Gap between demand for services and cost of providing them should certainly be assessed

EDITOR—As Frankel at al note at the start of their article, the notion that demand in the NHS would always outstrip supply has a long history.1 Roberts had an especially important role in the generation of this fallacy when he warned that the NHS would drain the national economy to such an extent that “the welfare state will surely end in the totalitarian state.”2

The fallacy was eventually laid bare by the researches of Abel-Smith and Titmuss.3 Their classic of economic analysis decisively discredited scaremongering concerning the escalating cost of the NHS. Among other things they estimated that the rising costs of the NHS consequent on ageing would be modest (they calculated a rise of 3.5% between 1951 and 1972) and easily contained. But the damage had been done. Soon, owing to the influence of alarmist tracts such as Powell's Medicine and Politics,4 the NHS became habitually characterised as fostering an “infinity of demand” and thereby as a bottomless pit for resources. Over the years this false construction became accepted as dogma by politicians and even members of the medical and allied professions.

These unsupportable and inappropriate catchphrases, by their implication of ultimate hopelessness, have done substantial damage to planning and morale in the health service, as well as being detrimental to the NHS's reputation abroad. What has been needed for decades is careful analysis of the extent of the gap between demand for medical services and the cost of providing them, and how this varies with time and place in different branches of the NHS. We therefore welcome Frankel et al's statement that “The proposition that the limits to demand lie within the capacity of a properly resourced NHS should be tested explicitly.”

Article contained several fallacies

EDITOR—Frankel et al's article on the limits to demand for health care argues that the potential demand is neither infinite nor essentially incapable of being satisfied.1 The debate about rationing health care is therefore led by a mistaken ideology fed by economists' pessimistic view of life as a continuing struggle to deal with scarcity.

The article contains a series of fallacies. The first is the “but we've put a man on the moon” fallacy. This argument is trotted out whenever a seemingly simple idea cannot be implemented. The National Aeronautics and Space Administration (NASA) put a man on the moon simply because that was the one goal it was set, and billions were poured into the project. No one has told the NHS that its one objective is to abolish waiting for the small list of operations that Frankel et al choose.

Then there is the “if each of us did a little bit more” argument. It looks appealing but breaks down on examination. If each of us saved just £1 a day we could, as a nation of 55 million people, wipe out developing countries' debt in a few years. The key word in that sentence is the first. Linked to this is the notion that surgeons do operations. From a systems point of view they are merely a part, albeit an important one, of a system that allows patients to have safe operations.

Next there is what I call the “Nye Bevan” fallacy. This is the notion that healthcare practices are static and that we can, over time, find the money to meet every demand. The ever increasing drive to innovate (older as well as younger patients being considered suitable for hip replacement; new methods of thromboprophylaxis, gene therapy, and microsurgery being developed) means that potential aggregate demand for health care will always outstrip resources.

Finally, uniquely in health care we believe that inequality is bad. We tolerate it in education, economic wellbeing, social environment, housing, employment, and transport. In none of these do we have the same problem of resources and demand being out of kilter for the simple reason that we allow the market to operate, with only marginal social intervention to look after the desperately needy. In health care we have rightly denied ourselves that option. We can resolve the resulting dilemma by overt, politically led, rationing2 or by arbitrarily restricting access (waiting lists) or by tolerating poor quality.3

Authors' reply

EDITOR—Now that substantial investment in the NHS is occurring, the claim is becoming more common that “rationing” is simply a neutral gloss for making sensible choices. This is completely unconvincing. The association between rationing and denial was deliberately evoked by those who coined this term: when did we hear lottery winners asked how they would ration their winnings? Those promoting rationing “adopted this term because it provokes the greatest public controversy.”1 The tendency to evacuate the distinctive meaning of the term rationing is apparent in Maynard and Sheldon's treatment of the provision of elective surgery. If people are exposed to the risks of surgery only when the benefits outweigh the likely harm, this is protection rather than rationing. The fallacy that public provision must fail to satisfy demand was always, and continues to be, more political than empirical, as Loudon and Webster authoritatively point out. Rao's concern with rationing for equity is dealt with elsewhere.2

An interesting instance of the difficulty that otherwise informed people have with questioning the assumption that supply cannot meet demand came from the editorial committee of the BMJ. An epidemiological paper that implied that rationing of primary total hip replacement was unnecessary3 was rejected by the BMJ on policy rather than scientific grounds: “We remain unconvinced by the argument about the lack of need for rationing [of total hip replacement] … You say … that an increased provision of 50% over a 5 year period would clear the backlog. But where is this increase to come from and so how is rationing to be avoided?”(rejection letter, 10 June 1998). The answers to these questions, which were not sought as the correspondence was firmly closed, is, first, one additional operation every three weeks by each consultant orthopaedic surgeon, and, second, from funds that have since been allocated. The BMJ's editorial committee could not conceive of the eventuality of a soluble problem and so was unwilling to publish a paper that might have pointed towards that solution.

The rationing debate has been almost unencumbered by the conventions of empirical inquiry, but one has to have passed through an intellectual hall of mirrors to be able to assert that “rationing will be good for our health.”4 Attempting to provide better coverage of unequivocally beneficial remedies would presumably be even better for our health, if, as seems likely, the barriers to doing so are based more on prejudice than evidence.

A longer version of this letter is available on bmj.com