David Oliver: Rationing care by delaying decisions
BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6620 (Published 27 November 2019) Cite this as: BMJ 2019;367:l6620
All rapid responses
David Oliver seems to suggest that the forms of rationing he describes are somehow of recent origin and undiscovered. This is not so. There is a sizeable literature on rationing to which I have contributed along with others including, from the UK, Rudolf Klein and Chris Newdick and, from the US, David Mechanic and Donald Light (eg see my 1997 book, Desperately Seeking Solutions: Rationing Health Care). Much of this literature exposes the various mechanisms and devices Oliver briefly mentions.
In 1994, a colleague (Steve Harrison) and I identified various rationing mechanisms which we termed the 5 'D's: Deterrence, Delay, Deflection, Dilution and Denial. Oliver focuses on Delay but the others are just as relevant and prevalent. The challenge for policy-makers is what to do about these mechanisms which largely operate at the frontline of care. Should rationing be more explicit or is there merit in some cases in it being (or remaining) implicit? This is a hugely difficult question to confront since there are no simple or straightforward solutions to such complex ethical issues. Delay, for example, need not always be a bad thing if it's part of a strategy of 'watchful waiting'. In any case, while being explicit conforms to a rational view of decision-making, the reality governing how decisions are made is rarely so clear-cut or linear.
The temptation in the face of such difficulties might be to do nothing - a form of 'masterly inactivity'. Alternatively, a strategy of 'muddling through elegantly' as I have advocated might hold greater appeal. It recognises that while the status quo is not an option, a wholesale move to an explicit system of rationing could prove damaging and too difficult for society to contemplate. Gradual improvement is required in an attempt to reconcile the competing moral concerns facing us. In short we should aim to settle for satisficing rather than optimising given the latter may not be possible to achieve. Rather than reinvent the arguments, perhaps as a first step there is merit in revisiting the literature from the 1990s which covers much of the ground that Oliver only recently seems to have discovered.
Competing interests: No competing interests
Dear Editors
I am sure Dr David Oliver knows very well the issues faced by clinicians and patients when dealing with the interface between the NHS and adult social care, when transition into community care is perceivably delayed for various administrative or process-related reasons in addition to a real limitation of resources.
Frustration inevitably will occur when these much needed services are seen to be rationed. I understand that very well and fully appreciate the gargantuan effort of the orthogeriatric team (my orthopaedic service was blessed to have access to) navigating hurdles and blocks to secure practical (and pragmatic) outcomes for older people according to their preference.
More importantly, I am relieved that Dr Oliver has NOT quoted certain statistics from Age UK (as reflected by a recent BMJ article - ref1) to support his assertions.
Specifically, "Age UK analysis estimates that in the 30 months between the last and the forthcoming General Elections, 74,000 over-65s in England have died or will die having never received the care and support that they have asked for. This means in the period 8th June 2017 – 12th December 2019, an average of 81 people a day, equivalent to three every hour, died while in this very unfortunate position." (ref 2)
The calculations and additional assumptions for the this statistics involved further extrapolation beyond what was used to justify their previous declaration in Feb 2019 that more than 50,000 older people have now died waiting in vain for care during the 700 days since the Government first said it would publish a Care Green Paper" and suggested an average of 77.18 people (aged 65 and over) died every day before social care services could be provided between 1 April 2017 – 31 March 2018, based on various assumptions using 2017/18 data from NHS Digital (ref 3)
Keep in mind the apparent 5% increase of "people (aged 65 and over) died every day before social care services could be provided" mirrors the overall increase in requests between 2017/18 and 2018/19.
Interestingly, Age UK's General Election Manifesto 2019 and their extensive list of references (ref 4) did not parrot such dramatic statistics, which no doubt could generate a huge groundswell of social support. The absence of this declaration is inexplicable since similar analysis is already available for the last 10 months.
There is no doubt that the gap between the NHS and community-based social care has reached a crisis point for some time, and that the election provides a valuable opportunity to promote the cause of better funding as well as process restructuring removing barriers and duplication. However, caution should be taken in using contentious statistics to advance these agenda, when credibility is becoming a rare commodity in these strange times.
References
1. https://www.bmj.com/content/367/bmj.l6653
2. https://www.ageuk.org.uk/latest-press/articles/2019/november/in-england-...
3. https://www.ageuk.org.uk/latest-press/articles/2019/february/more-than-5...
4. https://www.ageuk.org.uk/latest-press/articles/2019/november/manifesto/?...
Competing interests: No competing interests
Re: David Oliver: Rationing care by delaying decisions
Editor
I thank Professor Hunter for his response. He will find that I haven't quoted any academic literature from the 1990s or any other era. A 600 word opinion column does not purport to be a systematic review of the literature or a thematic analysis. I am describing what it feels like on the clinical frontline of the NHS - albeit citing some more recent data from the National Audit Office and reports on the state of social care and continuing healthcare provision. It seems to have resonated with many other practitioners on the shopfloor and stirred debate, which is the aim.
It is unlikely as a doctor with a 30 year careeer working in this field and a former Department of Health National Clinical Director and ex President of the British Geriatrics Society that I would be unaware of the policy history in this field.
David Oliver
Competing interests: No competing interests