Intended for healthcare professionals

Education And Debate

The rationing debate: Central government should have a greater role in rationing decisions – The case for

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7085.967 (Published 29 March 1997) Cite this as: BMJ 1997;314:967
  1. Jo Lenaghana
  1. a Institute for Public Policy Research London WC2E 7RA

    Introduction

    Rationing decisions in the NHS have largely been controlled by the medical profession and have tended to be implicit, with little reference to agreed systems or criteria.1 Central government is responsible for deciding how resources for health care are distributed around Britain and sets the legal context, but should it do more and develop a national framework for rationing health care? A recent spate of reports and articles revealing variations in the provision of and access to healthcare services highlight the urgent need to address this question.

    The House of Commons Select Committee on Health surveyed the priority setting practices of 49 health authorities, noting: “We have been struck by the seemingly enormous variation in access across the country.”2 Redmayne revealed that one in six health authorities are now excluding treatments from public provision,3 while a recent survey has shown that couples in Scotland are seven times more likely to get NHS in vitro fertilisation than those in the south west region.4

    Variations in healthcare provision are nothing new, but the purchaser-provider split has made them more explicit, and, more importantly, revealed variations in the criteria used to justify these decisions. For example, in Humberside fertility treatment is provided to women until the age of 40, whereas Liverpool provides it until the age of 35.2 As New and Le Grand have observed, explicit rationing has not been accompanied by an explicit or shared understanding on how such decisions should be made.1

    It has been argued that if the government increased the amount of resources available to the NHS, then this would remove the need to ration. However, this ignores the fact that decisions about whether to provide a treatment are not always determined by financial considerations alone. For instance, the new genetic technologies may cause us to question not just whether we can afford to fund particular types of screening but also whether it is appropriate for the NHS to provide certain services at all.5 Such issues raise fundamental questions about the nature and purpose of our health service, the rights of citizens, and the responsibilities of professionals and are too important to be left to individual health authorities and medical practitioners to resolve alone.

    Lack of coherence

    From April 1996 each health authority has had an explicit and different working definition of health care (funded by the NHS) and social care (means tested). Definitions of what constitutes a terminal illness, and therefore qualifies for NHS funded palliative care, vary between health authorities, from 2 weeks' to 12 months' life expectancy.6 This unacceptable variation not only causes problems for the individuals concerned but also helps to fuel public fears. What and who is the NHS for? What is an illness? What treatments can we legitimately be expected to receive on the NHS, to which all citizens contribute?

    Doctors and health authorities have responded to increased demand and reduced budgets by limiting or delaying the services they provide. This not only makes life difficult for those involved in providing and planning health services, but as the process becomes more transparent it also increases the anxiety and uncertainty of those who use the NHS. Some have argued that rationing decisions, to be responsive and flexible, must be left to the micro level. Rationing, they claim, is essentially a messy business.7 However, as Kennedy has written, this “ad hocery” means that medical practice lacks an internal coherence and consistency of principle, and therefore the interests of patients, doctors, and the community are not fully served.8 The challenge is surely to identify what kind of decisions can be taken appropriately at the micro, meso, and macro levels.

    Erosion of public confidence

    The lack of a coherent vision of what and who the NHS is for is in danger of undermining public confidence. The increased media interest in issues such as Child B and the withdrawal of NHS provision of long term care has helped fuel anxiety among the public, who fear that the NHS will no longer provide a comprehensive service, free at the point of delivery.9

    Some critics have argued that the creation of an explicit policy on rationing will erode public confidence. This position fails to acknowledge that public confidence is already ebbing. The Institute for Public Policy Research pilot citizens' juries have suggested that the more information you give people, the more confidence they have in the NHS.10 If left unchecked, health authorities are bound to continue to exclude various treatments. The media and the opposition parties are well aware of the publicity to be gained from such incidents, and the public will be left confused. The private sector is likely to benefit from this increasing uncertainty.

    Equity and local flexibility

    Inequity of access may have been an unwanted occurrence in the NHS of the past, but it now appears to be built into the current system.11 The logic of the internal market and the devolving of powers to individual health authorities have made geographical variations in provision of healthcare services not just more common, but inevitable. As argued above, however, it is not just the variations themselves which give cause for concern, but the variations in the criteria used to make such decisions.


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    In the case of in vitro fertilisation, for example, it is often non-needs based characteristics which can determine whether a woman gains access to treatment. A decision may depend on where she lives, whether she is married, or how old she is, and these criteria vary from region to region. The variations in provision reveal that we do not have equal rights to treatment and care and that finite resources for health care are being distributed according to criteria not solely based on clinical judgment.

    The goal of equality is increasingly being sacrificed to the new religion of “local flexibility.” This is indeed an important aim, but, as New and Le Grand have argued, the level of service may reasonably vary according to geography, but whether a service should be provided or not should not vary between regions as this may offend our sense of territorial justice.1

    Others have argued that the responsibility for purchasing health care should lie with local authorities.12 This idea certainly has merit and the Institute for Public Policy Research has argued that this should be piloted.13 Nevertheless, as New has pointed out, “this might cause difficulties for a national health strategy, geographic equity and allocating between finance between ‘free’ health care and means tested social care.”14

    Competence and legitimacy

    The House of Commons Select Committee on Health expressed its concern at the variations in competence between different health authorities.2 The members of health authorities are appointed by the Secretary of State, and as such are not elected or accountable to the public. Rationing decisions are political decisions, as they involve the distribution of public money. These quangos seem to lack both the competence and the legitimacy to make rationing decisions on our behalf.

    It is perhaps tempting at this point to retort “leave it to the doctors,” but do doctors possess any more legitimacy or competence for rationing decisions than health authorities? Kennedy has argued that the issue of whether a treatment is effective or not is clearly a medical decision, but whether or not a treatment is the best use of public funds is a political decision.8 Other issues, such as quality of life, involve questions of moral and ethical concern. All of these are involved in a medical decision, but are beyond the competence and legitimacy of a doctor to resolve alone. The medical profession has recognised this for some time and has called on the government to share the burden of these difficult decisions. Converting political problems into medical problems15 might be convenient for politicians, but it overburdens doctors, excludes the public from debate, and prevents us from holding the decision makers to account.

    Others have expressed concern at the prospect of local authorities purchasing health care, for fear that this will “legitimise” unpopular or unfair rationing decisions. Indeed, will the public perceive regional variations in healthcare provision to be legitimate if made by elected bodies? New and Le Grand warn of a “legitimisation crisis” if the NHS is unable to distribute resources fairly or match expectations.1 As Busse et al have observed, for the benefits provided through the welfare system to provide solidarity they must be comprehensive enough for the recipients to value them and provide a clear element of redistribution in order for the nation to appreciate the solidarity.16

    To argue for a greater role for the centre in rationing decisions does not mean that there will be no room for local flexibility. Indeed a code of practice, developed at the centre, could provide a framework within which local decision making could flourish. The challenge is to develop a policy which enables us to define the limits and extent of local flexibility, rather than allowing it to continue to be used as an excuse for all manner of inappropriate variations.

    A greater role for the centre

    To increase the coherence and legitimacy of decision making in the NHS, we need to redefine what kind of decisions are appropriate to be taken at which level. We need to define the boundaries within which doctors can be free to exercise their clinical judgment, and create a principled framework within which health authorities and managers can legitimately make their decisions.

    The Institute for Public Policy Research has rejected the idea of a defined package of care and instead has proposed a national advisory body to develop appropriate national guidelines, within which the different groups can exercise their particular skills and judgment.9 A national health commission should be set up to advise parliament on devising guidelines and a code of practice. This would draw on a wide range of experience and skill, involving all interested parties in the process and pooling ideas. Its aim would be to build a broad consensus for the criteria by which decisions about resource allocation for health care can reasonably be made and to keep matters under review. Our recommendations are similar to proposals made by the Royal College of Physicians17 and are consistent with the findings of a pilot citizens' jury on rationing.18 Our proposals are based on an assessment of the experience of other countries, which suggests that rationing by exclusion is neither helpful nor desirable and that developing guidelines in order to ensure fair and consistent decision making processes offers a pragmatic way forward.9 19 20 The exact mechanisms and functions of the proposed commission are discussed in detail in the report, Rationing and Rights in Health Care.9

    Although at the end of the day doctors must actually take the decisions in the surgery, the clinic, and the ward, the criteria they use should conform to standards which are seen to be consensual, legitimate, and consistently applied. More open and fair decisions will help to rebuild public trust and establish new relationships between all the stakeholders.

    Possible objections

    It has been suggested that any attempt at rational rationing is futile and that it would be impossible for any national body to reach a consensus on the difficult issues it would be asked to resolve. If rationing issues are too difficult to resolve on a national level, involving all the expert and interest groups, then what chance do hard pushed local health authorities have? Surely the recognition that rationing is so difficult merely demonstrates the need for us to pool our knowledge and experiences? Rationing, of course, neither can and never should be reduced to a precise mathematical formula, but it should be possible to develop rationing policies that are socially acceptable and which conform to standards of common justice.

    Other complaints, such as increasing bureaucracy and costs, limiting clinical freedom, etc, all depend on what kind of policies are created, and with what objectives. They also depend on the level of public involvement and support, and on how much professional confidence such policies can command. None of these legitimate concerns should be dismissed lightly, but potential problems can be overcome by commitment and imagination, and cannot justify inaction. Once we have agreed that the centre does need to have a greater role in rationing decisions, we can then begin to debate the form which such a policy should take, in order to ensure that these concerns are fully addressed.

    As New has argued, views about rationing may remain persistently polarised among members in society, thereby increasing the need to develop democratic systems of decision making in order to resolve these conflicts. It is unlikely that different views will ever be entirely reconciled, but it should be possible to build confidence and support for the process by which such decisions are made.14

    Conclusion

    The arguments in favour of a greater role for the centre in rationing decisions must be compared not to some imaginary perfect future but to the poverty of the status quo. New policies always involve risks, but the option of doing nothing is far from risk free. If we fail to tackle rationing in the NHS, if we leave the health authorities to muddle through, the media to seize on the inevitable inequities, and the public to worry about the consequences, then the middle classes may increasingly turn to private insurance in pursuit of peace of mind, eventually reducing the NHS to a safety net service for the poor.

    We have a clear choice: either we attempt to shape the future of healthcare provision in the public interest, or we allow it to be shaped for us, by the workings of the internal market, the influence of vested interests, and the ad hoc decisions of individual health authorities. The future of the health service in the UK is too important to be shaped by default. For the NHS to survive and succeed in the next century it must earn the trust of the public, and therefore it must offer services which all citizens value, and allocate its resources in a manner which is seen to be fair. A greater role for the centre in rationing health care may help us to achieve these aims.

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