Rationing and Rationality in the Health Service

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

The Case for Space

Space exploration is often seen as an excess of Humanity, funded at the expense of more important needs. Surely the 150 billion dollars spent on the International Space Station would have been better used combating poverty, or cancer, or climate change? However, people often don’t look beyond the immediate and the conspicuous elements of space travel, and thus ignore the important effects that space exploration has on civilisation.

For a long time space exploration has perched on the edge of technological know-how. Many people are familiar with the fact that the Moon landing was achieved with less than the computing power of a pocket calculator. The list of technologies that were either developed or improved through the space programme is enormous. A cursory glance at Wikipedia’s ‘NASA spin-off technologies’ page will show you an imposing list of such technologies, including light-emitting diodes (LEDs), radically improved solar energy and structural analysis software. Whilst even these important technologies pale in the face of the many billions that were poured into the Space Race, they cannot be ignored when looking at the value of that funding.

Space exploration is not just about landing people on other planets; it is about putting satellites into orbit, sending unmanned probes to distant reaches of the solar system, and learning more about the Universe we inhabit. The benefits that satellites have brought us are immediately clear – information networks, weather forecasting, monitoring farming, atmospheric studies and so on. An understanding of climate change, a phenomenon that could prove to be the greatest threat humanity has ever faced, would have been immensely more difficult had we not made such concerted efforts to leave the planet. Our ability to communicate would also have been greatly diminished without satellites that can send signals to the other side of the Earth in a fraction of a second.

Sending unmanned probes has improved our knowledge of other planets and other-worldly bodies, and by extension has augmented our understanding of our own planet. By looking at how the climates of planets like Mars and Venus have changed we gain insight on the mechanisms that affect our own. Space-based telescopes have allowed us to peer into the depths of space, showing us a previously hidden Universe that has lent help to our knowledge of physics. Even today space exploration is trying to answer the most important questions that we can ask: Are we alone? Why is there something instead of nothing? What does out future hold? In this respect, space exploration is a necessity for us to satisfy our species’ endless search for knowledge and new frontiers.

Our tentative first steps into space have also had a cultural effect. The heavily publicised major events of space exploration have likely inspired a generation of engineers, scientists and technologists. It was an affirmation of the exciting ideal that anything humanity can imagine, it can achieve; to paraphrase Kennedy, ‘We choose to go to the moon not because it is easy, but because it is hard’. Undoubtedly the earlier stages of the journey into space may have had an even greater effect if it was in the spirit of co-operation, as it is increasingly nowadays, but the direct and indirect effects of the events that captured the entire world’s imagination cannot be understated.

Our decision to beginning, and continue, our forage into space will be crucial to Humanity’s long-term survival. The impact by a large asteroid (or similar apocalyptic event such as nuclear war) is not a matter of if, but when. We will be very glad when that we started when we did, when that time comes. If we had dismissed space exploration as an unnecessary luxury, we would have literally putting all our eggs in one basket. It only needs one rouge comet (or nation!) to put an end to virtually all human life on Earth, and at least now we stand a fighting chance at being able to do something about it.

 

Some of the effects of space travel are not easily tangible. Arguably pictures from space, such as Earthrise (right) or the Hubble Ultra Deep Field (see elsewhere) have given many people a new world-view. To see our small oasis in an endless sea of unforgiving space underlines our need to protect it, and maintain a sense of perspective. In the words of Carl Sagan:

“Look again at that dot. That's here. That's home. That's us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every "superstar," every "supreme leader," every saint and sinner in the history of our species lived there--on a mote of dust suspended in a sunbeam.”

- Daniel