The rationing of health
provisions is something that garners considerable controversy, so I felt it would be worthwhile to go into it in more detail.
As you’ll know, the NHS is a
publicly funded health provider, with finite resources to treat and care for
patients. However, if the very best interventions were used for every patient,
the NHS would need many times the funding it currently receives. As a result, something
has to give, and certain drugs, procedures and care elements must be withheld
to stay within budget. The billion-pound question is how the service should be
rationed – what should be provided, and to whom.
Intuitively we might be lead to a
simple cost to benefit ratio system. Each treatment could have the years of
life, or better still years of life adjusted for quality, compared with its
cost. This could give a simple value of the cost per year of healthy life.
However, it cannot be so simple, in part because the use of one treatment may
in time lead to far more expensive care for an illness in later life, such as
dementia. A doctor I shadowed during the Summer actually suggested that, if the
NHS wanted to save money, they should encourage people to smoke so that people
died from acute rather than chronic diseases.
Ignoring the indirect effects for
now, here’s an example: A Primary Care Trust (or soon to be Clinical
Commissioning Group) has a portion of its funding left to spend, and has two
options. It can provide statins to all those with moderately raised cholesterol
levels thus reducing the risk of vascular or cardiac diseases slightly for each
individual, or artificial dialysis for all those in renal failure, which is
clearly saving lives directly. Both cost
the same, but spending the money on providing statins has a cost per healthy
year of, say, £10,000, whereas the figure for dialysis is £20,000. This
situation is simplistic and ignores the side effects of both, and the figures
are made up but not far from reality. In this context ‘Statins’ could be replaced
with any risk-reducing, preventative or early diagnostic measure, and
‘dialysis’ with any direct intervention with a greater cost to benefit ratio.
If we were only to use a simple ratio
we would consign those in renal failure to certain death in order that a much
larger number of people will have only a slightly reduced risk of disease
because the net benefit is greater if we provide statins. However, this seems
intuitively wrong to us, and the potential recipients of the statins would
likely prefer that the money be spent on providing dialysis rather than giving
them an insignificant reduction in personal risk.
This is known as the ‘rule of
rescue’, that we see ourselves as having an ethical prerogative to save an
identifiable person, even if the resources put into it would be better used on
what could be termed ‘statistical’ people. The term comes from the enormous
resources that are often put into finding a missing person, or rescuing one in
danger. You may have noticed that, to quite an extent, this is how the NHS
functions, with things like intensive care units, expensive ‘last-ditch’ cancer
drugs, and arguably many surgical procedures. In other words, prioritising care
to people who require it immediately at the expense of people who could have
their risk of disease reduced. The fact remains that those ‘statistics’ are
still people in need of healthcare, and that their eventual illness and death
is just as real as the individual’s. The rule also acts the other way -
patients believe, rightly or wrongly, that they are entitled to certain
treatments. This can be very difficult for doctors if the expected treatment is
not within guidelines.
The ethical dilemma of a cost to
benefit ratio is deepened when we consider groups such as the users of tobacco,
the overweight, the elderly and other at-risk groups. It seems reasonable that the
future prospect of life, which is often limited for, say, the elderly, should
also be factored into healthcare rationing decisions. The practical implication
of this would be that that the prior-mentioned groups may have certain
treatments withheld on the grounds that they will get less benefit than a
young, healthy person would. This runs against our intuitions about the need
for equality in healthcare provision, and again for providing care to those who
need it immediately.
In an ideal world we should want
to help all groups of people, be they identifiable individuals or ‘statistics’,
and be they young or old, but we often aren’t able to do so. In these
times of economic trouble, perhaps we have an imperative to move from the ‘rule
of rescue’ to a more holistic provision of healthcare which has greater
emphasis on prevention and early diagnosis, lest the service run into such financial
difficulties that it cannot adequately provide either. By the way, this is not a manifesto to stop dialysis or shut
down ICUs, but simply something to get people thinking about how healthcare is
rationed, and whether some parts of the NHS may have become too bloated at the
expense of simpler preventative intervention.
So, do you agree with my
tentative conclusion? Do we base too much of our health policy on the rule of
rescue at the expense of healthcare? Where should we draw the line between expenditure
on public health and on treatment?
- Daniel
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