Choice GP

Healthcare rationing: no desistance, no completion

"Yours is not to complete the task/Yet neither are you free to desist from it." This phrase from the Ethics of the Fathersquoted in an account of attempts to ration health care in Israel (p 1005)sums up beautifully the duty of those who must serve as stewards of the resources of health care. Politicians in many countries and some doctors try to desist. But desistance is in this case actionbecause choices will still be made. They have to be made because not all can be provided. Even if not articulated choices are still made. Yet we can never complete the task of healthcare rationing, never solve the problem. That seems to be the central message that is emerging from the experience of those countries that have attempted to tackle the problem head on (p 959, p 1000, and p1005). Progress seems to lie with concentrating on the processes, making them transparent. We will hear more at the second international conference on priority setting in health care, which the BMJ is hosting in London this week.

Those who have entered the rationing debate by trying to examine treatments and find a universal law for deciding which should be made available might be described as "positivists." Most of you reading this have been educated according to positivist theory. But you probably don't know it because doctors tend to be scornful of theory. They think of themselves as people of action who don't sit around in armchairs developing theories. But, as Priscilla Alderson explains in the first of a series on theories in health care and research (p 1007), all thinking involves theories, and doctors are, like everybody else, operating within a theory. The first article sketches out different theories that are used within health care. I urge readers to "have a go" with this series. The authors have worked hard to try and present ideas to which many doctors are unsympathetic in a way that will appeal.    GP choice

Two papers offer advice on treating asthma. Laurie Plotnick and Francine Ducharme have conducted a systematic review to see if adding inhaled anticholinergics to ₂ agonists might improve the outcome in children and adolescents with acute asthma (p 971). They find that multiple doses do improve outcome in those with severe attacksless than 55% of predicted forced expiratory volume in one second. The anticholinergics do not help in those with less severe attacks but will avoid hospital admission in 1 in 11 of those with severe attacks. Finally, a New Zealand study suggests that budesonide has only about two thirds of the potency of inhaled beclomethasone when used in primary caredespite randomised controlled trials suggesting they are equally potent (p 986).