Moving forward on rationing: an economic view
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1872 (Published 09 October 2008) Cite this as: BMJ 2008;337:a1872
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Editor
The intellectual horsepower that has been devoted to rationing, in
all its protean aspects, is daunting. I hesitate to essay a contribution.
The difficulty of explaining the whys and wherefores of rationing to
a sceptical press and public is probably the chief reason for the 'R' word
being heard so rarely from the lips of Ministers.
Usually the public spats between press, pressure groups, NICE and the
government of the day revolve around spectacularly expensive drugs for
less common or more fatal diseases. I cannot recall a substantial debate
taking place about the necessity for the NHS to fund the large volume but
cheap drugs that are so often used for self limiting or self induced
ailments.
For example:
If patients with gastrointestinal symptoms, but no objective evidence
of important disease, still require costives, laxatives, bulk enhancers,
antispasmodics, antacids, flatus nostrums, motility enhancers or anal
unguents they could reasonably be expected to self medicate or adjust
their 'lifestyles' (aka - food type and volume/smoking/alcohol use etc.).
A thousand fewer low cost prescriptions, especially when on regular
repeat, could fund one patient on Maxsponduliksamab.
I am sure that readers can supply other examples.
Assessment and advice for any problem should always be free. Serious
illness ought to be treated with whatever has been shown to have
measurable, reliable efficacy. The promotion of self treatment, after
assessment, is an area that could reap huge dividends in several ways.
The NHS cannot and does not need to shoulder responsibility for
everything but the rationing debate's focus needs to be on both the
cheapest and the most expensive.
Steven Ford
Competing interests:
None declared
Competing interests: No competing interests
PBMA or HTA is no choice at all
Donaldson and colleagues complain of a pandemic of Health Technology
Assessment (HTA) organisations, that is skewing health care resource
allocation in favour of a few “powerful providers, who do not represent
any well defined population”. An ethical solution to this problem, they
argue, is the widespread adoption of Programme Budgeting and Marginal
Analysis (PBMA).
We are concerned that the authors’ description of the role and impact
of HTA organisations is based upon the almost unique characteristics of
the UK’s National Institute for Health and Clinical Excellence. In the
international context, HTA organisations specialise in the identification,
assessment and synthesis of evidence to inform resource allocation
decisions. They do not, and would not claim to manage scarcity of health
care resources. NICE is exceptional as an HTA organisation because it
actually makes binding resource allocation decisions, and because those
decisions explicitly eschew consideration of budget impact. It is somewhat
unfair to argue that HTA is a smokescreen getting in the way of good
resource allocation on the basis of problems with one atypical HTA
organisation.
Donaldson and colleagues then go on to propose PBMA as a superior
resource allocation process. A central component of the PBMA process is
identifying those services that do and do not offer good value for money.
Establishing the value for money of a service requires analysing its
clinical, social, ethical, and economic; i.e. health technology
assessment. HTA is a necessary component of good quality PBMA. The
proposed choice between HTA and PBMA is no choice at all.
PBMA is also proposed to have ethical advantages over current
decision making processes because it has been shown, in at least one case
study, to comply with the principles of Accountability for Reasonableness
(A4R). A4R is a set of principles to which decision-making bodies might
choose to adhere in order to increase the acceptability of their decisions
to stakeholders. It promotes equity in process, but says nothing about
equity in outcome. Health Technology Assessment organisations are equally
capable of adhering to the principles of A4R. It is not obvious that
adherence with A4R is truly a differentiating factor between HTA and PBMA.
The most significant problem with PBMA appears to be its
acceptability. The first reported application of PBMA in health care dates
back to the early 1970s. Mitton et al reviewed the literature and found in
the region of 80 applications in approximately 60 authorities over a 25
year period. The lack of uptake of this particular technology suggests
that it too may have characteristics that mean it is not fit for purpose.
Donaldson and colleagues do raise an important issue – that of
opportunity cost. Resource allocation processes that ignore opportunity
cost are unlikely to lead to either an efficient or equitable health care
service. When the decision making system separates the decision making
power from the responsibility to balance the budget – the risk of mis-
specifying the opportunity cost is necessarily increased. This is in fact
a problem with some decision making processes and not necessarily a
problem with the tools that feed into that process.
Christopher McCabe
Tania Stafinski
Devidas Menon
Competing interests:
All authors have been, or are, involved in health technology assessment research to inform health care resource allocation processes
Competing interests: No competing interests