The real ethics of rationing
BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7100.112 (Published 12 July 1997) Cite this as: BMJ 1997;315:112
- Donald W Light, Glaxo-Wellcome visiting professor of primary care (dlight{at}fs1.cpcr.man.ac.uk)a
- a National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL
Introduction
Since 1996, the BMJ has published a series of articles about the nature of rationing in health care, several by the Rationing Agenda Group, an influential group of policy advisers.1 This brief essay will question some of their arguments and then suggest that the real ethics of rationing should first address the sociological and managerial forms of inequality, power, and privilege upstream that force rationing downstream at the point where doctors treat patients.
There is a strange kind of schizophrenia in the arguments about rationing. One part holds that funding for the NHS is adequate and likely to be so for the foreseeable future2; another holds that rationing takes place in the NHS and always will, because rationing is inevitable.3 Yet these two central themes of policy are not joined. Surely the amount and kind of rationing, affects perceptions of the adequacy of funding. If it does not, then “rationing is inevitable” can be a paternalistic justification for playing Scrooge. It can justify as low a level of funding and supply of doctors and nurses as those in power want. If we conclude from the start that we can never adequately meet all needs, why bother trying to meet them as inadequately as we do already? Why not cut the NHS budget by 10% or 20%?
“NHS funding is fine”
If we examine the funding article2 of the Rationing Agenda Group3 more closely, we learn that the extra burdens of aging fall within the projected growth of real NHS expenditures and that changes of morbidity will neither accelerate nor retard expenditures. The authors show that so called efficiency and activity gains are increasing faster than expenditures. Expectations may change, but they are subjective, political, cultural, and impossible to predict; so on balance NHS funding is likely to be adequate for years to come.
Summary points
One part of the rationing debate maintains that NHS funding is adequate by ignoring how much rationing takes place, and another part holds that rationing is inevitable; surely the latter affects judgment of the former
Our goal should be to minimise the need to ration by eliminating ways that entrenched institutional, political, and professional interests lock in waste, not to figure out how to ration fairly in the context of a segmented, unintegrated system with wasted resources. This is the real ethics of rationing
There are extensive inequalities that lead to rationing, the largest being unexplained inequalities in how many resources different doctors use; private insurance that skims off the easy, profitable cases rather than being structured equitably; and an arrangement that rewards minimising surgery to NHS patients in order to maximise private surgery. These inequalities should be eliminated
A central plank of the new charter for the NHS in 1998 should be to provide effective treatments at minimal cost in an equitable manner
One telling detail in this “funding is fine” argument is that no estimate is made for the increasing cost of improvements in technology and pharmacology. The authors indicate that past improvements have increased costs substantially but then make no provision for them in their estimates of how adequate NHS funding will be. Nor are these costs offset by any measure of benefits. Yet these are at the heart of modern medicine and of its ability to help patients reduce pain and regain health. Moreover, the article has a reassuring, Olympian—and unreal—tone, as if it were about a healthcare system with clean modern hospitals, good support staff, ample specialists and hospital beds, and prompt service. No mention is made of crumbling, unsafe hospitals; a £10bn backlog of needed maintenance; nurses and doctors stretched to the limit; million-plus waiting lists; and thousands of patients who never even get on the waiting lists, though little local difficulties are acknowledged in a subsequent article.4
This “see no problems” argument might be called the Procrustean bed approach to adequate funding: you set a budget, chop off what you cannot afford, and point out that the service fits into the funding. For example, when I helped to develop the first needs based purchasing plan for child and adolescent psychiatry, we found that about 90% of sexually and physically abused children, children with conduct disorders, and children with other important disturbances are not seen by a qualified mental health team because the training, supply, and funding of specialty teams effectively shuts them out.5 Yet there is no concern about the tragic consequences for these children or the large knock-on costs to the NHS, to schools, to the criminal justice system, and to welfare for not treating them. The funding is accepted “as is.” Many other subspecialties could document similar serious shortages.
The NHS already rations on a massive scale. The NHS rations by delay to get on waiting lists, and then on the waiting lists themselves, and then with the further wait after an appointment has been made. It rations by undersupply of staff, doctors, machines, facilities, etc; by undercapitalisation of run down facilities; by dilution of tests done and services received; by discharge earlier than desirable; and by outright denial to even the chance to wait or be undertreated. Yet the Rationing Agenda Group points out that no criteria have been established for defining need and for when rationing takes place. Lack of criteria and measurement can be used to conclude that rationing is not taking place.6 An important task for the medical and nursing professions is to establish criteria and a system for recording the clinical effects of undersupply and underprovision—for without documentation, any arguments of underfunding run on anecdotes.
Rationing is inevitable
Oddly juxtaposed to the argument that NHS funding is adequate are arguments about how to deal with the inevitability of rationing. But to say that “rationing is inevitable and therefore we should focus on how to ration reasonably” is like the medical profession deciding that “death is inevitable and therefore we should focus on how to die reasonably.” Death is inevitable, but the conclusion denies the whole purpose of medicine. Likewise, our purpose should be to postpone and minimise rationing as much as possible. This should be the first goal of the Rationing Agenda Group, and it forces us to be frighteningly honest about the ways in which current practices hasten and maximise rationing. But first I want to pause and address whether rationing is inevitable.
The myth of the bottomless pit
When the argument that “rationing is inevitable” is applied not to situations with effectively absolute shortages like liver transplants, but to the healthcare system as a whole, it assumes that there can never be enough money, or surgeons or drugs or child psychiatrists, to satisfy all the needs that people have. Interestingly, I hear this argument most in Britain, which spends the least money from direct taxes trying to meet those needs and demands. And I don't hear it from ordinary citizens, only from people with university degrees. Ordinary citizens tell me about a family member who is not getting adequate care for a serious health problem and wonder why. They don't know that they could get it if they were in a nation with an adequately funded free health service with no waiting lists, like Holland or Germany.
The claim that health needs are bottomless is an empirical question, not an assertion or article of faith. What makes it a myth and an indefensible form of paternalism is that no one making this claim goes out and tests it. Yet the depth of the pit can be determined by taking people in a well funded healthcare system who face no barriers of time, distance, money, or delays and measuring their rates of surgery, or drug use, or visits to the doctor. If the advocates of the bottomless pit are correct, average citizens in such a system would see the doctor every day, take multiple drugs, and have an operation a week. They and their doctors would come up with a new “need” as quickly as you can say “Rationing.” In fact, Dutch people or Germans see the doctor and have operations at somewhat higher rates than do the British, but the rates are far from infinite.
What this means is that rationing by any reasonable definition is avoidable, and the British can have a healthcare system without widespread denial of care, waiting lists, run down facilities, and underservice. It's just that the layers and layers of rationing and underprovision make it seem as if the pit of medical need in Britain is bottomless. For if tomorrow all those waiting more than eight weeks for specialty services were seen, the increased supply of specialists and availability of services would lead general practitioners to put forward patients whom they are now keeping off the lists. To minimise the danger of provider induced demand, however, it is vital that agreement be met and criteria set for the levels of need to be attended.2
Upstream sources of rationing
While healthcare systems are inherently “inefficient” compared with most industries, NHS resources are substantially locked up in organisational, professional, and political arrangements that force rationing downstream. The real ethics of rationing should focus on these arrangements, for when moral philosophers or concerned individuals focus on how to ration fairly in a given situation, they in effect legitimate and support those who have set that budget or who benefit from institutional, budgetary, or professional arrangements that help produce the existing situation of scarcity. The first priority of moral philosophy is the ethical dimensions of the larger political system and institutional arrangements, not the ethics of individual cases. Now that bioethics has reduced paternalism in doctors, it is time to attack more powerful forms of paternalism upstream. This is the real ethics of rationing, the kind of bioethics we are developing at the Center for Bioethics at the University of Pennsylvania under the leadership of Arthur Caplan.7 It holds that principlism (medical ethics deduced from abstract principles) has serious limitations and that bioethics must be fully engaged with the social sciences and empirical studies. I shall illustrate this approach by describing briefly some upstream causes of rationing faced by patients and their doctors.
Entrenched waste causes rationing
If the government and the healthcare professions seriously want to minimise the rationing of care to sick patients, they need to address the sorts of waste that have been identified by the Anti-rationing Group8—including overtesting, inappropriate prescribing, the organisation of follow up for new outpatients, and the provision of care by doctors that can be done by nurses.9 The Anti-rationing Group has concluded that if these sources are eliminated, the waiting lists “would disappear within a year, never to return.”
Beyond these documented forms of waste that lead to rationed services are other forms entrenched in the structure of the NHS, like budgets and contracts that protect hospitals, consultants, and general practitioners from more cost effective forms of integrated services through integrated contracts. Other forms of waste which I found seven years ago and which still remain lead to low productivity, high staff turnover, and gross underuse of facilities.10
The sociological and ethical point is that these forms of waste do not merely exist; they reflect powerful interests that give priority to their own concerns over treating sick patients on the waiting lists. They remain entrenched because there are no rewards or penalties attached to the degree of health attained or even to the amount of disability and pain caused by protecting forms of entrenched waste. Will the new government's “relentless war on waste”11 and policy of integrated services take on these sources of waste?
Critical to reducing such waste and the need for rationing is the strong implementation of evidence based medicine.12 So long as good outcomes are not measured and resources directed towards them, everything will be a “cost” without a benefit and wasteful practices will have equal weight with effective practices. As Muir Gray points out, the NHS must shift from maximising the number of episodes, as the efficiency index does, to maximising the number of effective interventions and beneficial outcomes. Fortunately, the new government promises to implement this historic change.11
Unnecessary rationing caused by inequalities
Inequalities in health care are an upstream cause of clinical rationing for less advantaged people downstream. The new government is committed to reducing differences in access for patients of fundholding versus non-fundholding practices, but this will leave three other forms of inequality that are more substantial and better documented: unequal funding between regions, unequal funding between districts, and unequal use of resources by general practitioners. Clinically unexplained variations in treatment and referral rates due to differences in “practice style” are forms of inequality that force others to be rationed.
Parasitic privatisation
Although private work is a fact of life, it should not exploit NHS patients and resources to create large inequalities that need not exist. But the NHS suffers from a two tier system of parasitic privatisation. One part consists of laws that allow private insurance companies to write policies that cherrypick the acute, easy cases and healthier people, leaving the NHS with proportionately more of the chronic, difficult cases and ill people. The private insurers also exploit subscribers; in recent years they have gone from keeping 11% of premiums for themselves to keeping 20%.13 I know of no good moral defence of risk rated health insurance,14 and bioethicists should insist on its being abolished. Just like a parasite that weakens its host, these laws foster more inequality and rationing. They need to be changed quickly, before private insurance expands, to laws that prohibit selection on the basis of risk and require community rated, egalitarian policies like those in Holland, Ireland, and other countries where insurance companies subscribe to these principles of solidarity.15
The other part of this two tier system causes a 30-fold difference in access to surgery between patients who can afford private care and NHS patients. One group waits 3-6 days, the other 3-6 months. This gap, I contend, is caused in whole or in part by an arrangement that rewards rationing surgery to NHS patients in order to maximise surgery to private patients. NHS surgeons do very little surgery in a week, averaging only 3-6 hours at the table compared with 20 hours at the table for full time surgeons elsewhere.16 17 18 If NHS surgeons operated on NHS patients just 15 hours a week, NHS patients who now wait 3-6 months or longer would wait only 3-6 days, like private patients. Employers and subscribers would save millions in premiums they now pay for private insurance they would not need.
At the heart of this manufactured inequality that makes access depend on having money is a two tier system of little accountability, loose requirements, and the “maximum part time contract.” This contract allows surgeons and other consultants to give up just 9% of their full time NHS salary in return for doing all the private work they want at rates that are many times their NHS rate of compensation. (The high private rates also mean that people with private insurance are paying much higher premiums than they need to.) Moreover, as consultants have explained to me in detail, they have to show up for a maximum of only 3½ days a week, giving them plenty of time to do private work on a nearly full time contract. To top it off, the surgeons control the waiting lists.
This arrangement provides strong incentives to minimise (that is, ration) operations for NHS patients and use the NHS as an operating base for maximising private work. The shortages in admission beds, theatre nurses, and recovery beds, as well as the short hours that NHS surgeons operate, can be partly traced back to the perverse incentives of this open ended invitation to ration services for NHS patients, with corrupting effects. I have been told by consultants that some surgeons walk out with NHS x ray films for their private patients under their arm. This is stealing. If a cook walked out with a ham, she or he would be arrested. Some surgeons work out deals with general practitioners to take care of their NHS patients promptly if the general practitioners will steer patients who can pay over to their private practice. Some surgeons are said to manipulate their waiting lists and what they tell a given patient in order to get patients with money to go private. I am told that the distorting effects of these “sweetheart contracts” lead the minority who exploit them to believe that politicians and NHS patients should feel grateful for whatever work they do for the NHS, given the pittance of £50 000-70 000 of lifetime salary, plus pension and perks, they are paid for the 91% of the time they are supposed to spend treating NHS patients. As Frank Dobson says, staff find the effects of two tier medicine “repugnant,”11 and the chairman of the BMA's Council, Sandy Macara, told the plenary audience at the Institute of Health Service Managements' June meeting that he thought consultants should work full time for the NHS.
Given the reality of private work, consultants should work full time for the NHS or full time for the private sector. Consultants should not manage the waiting lists. They are a payer's tool for maximising equity and efficiency in allocating work. Most consultants dedicate long weeks to helping NHS patients, but as the 50th anniversary of the NHS comes up, this structure for manufacturing inequality should be eliminated. A central plank of the new charter for the NHS in 1998 should be “to provide effective treatment at minimal cost in an equitable manner.”
Conclusion
Concern about rationing should focus on how to minimise it in the first place, by eliminating large sources of waste built into the organisation and structure of the NHS and by ending parasitic forms of privatisation that allow the privileged to ration ordinary citizens. If the new government delivers on its deep commitment to equality, most forms of rationing and long waiting times will come to an end.
Acknowledgments
This is a shortened version of the inaugural lecture given at the Institute of Medicine, Law, and Bioethics of the University of Manchester on 26 March 1997. I thank Professors Max Elstein, Martin Roland and David Wilkin for their role in this lecture and am grateful to an excellent referee and several readers for their critical comments.