Ahead of NHS Providers' annual conference and exhibition conference 2022, Dr Julian Sheather reflects on healthcare rationing in the NHS and the need to transform the debate around prioritisation.
This winter we are set for a fresh intensification of an enduring phenomenon: scarcity. More specifically, how to manage the allocation of a valuable resource, the demand for which significantly outruns supply.
Outside of state obligations the market does its cold magic: as scarcity of desirable goods increases, prices rise. If you cannot afford something – or the opportunity cost is too great – you don't get to enjoy it. Fairness is not the issue: it's purchasing power. Few of us have qualms about this when it comes, say, to buying Maseratis. But health is foundational. Without health we struggle to lead the lives we choose.
Unlike a market, the state has equal obligations – legal, ethical – to all citizens, irrespective of their purchasing power.
Specialist Adviser in Ethics and Human Rights
Which is why, in the UK, healthcare – unlike the purchase of Maseratis – is socialised. Because of its importance, we provide healthcare free at the point of need. The money comes from taxation. Our risks of ill health are pooled. None of us worries if an episode of sickness will bankrupt us with health costs. But unlike a market, the state has equal obligations – legal, ethical – to all citizens, irrespective of their purchasing power.
So what does fairness in the state distribution of health goods look like when need overwhelms supply? Who should get priority and why? And almost as important, who gets to make such decisions and how? Questions of substance and of process.
Rationing and the relationship with the NHS
Rationing is – and has always been – a feature of the NHS. The two ordinary approaches are waiting lists and dilution of care. We are not seen as early as, ideally, we should be, and we may not get all the care we could benefit from. In reasonable times this largely holds together. But we are not in reasonable times.
A combination of progressive funding decisions and unanticipated, if broadly predictable, events – most obviously COVID-19 – have put the NHS under the greatest pressure in a generation, maybe more. In the short-term, NHS leaders are warning of a bitter winter: urgent and emergency care, along with ambulance waiting times, are where the big, immediate risks lie. But winter pressures are squeezing an already throttled system. Add in demographics, a cash-starved social care system, medicalisation and the ballooning costs of medical tech and without significant investment, you have a system unable to deliver care to a standard anyone can accept.
At the heart of rationing is an unpalatable truth: some serious health need will not get met.
Specialist Adviser in Ethics and Human Rights
At this point the word rationing gets bandied about more often. At the heart of rationing is an unpalatable truth: some serious health need will not get met. No incumbent government wants its voters to hear that, so they pass the buck: it is for clinicians to prioritise. Talk of clinical priorities has a reassuringly scientific ring to it: it is all about clinical data. If we are lucky the intervention may have a National Institute for Health and Care Excellence (NICE) seal of approval – cost effective as well as clinically indicated. But a word about cost-effectiveness and the utilitarian ethics that lie behind it.
Ethical factors of rationing
When it comes to deciding the allocation of health care, value for money – or maximising the benefit in health gain from every pound spent – is only one of the ethical factors in play. By itself it can lead to repugnant conclusions. It can undermine plausible claims to rights to certain kinds of treatment. The interests of people with rare, disabling conditions that are expensive to address can be ignored. It can also contradict deeply-held professional obligations to give priority to those in greatest need. It is unclear, for example, that a strictly utilitarian approach to rationing would support intensive care units. Even at its simplest, rationing involves negotiating between population wide utility and the fundamental rights and interests of individuals.
There is also the problem of comparing different kinds of suffering – sometimes called the incommensurability problem. Is there a single scale on which we can weigh the suffering of depression and diabetes such that priorities are transparent? And consider the issue writ large: is the relative underfunding of mental health care justified on utility grounds, or are prejudicial social attitudes still at work? As even NICE agree, there is simply no escaping value judgement when it comes to rationing health care services.
Transforming the rationing debate
In such complex and contested territory moral concern often shifts to the process behind decision making. We may not be able to agree on the decision, but we can agree on the process for making it. And this is where we must transform the rationing debate.
Serious public engagement and deliberation is required about health priorities in the face of extreme shortages.
Specialist Adviser in Ethics and Human Rights
Serious public engagement and deliberation is required about health priorities in the face of extreme shortages. And this must be followed through with political commitment to realising the outcomes. Sticking our fingers in our ears and chanting "la la la" in the hope that someone else will carry the can is no longer an option. And as we are talking ethics, any such debate must be driven by core virtues, most obviously honesty and courage. Real political courage is required to tackle this issue.
We are at the end of the era for political fudges in the health services. Time to be clear about our priorities – and their consequences.
Dr Julian Sheather will join us as a panellist for our 'Radical innovation for a resilient health service' plenary at this year's annual conference and exhibition on the 15-16 November at the ACC Liverpool. See the full programme here.
There's still time to get your tickets and follow the hashtag #NHSP22 on Twitter for all the latest updates.
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