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Getting to grips with health care rationing

Need, urgency and fairness should guide rationing, according to

Dr David Molyneux

emand for health care will always outstrip funding. Increasing the amount of money available will reduce the problem but is unlikely to eliminate it completely. Even in societies that spend a great deal more of GDP on health care than we do, the imbalance between provision and funding still exists.

Given this problem, what can be done?

Three solutions

lRationing of services Certain services are removed from the health care budget, but can be obtained privately. Examples might include dentistry, IVF or tattoo removal.

lRationing of cost per procedure Services are provided, but in a cheaper form. Sometimes this has little effect on quality. Substitution of generic for brand-name treatments is (usually) a good example. Sometimes quality is affected. Most GPs felt Department of Health advice to avoid SSRIs in favour of TCAs for the treatment of depression represented a decline of quality.

lRationing for individuals A service is provided but not for everyone. This is usually the most controversial form of rationing and raises ethical problems.

An example is explicit rationing of the prescription of Viagra to patients with certain conditions (diabetes, prostate cancer) but not to others (hypertension, depression). Why should one group be entitled to the medication and another have to buy it privately?

Poor rationing decisions

There do not seem to be any other separate methods for rationing, although many rationing decisions involve all three methods. How can decisions be made ethically to fund one service (or individual) over another? To answer this, it is helpful to set out inappropriate reasons for rationing.

lSelf-induced illness Individuals who (say) smoked would be punished both for getting the illness and again for not being treated. Smokers have often funded the health service to a greater extent through taxation.

lNumber of dependents Unfair and would penalise those who did not have children.

lMoral worth Difficult to assess. People who are real blackguards may be considered model citizens by their physicians.

lPatients' wants As opposed to needs. If wants were important, the health service might be hijacked by articulate demanding individuals, leading to huge amounts being spent on the worried well.

lAge Everyone has a right to life (murdering an 80-year-old is no less serious than killing a child)

lDisability Think how you would feel if you were denied health care because of a disability.

For these last two reasons, quality adjusted life years (QALY) measurements are suspect, because they automatically discriminate against the old and the disabled.

Fair and ethical rationing

Having eliminated these methods, then what is left? What would be a fair and ethical method of rationing?

lNeed It seems intuitively wrong to have a system where patients get breast implants, but there is no money left for surgery for early colonic cancer. How do we measure need?

Various methods have been used, none are completely satisfactory. Some countries (for example, Norway) have tried to produce a league table of need, with lifesaving treatment at the top, followed by treatment to prevent disability and suffering, and then treatment with a lesser degree of certainty that it would prevent suffering.

Despite the problems with wants (see above) there has to be some emphasis on patient autonomy.

Doctors alone cannot decide patients' needs. In Oregon, patients are involved in deciding a list of 'needs' and agreeing what the health service will provide and what it will not.

lUtility Need for health is not the same as need for health care. If someone has an untreatable condition, there is tremendous need, but no value in spending health care resources on an attempted cure (though money will still be spent on palliation). Similarly, futile treatments should not be funded.

lTime with the illness Someone who has just developed a hernia should not have preference over someone who has been waiting for two years.

How would this work?

Illnesses that are life threatening or causing severe disability would be targeted first. Treatments not proven would not be funded. For serious conditions that cannot be treated adequate resources should be made available for palliative care.

Uncertain treatments (some evidence for and against) would be tried until better evidence emerged. Futile treatments would be removed until there was new evidence for their efficacy. For non-urgent treatments, waiting lists would work on a first-come, first-served basis.

Increasing the amount of money available will reduce the problem but won't eliminate it completely~

ethics for the MRCGP

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