Reporter 424, 5 October 1998

Viagra raises profile of health rationing debate

David Hunter is Professor of Health Policy and Management at the Nuffield Institute for Health. His book, Desperately Seeking Solutions: Rationing Health Care, was Joint Winner of the 1998 Baxter Healthcare Management Award. Here he explains why rationing should remain a clinical decision.

The goverment’s recent refusal to make Viagra available on the NHS has provoked protests – but the dilemma of rationing health care and treatment is not confined to such ‘wonder-drugs’ nor to the British National Health Service. All health care systems must confront the challenge of making choices between different types of medical care, and the individuals that receive it. These decisions are becoming more difficult in the face of new treatments, many of which can be used against disorders for which there was no previous remedy.

Because rationing (or whatever term is preferred) is pervasive, the questions for debate are: who should ration health care, and how should it be done? Many commentators believe the public should be involved in these rationing decisions, if only to dispel the illusion that an all-powerful NHS can do everything for everybody, regardless of cost. I believe such calls are seriously flawed.

Involving the public through surveys and focus-groups implies that rationing should become explicit and not remain the preserve of clinical judgment. In particular, supporters of explicit rationing believe that central government should give a national lead on such matters, stating clearly what the NHS will or will not fund.

Despite their superficial attractions, such solutions are ultimately politically naive. The demands of the ‘rational rationers’ for explicit rationing and more public debate risk over-simplifying and sensationalising complex issues, which is all too likely given the media’s recent handling of the subject. They overlook the politics of rationing and the messiness of the whole process. No minister is going to stand up and accept responsibility for life and death issues. Nor should they, when decisions are contingent on multiple, complex individual circumstances. As a result, any national guidance on rationing will be so vague and vacuous as to be meaningless.

Implicit rationing has much in its favour. Clinicians, in conjunction with patients and their carers, are best placed to reach treatment decisions. These are not issues on which an imperfectly and incompletely educated public can readily pronounce. Nor should they be asked to. We train and employ accountable professionals to take these decisions in partnership with individual patients, who often know a great deal about their own condition.

‘Empowering the public’, ‘explicitness,’ ‘transparency,’ and other fashionable managerialist fads may actually make the situation worse. The constant desire to probe, tinker with, and scrutinise the delicate workings (evolved over many decades) of the decision-making process could prove counter-productive and subsequently affect patient care.

Explicit rationing brings into a public forum conflicting needs and preferences which may be irreconcilable. What then?

Far from helping society to function better, such forensic behaviour may be creating a set of circumstances in which sensible business is impossible. Implicit rationing, in contrast is able to respond to complexity and diversity in a discrete, timely and sensitive manner. That it may fail on occasion is not a fault of the approach itself.

Rationing health care is a dilemma of public policy for which there is no perfect solution. Hence the preference for a humble, flexible strategy of ‘muddling through elegantly’. The present arrangements are far from perfect but any improvements must be sought incrementally, rather than replacing them with a spurious and potentially risky pretence at rationality.

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