Rationing health care: moving the debate forward

Groups in Britain are encouraging the debate that the government won't lead

When governments and politicians do not act, the people may. In Britain neither the government nor the main opposition party will openly acknowledge the inevitability of rationing health care. Instead, they talk of increasing the effectiveness of health care, spending more on the health service, and setting priorities locally.

Their implication to the public is that nobody will be denied potentially beneficial treatments. But almost all of those who spend any time studying this subject recognise that people have always been denied potentially beneficial treatments, and they always will be no matter how much is spent on health services. These commentators believe that governments should come clean with the public and lead a debate on how best to ration health care. Because British political leaders will not accept this challenge, various organisations and ad hoc groups have begun to try to find ways to include the public in the debate on rationing health care. Some of these initiatives are covered in this week's and last week's BMJ.

Most commentators accept that rationing is inevitable, but the debate keeps returning to this point because the politicians refuse to acknowledge it. Yet many health authorities in Britain are explicitly excluding beneficial treatments.1 Some sorts of care that were once available on the NHS—adult dental care and long term care of elderly people—are falling away. Britain's mental and geriatric health services are threadbare. Doctors' time and attention—which are effective in themselves for many conditions—always have been and always will be rationed. New and expensive treatments, like interferon beta for some sorts of multiple sclerosis, are not available to many people who might benefit from them.2

The British government likes to suggest that the drive for effectiveness will obviate the need for rationing. No doubt substantial sums can eventually be saved by stopping ineffective interventions, but there are increasing examples of treatments that have been proved effective but which are hugely expensive when given to certain sorts of patients. Thus statins have been proved beyond doubt to reduce deaths in patients with coronary artery disease and raised serum cholesterol concentrations. But the cost of a life year saved in women aged 45-54 years with angina and a cholesterol concentration of 5.5-6.0 mmol/l is £361 000 ($541 500).3 The same story—of proved effectiveness but impossibly high costs for some patients—is true for treating patients with hypertension with angiotensin converting enzyme inhibitors, screening for cardiovascular disease,4 and many other interventions. The last drops of effectiveness are available at unaffordable costs, which means that decisions must be made to deny some people effective treatments.

The debate over rationing should not be confused with debates over effectiveness and funding of the health service. Few people disagree with the need to increase effectiveness, and there is little controversy about denying ineffective treatments. Many people in the health service think that more funds should be available for health care, and many members of the public support such a proposal. But these are separate debates. More effectiveness and more money will not remove the need to deny effective treatments.

In other countries, governments or state legislatures have taken the lead in the debate on rationing health care. The well known Oregon experiment is almost a decade old,5 and the governments in Sweden,6 Norway,7 New Zealand,8 and the Netherlands9 are all active in continuing projects to involve the public in rationing health care. In Britain several local health authorities have consulted the public on the subject,10 various researchers have sought the public's views,11 12 the BMA has passed motions at its annual meeting calling for a national debate on rationing,13 the Royal College of Physicians has called for a national council for health care priorities,14 and the media keep returning to the issue as cases of “rationing” are uncovered.