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Rationing
of Health Care
The near hysterical reaction to calls for health rationing
is not because people are interested in the health of the nation
but because they are afraid of their own future, afraid of diseases
such as cancer and afraid of old age. Who will be there to care
for me when I am dying and alone?
Rationing has always been
with us. I remember my first year as a house doctor, straight out
of leaving medical school. One of my patients was a man dying of
kidney failure. We only had a limited number of places on the dialysis
programme. He was never offered the treatment because he was "too
old and not intelligent enough". But how to you decide? One
doctor commented that anyone who could start the last war in the
army as a private, and still be a private at the end with so many
losses, was clearly someone with limited abilities, who would be
unlikely to be able to manage dialysis machinery at home and would
"do badly".
I
would not seek to justify his logic, but some kind of rationing
is essential in any free system and to argue otherwise is foolish.
All free offers of things worth having tend to be oversubscribed
- which means that supplies run out, and then many people get nothing.
The answer is to manage supply and demand. True, we could always
boost taxation, until each of us is spending up to a third of all
we earn, paying our health insurance premiums to the government
in return for unlimited NHS treatment. However few people would
chose to do that. But even if the health spending in Britain was
trebled, there would still not be enough resources to meet every
wish. For example, if there was unlimited access to counselling
or psychotherapists or cosmetic surgeons or to infertility clinics.
So then, if it is true that whatever is free tends
to be undervalued and abused, then demand has to be limited in some
way, either by restricting supply on a priority basis, or by making
life difficult for people wanting more care. Both these systems
are operating. Doctors are vetting cases before treatment, especially
in fund-holding practices and in specialities such as neurosurgery,
and people are made to wait.
Waiting lists are the
oldest and most subtle rationing device. It starts to operate the
moment you crawl out of bed in the morning with a blinding headache
and decide not to bother the doctor because it will take twenty
minutes to get through the switchboard, and then half an hour to
get dressed, park and walk in, and then another half an hour to
an hour to be seen - if they will see you today at all.
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The waiting continues when your doctor writes to the
hospital requesting an appointment. By the time the date is confirmed,
many people feel better. The crisis is over and the thought of more
time off work or more favours begged from friends for childcare
is too daunting. And so it goes on. At every stage people melt away.
Only a few make it to the clinic, and then land up on another waiting
list for treatment.
However the latest revolution in the NHS has produced
trusts which are now taking the opposite line: in the past they
had no incentive to work hard, and indeed welcome the waiting list
system. Now many are vying with each other for patients, and we
are all bombarded with a subtle advertising campaign from the moment
we enter a hospital site.
There has been a dramatic change in psychology. Clinics
no longer keep people waiting. Casualty departments pride themselves
on rapid case assessment. More people means more money - but from
the same pot. This new welcoming face in hospital care has meant
that GPs are now being pushed to make decisions themselves about
rationing.
So what is the answer? The situation is made ever
more difficult by astounding advances in medical technology, some
of which save money, but most simply gobble up resources faster
than ever. Once a treatment is available (and free) the pressures
become almost irresistible to use is, especially where it is a matter
of "life and death", or where children are involved. The
slimmest hopes of cure drive doctors and patients alike to ever
more exotic approaches. But high-tech medicine is often medicine
gone stark raving mad, where those who are ill become dwarfed by
tubes, wires and machines in a desperate fight against the inevitable
in a culture that seems to see all death as failure.
Rationing has always been with us,
and should continue to be. The only alternative is an arbitrary
"first come, first served" handout of care packages
that will leave the less articulate and most vulnerable at terrible
risk of receiving nothing at all. Health care needs managing,
and we will all be healthier for it.
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Video / Articles by Patrick Dixon - 24 million requests in year - 10 million visitors - Conference Speech/Event? 
I
would not seek to justify his logic, but some kind of rationing
is essential in any free system and to argue otherwise is foolish.
All free offers of things worth having tend to be oversubscribed
- which means that supplies run out, and then many people get nothing.
The answer is to manage supply and demand. True, we could always
boost taxation, until each of us is spending up to a third of all
we earn, paying our health insurance premiums to the government
in return for unlimited NHS treatment. However few people would
chose to do that. But even if the health spending in Britain was
trebled, there would still not be enough resources to meet every
wish. For example, if there was unlimited access to counselling
or psychotherapists or cosmetic surgeons or to infertility clinics.
