Health-care rationing comes into the open

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HOW SHOULD health care be rationed? The very idea that it needs to be rationed at all seems to strike at the roots of the National Health Service, for the 1946 NHS Act provided for 'a comprehensive health service designed to secure the physical and mental health of the people'. Opinion polls suggest, moreover, that voters in Britain strongly oppose the rationing of health care, even for non-essential treatments.

In practice, though, the NHS has rationed health care ever since it was set up, partly by imposing a queuing system, and partly by doctors making what appeared to be clinical decisions about treatment which were also economic decisions. Take the use of intensive care facilities: these are - and were - much less likely to be made available to people over 75 than to the rest of the population. Doctors make their own judgements between available resources and patient needs, rendering the rationing element almost invisible to the layman.

Now, three things have happened to alter the public perception of NHS rationing and its acceptability. We have become less willing to wait for treatment. A more articulate and 'consumerist' attitude among patients is challenging the 'doctor knows best' approach. And some of the doctors' discretionary power to ration treatment has passed to hospital administrators, whose responsibility is seen as financial, not clinical.

As a result, while there may have been little change in the fact of NHS rationing, we feel less and less comfortable with it. So it takes courage to say that health care must be rationed and call for a debate about how to do it. That is why a new paper by the left-of-centre think-tank, the Institute for Public Policy Research (Rationing Health Care, by Stephen Harrison and David J Hunter) should be welcomed.

It tracks through the three really big questions. Who should make the rationing decisions? What are the right criteria? And what mechanism should be used to enact them?

There are five candidates for making the decisions: the medical profession, the health authorities, the public, the government and the courts - and there are problems with all of them.

Once upon a time the obvious answer would be the doctors. But people trust doctors less, or at least are more likely to challenge their decisions. In any case, the medical profession is not in a position to give guidance as to how much money should go into health care, as opposed to education, housing, consumer durables or holidays. The health authorities are distrusted as unelected agents for central government. The public, already opposed to the idea of rationing, tends to be unwilling to make hard choices and lacks the background knowledge to do so in an ordered way.

Central government will inevitably have a say, but there is no direct link with voter preferences for health care. As for local government, the IPPR argues that local authorities might have a greater role - but this raises what might be called the 'Westminster Council objection': do we really want councils to allocate health care in the same way as they allocate housing? As for the courts, they may have a greater role in future, but it is difficult to see that as an attractive solution.

Moving to the criteria for rationing, the waters become even deeper. There are, in particular, two pioneering experiments that seek to establish such values. One is the 'Oregon experiment'. Since February this US state has run a scheme that tries to extend health care to most, if possible all, those 16 per cent of the population with no health insurance.

The plan was to extend the Medicaid programme, which covers about half the people below the poverty line, but spread its dollars more thinly so that more people were covered. Resources were increased by using revenues from a tobacco tax, but care had to be restricted. Medical professionals drew up a list of priorities which was modified after public consultation. The result is that priority number 695, a liver transplant needed because of alchohol-induced cirrhosis, does not get treated, while number 365, a liver transplant where no alchohol is involved, does.

The other interesting approach comes from Britain, where we are calculating the cost of each 'Qaly'. A Qaly is a 'Quality Adjusted Life Year' and the idea is to work out how cost-effective a medical procedure is in adding a year of decent quality to a person's life. The single most cost-effective step is for GPs to advise their patients to stop smoking. This is followed by heart pacemakers, hip replacements and heart- valve replacements. The least cost-effective is renal dialysis in hospital, followed by heart transplants, and (surprisingly, perhaps) breast cancer screening.

There are many objections to this method of assigning priorities. And the concept of a Qaly does not encompass treatments such as in vitro fertilisation for childless couples, something that seems to come very low in public perceptions of priority, yet has given enormous joy to many couples. What price you put on a life may seem a tough question, but what about the price you put on human happiness?

Finally, we turn to the mechanisms that are used to enact the decisions: the IPPR suggests two options. One is that local organisations should have a role in rationing health care; the other that there should be national health-care rights.

The IPPR is quite keen on both, pointing out that the two could be combined. Many people, however, might resist the idea of handing the authority to assign health priorities to councils that have difficulty running housing estates. It would, as the IPPR acknowledges, require a complete change in local government. But the idea of national health-care rights, perhaps using Oregon's method of establishing priorities for treatment, does seem useful. At least people would then have to confront the fact that priorities have to be set, and any decisions reached by popular consent would have a certain legitimacy. The main danger is that people would not accept the priorities and would keep calling for more to be spent on health - without accepting the corollary, that in other respects they would be poorer.

No solutions? No. But the IPPR should make us think.