Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Removing liberal discourse from rationing debate...
- Murat Civaner (13 October 2008)
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Benign rationing or fierce competition?
- S. Michael Crawford (20 October 2008)
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Funding hospice care in Wales
- Ilora G Finlay (21 October 2008)
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Rationing as opportunity
- Alfred P J Lake (22 October 2008)
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Priority setting needs strong leadership
- Jonathan V Howell (28 October 2008)
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Do we need rationing?
- stephen black (28 October 2008)
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Murat Civaner, Lecturer Dept. of Medical Ethics, Uludag University School of Medicine, Bursa, Turkey
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After governments' rescue plans worthed trillions of dollars worldwide in response to the last financial crisis, it was clearly seen that the liberal discourse about "limited financial resources" in healthcare services is not valid, and cannot persuasively ground any argument especially on macro level. One thing is for sure: Companies have limited resources. The question is, should we take into consideration this fact while trying to justify professional values? I don't think so. I think it is time for us to remove this discourse from the rationing debate... Competing interests: None declared |
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S. Michael Crawford, Consultant Medical Oncologist Airedale General Hospital BD20 6TD
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Even thought the NHS is free at the point of use it is not equitable. It shares with othe countries evidence of differences in cancer survival. [1] Patients who are deprived are less likely to receive major treatments for cancer especially if they live at a distance from specialised facilities [2]. The effectiveness of rationing within the NHS as a means by which equal access to diagnosis and treatment is attained must therefore be questioned. The NHS defines the size of its resources cake, or rather this is decided by HM Treasury. There is then an attempt to design services around the sharing of that cake. This differs from countries where clinicians provide a service and then charge the State for doing so, or charge the patient who seeks reimbursement from the State. The effect of this is that NHS patients are in effect competing with each other for resources; the rôle of doctors is to adjudicate that competition. Since affluent, educated people are undoubtedly more effective competitors than others the tendency to regard use of the NHS, rather than privately-funded healthcare, as a moral obligation means that for a given health need socioeconomically deprived people have less resource available to them than would be the case if the affluent “went private.” Perhaps the philosophy that discourages the private financing of healthcare needs to be revised. References 1] Woods L. M., Rachet B. & Coleman M. P. Origins of socio- economic inequalities in cancer survival: a review Annals of Oncology 17: 5–19, 2006 2]. Jones A.P, Haynes R., Sauerzapf V. Crawford S.M., Zhao H., Forman D. Travel time to hospital and treatment for breast, colon, rectum,lung, ovary and prostate cancer EUROPEAN JOURNAL OF CANCER 44; 992 –999. (2008) Competing interests: None declared |
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Ilora G Finlay, Professor of Palliative Medicine, Cardiff University, CF14 2TL
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Following a report on palliative care services in Wales (Chairman Viv Sugar), a strategy implementation board has been established by the Minister. In determining the configuration of specialist palliative care services across Wales we agreed key fundamental principles. These underpinned the distribution of funding and were: fairness, evidence-based care, the ability to revise the formula for service configuration, avoiding duplication with other specialist services and with generalist services, establishing a stable direction of travel for service development, and avoiding seriously destabilising services. For transparency, stakeholders (All Wales palliative medicine consultants group, Independent Hospices Cymru and most hospice services) were consulted on the proposed formula for a core service configuration across Wales and the full report to the Minister was published on HOWIS. The funding decisions for the voluntary sector for 2008-09 were based on the cost of the core clinical service that would need to be provided if that charity provider did not exist, minus the amount of local health board funding already received. Decisions based on a percentage of service cost were rejected. They perpetuate inequity because some providers have high management, building maintenance and fundraising costs whereas others fund the employment of staff through their local NHS trust, thereby keeping overhead costs to a minimum. The move away from competitive bidding with market forces has meant that a minority of (powerful) stakeholders with vested interests continue to act as lobbyists, but the majority have been able to look for mutually justifiable decisions and can see the merit in decreasing duplication, working collaboratively and potentially examining the relative value of different service configurations. Goold and Baum’s editorial and the three analysis papers(18 October 2008) provide a helpful benchmark that confirms the basis for decisions in Wales. Competing interests: None declared |
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Alfred P J Lake, Consultant in Anaesthesia and Pain Medicine Glan Clwyd Hospital, Rhyl. LL17 0SU.
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Rationing in some form is inevitable and necessary whatever the size of cake, simply increasing the resources made available does not alter this basic truism. The cornerstone of the NHS is equity of provision but the existing service fails to deliver this because it is not applied in an objective and fair way across the board. To ensure this equity, proper systems are, of course, necessary; both the public (in its widest sense) and profession must work together to put them in place; we must all support the agreed health expenditure. Simply allowing market principles to operate and allocating by price is not the right way. What appears to be holding the process up is a failure to separate the two distinct elements of the problem which can, and should, be considered separately. First, rationing (or call it what you will) needs to divide procedures or treatments into three groups and ensure agreement with all providers and insurers. Group 1 – fully funded. Core services of high quality free at the point of use to be provided as part of the tax-funded NHS. Identifying core services and setting a relative value to the others would be the task of a body (such as exist elsewhere) set up for the purpose. Group 2 – partially funded. Desirable, clinically appropriate and evidence based. Cost effective services outside core open equally to all. Group 3 – not funded. Perhaps undesirable, inappropriate, not adequately evidence-based. Services at the margins which would be down to the individual to fund in full. Re-categorisation of procedures or treatments between the groups possible by agreement. Secondly, how to charge for those in Group 2? Already many users of NHS services quite effectively ‘top up’ by paying for private care (or drugs) which serves to discriminate against those who cannot, for whatever reason, pay. Open equally to all, the cost to the patient should be in proportion to their disposable/taxable income from 10 to 100% (1). Once the principle of, and system for, rationing has been agreed, an acceptance of the need to ensure fairness has an added benefit. The NHS, as such a powerful national institution encompassing all the population, could, though this, become the driver for the removal of inequity by ensuring the introduction of a properly graduated and integrated tax and benefit system to remove the poverty and other traps which bedevil the present overly complicated arrangements. 1. Lake APJ. Patients should pay a percentage of income. BMA News Review 2000; January: 30. Competing interests: None declared |
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Jonathan V Howell, Consultant in Public Health Edwin House, Second Avenue, Centrum 100, Burton upon Trent DE14 2WF
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The papers on rationing healthcare (1) provide a good overview of the present state of affairs. Daniels and Sabins’ Accountablility for Reasonableness (2) provides some firm ground if you think that priority setting is inevitable (and it is). Tough decisions are needed in priority setting. Hard won experience suggests that Daniels and Sabins’ approach around process and reasonableness is important if commissioners are to gain legitimacy. The stability this approach should provide is needed to help resist the legal, media and commercial challenges that sometimes combine to provoke politicians to intervene. Although the rationing papers are wide-ranging there are some important issues that are only touched upon. The lessons from the Herceptin affair are still there and the commercial sector knows that using patient groups and the media can allow pricing at what the market will bear. Donaldson et al (3) show that health care is not a true competitive market. Health technology agencies, such as NICE in England, often do not make a realistic connection between making national decisions on behalf of local budget holders and the need to balance the opportunity costs at that level. There is something odd about having a rationing mandate but with no budgetary responsibility. However, it is also true that the main budget holders in England, the Primary Care Trusts (PCTs), have no direct public accountability for their prioritisation decisions and this gap needs working on. Public engagement work and debate will help this and there are also mechanisms whereby PCTs could help to explain their annual budgetary decisions to the local politicians. This might help to get behind the technical nature of some priority setting decisions, which are often difficult to explain fully in the media. However, the key missing element is the overall political ownership of the need for priority setting and leadership at the national level. We have seen politicians fudge difficult rationing decisions and provide justifications that are too simplistic whilst ignoring the opportunity costs. Politicians need to support local decision makers, who are best placed to make everyday rationing decisions. Politicians should set the strategic framework and then stand back and hold their nerve in the face of media simplification or commercial pressures. My judgment is that we still have some way to go and much more work to do on the whole process of priority setting. 1. Goold SD, Baum NM. Where are we in the rationing debate? BMJ 2008;337:a2047, (and linked papers). 2. Daniels N, Sabin JE. Accountability for reasonableness: an update. BMJ 2008;337:a1850. 3. Donaldson C, Bate A, Brambleby P, waldner H. Moving forward on rationing: an economic view. BMJ 2008;337:a1872. Competing interests: JH is involved in priority setting decisions for NHS commissioners. |
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stephen black, management consultant london sw1w 9sr
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The belief that we need rationing is driven by two interlinked assumptions: 1) demand is insatiable; and 2) more treatment is better. Both of these are probably wrong. The trouble with these assumptions is that they are plausible enough that they are accepted as axioms and never questioned. Sure, the population of western countries is getting older so demand is bound to increase; sure there are plenty of people waiting for treatment, so we could make things better by providing more. But there is surprising evidence that both are just wrong. Worse they are directing policy makers to focus on the wrong problems. The best evidence that undermines the myths is from Wennberg's work on The Dartmouth Atlas of Healthcare (www.dartmouthatlas.org). The project uses the highly variable rates of spend on Medicare in different states in the USA to ask what more spending achieves. While there are some areas (mostly about prevention and primary care) where many areas under-treat their populations, the dominant pattern is of over-treatment. The Dartmouth work convincingly demonstrates that high-spending states get nothing for their extra spending except more activity. In some cases outcomes are worse as the side effects of excessive treatment dominate any potential benefits. Outcomes for patients are no worse in frugal states. What seems to drive the activity in the USA is not the needs of patients but the capacity of providers. Wennberg's term is "provider driven demand". And it is this, not the real healthcare needs of patients that is pushing up activity and budgets. In fact, once we acknowledge that more is not better we undermine the first myth as well. At the very least we should investigate whether budgetary and activity inflation is driven by patient need or by provider need. It could be argued that the USA is a uniquely bad example. As far as I know there have been few definitive attempts to replicate something like the Dartmouth atlas work in other economies. But some preliminary analysis I conduced suggests that even the UK (historically centrally planned which in theory should offer some counter weight to the power of the provider lobby) suffers from similar patterns of provider-driven demand (at least if we use hospital beds as a proxy for provider capacity). The two biggest problems, i believe are not about rationing as such but about curbing the power of providers. We need to stop over-treatment, because it is bad for patients. And we need to curb their power over prices (especially in the USA, but to some extent everywhere else). There is plenty of scope for both and the extent of the gains are such that we should be able to postpone severe rationing in the foreseeable future. Consistent clinical thresholds for treatment can curb volume growth and improvements in provider efficiency can curb cost inflation. We don't have to accept the myths; more isn't always better: an apple every 8 hours won't keep three doctors away. Competing interests: None declared |
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