, however, an argument that is easily dismissed, as any visit to a busy outpatient department or a reading of the King's Fund report on London's mental health services will testify.(3) Move then to the third option: why not sacrifice comprehensiveness in order to achieve at least a core of high quality care freely available to all? Perhaps when drugs were few and treatments simple it was possible to be comprehensive, but now we know that, for many patients, there will be possible treatments that are disallowed on the grounds of cost, either implicitly or explicitly. Honesty about lack of comprehensiveness and the definition of a core range of services might go some way towards a solution. The trouble with this proposal is that, though many have tried, none has succeeded in defining a core range of services that can be made to work without severe qualifications. As Rudolf Klein has pointed out, the various committees around the world that have looked at the problem have simply come up with the same candidates for exclusion (vasectomies, sterilisation, tattoo removal, in vitro fertilisation, gender reassignment), all of which are marginal to the problems of allocating resources in health care.(4) This conflict, implicit in the basic principle of modern health care, is not one that is best approached by treating it as logical puzzle to be resolved by dropping the least credible proposition. Such value conflicts are the essence of public policy: between economic growth and environmental protection; between individual freedom and social stability; between humanitarian intervention and recognising the right of national self determination; between comprehensiveness, quality, and availability in health care. As Sir Isaiah Berlin said, 30 years ago, we live in a world of conflicting values where clearcut solutions cannot in principle be found. To suppose that we can escape this conflict of values by retreating to an ideologically and organisationally simpler world casts a veil of deceit over the choices that must be made.(5) Albert Weale Professor of government Department of Government, University of Essex, Wivenhoe Park, Colchester CO4 3SQ email: weala@essex.ac.uk References 1 Aaron H, Schwartz W B. The painful prescription: rationing hospital care. Washington DC: Brookings Institution, 1984. 2 White J. Competing solutions: American health care proposals and international experience. Washington DC: Brookings Institution, 1995:123-4. 3 Johnson S, Ramsey R, Thornicroft G, Brooks L, Lelliot P, Peck E. London's mental health. London: King's Fund, 1997. 4 Klein R, Day P, Redmayne S. Managing scarcity. Buckingham: Open University Press, 1996:109-19. 5 Berlin I. Four essays on liberty. Oxford: Oxford University Press, 1969:167-72. 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