Puzzling out prioritiesBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7164.959 (Published 10 October 1998) Cite this as: BMJ 1998;317:959
Why we must acknowledge that rationing is a political process
Education and debate pp 1000-7
The second international conference on priorities in health care, held in London this week, is important for two reasons. Firstly, it provides a reminder that the phenomenon of rationing is indeed international and not just a byproduct of the way Britain's National Health Service is designed or funded. Countries with very different healthcare systems and levels of healthcare spending are all grappling with the problem of how to reconcile growing demands and constrained resources. Secondly, as the three conference papers published in this issue show (pp 1000-7),1–3 it marks recognition of the fact that priority setting is inevitably messy and difficult.4 The challenge everywhere is about how to organise and orchestrate what, for the foreseeable future, will be a continuing dialogue between politicians, professionals, and the public about the principles that should be invoked in making decisions about rationing and about how best to reconcile conflicting values and competing claims.
This may seem a depressingly negative conclusion. It yields, however, a very important and positive one. Once we acknowledge that setting priorities is inescapably a political process—it involves making painful decisions socially acceptable and mobilising consent among both the health professionals who have to implement them and the public who are affected by them—we can turn to devising the appropriate mechanisms for doing so. Here the starting point must surely be open acceptance of the fact of rationing.5 Denial is not an option. If Frank Dobson, the secretary of state for health, continues to ban the word from the ministerial vocabulary it will only make him look foolish and undermine his credibility. Once the inevitability of rationing is accepted, we can then get down to the serious business of discussing how to devise the appropriate mechanisms and addressing some of the intractable questions involved.
A National Council for Health Care Priorities, along the lines proposed by the Royal College of Physicians,6 would clearly provide an institutional setting for the rationing debate in Britain. But what should its function be? Should it be simply to provide a forum for analysis and debate? Or should it be to make specific recommendations? And if so, should they be on an ad hoc basis when a new drug like sildenafil (Viagra) appears on the market? Or should the recommendations involve examining different treatments for the same condition (impotence in this case) or the competing claims of resources for different conditions when a flood of new products becomes available (for example, impotence v obesity)? Or, going a step further, should its function be to review the priorities implicit in the existing distribution of resource in the NHS as a whole?
These questions reflect some general dilemmas about how to develop the way we think about rationing. The narrower the focus, the more feasible the task. For example, it might not be too difficult to get widespread agreement that the elderly should have less priority than the young in getting lifesaving cardiac surgery. Once the focus widens, however, the task becomes harder: there might be much less agreement over the priority to be given to services for the elderly that enable them to remain active members of society and avoid institutionalisation. Again, much of the discussion about rationing is about limiting access to, and the availability of, specific procedures or drugs. But this tends to overlook what is probably the most prevalent form of rationing: the dilution of services—for example, a reduction in the number and quality of nurses on a ward, the number of tests ordered, or the time doctors can spend with individual patients. Lastly, there is the dilemma of striking a balance between moving towards explicit national decisions about what should or should not be provided and allowing individual clinicians discretion when implementing those decisions face to face with individual patients. In the absence of national decisions, equity is in danger.7 In the absence of discretion, injustice may be done to individuals. Yet too much use of discretion may subvert national policy: medical necessity is a flexible concept.
Such dilemmas reinforce the case for more debate while also warning against optimism about their early resolution. The aspiration should be to move towards a situation where decisions—whether taken by politicians at the centre or by individual clinicians—pass the test of being reasonable8 in the sense of being publicly defensible on grounds that most people would regard as being relevant and fair (without necessarily agreeing with the decision). It will inevitably be a slow, step by step process. But “muddling through” 9 10 —that is, seeing policymaking as an experimental and incremental process—may represent a more sophisticated as well as a more realistic form of rationality than attempts to devise technical fixes. It is a conclusion that appears to be confirmed by international experience.