Where are we in the rationing debate?
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2047 (Published 10 October 2008) Cite this as: BMJ 2008;337:a2047
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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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Do we need rationing?
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
Competing interests: No competing interests