Health care rationing used to conjure up images of wartime austerity, of bureaucrats meddling in matters of medicine and children being denied life-saving treatment. It was not, until recently, associated with the NHS. That is starting to change. Examples of people being denied treatment regularly appear in the press. A man can no longer receive physiotherapy because he is too old; another man is denied a heart operation because he refuses to stop smoking; a couple in one part of a town receives fertility treatment while another couple in another area does not.
Rationing has come as a surprise to the British public, but in fact it has always existed within the NHS. Because of its life and death sensitivity politicians usually deny its reality. I want to look at the way it has operated in the past and how this is changing.
How does rationing work?
A political decision was taken during the second world war that something as important as health care should be provided free at the point of use: one's level of income should not influence one's access to health care. But although the price mechanism does not operate for individuals, scarcity and opportunity cost are still present. Resources that are used for health care cannot also be used for education, housing or the production of television sets. More specifically, resources devoted to treating those with heart disease cannot also be used to treat those who are mentally ill. Further, because patients do not bear any of the cost when they use NHS services, they may demand repeated diagnostic tests, the most expensive drugs, or long consultations with their doctors-quite reasonably wishing to maximise benefits for themselves, without considering the limits imposed by broader resource constraints. So rationing must take place to bring the demand for health care into line with available supply.
The need for rationing was not initially recognised by the architects of the NHS. In 1948, it was believed that as the service developed, the need for spending on health would diminish as existing ill health would be "mopped up." At the time, ill health was in large measure the result of easily curable diseases such as tuberculosis and poliomyelitis. But the eradication of such diseases revealed a deeper well of ill health. As premature deaths were reduced, an ageing population increasingly suffered from chronic conditions such as cancer and cardiovascular disease. Health technology also made previously incurable conditions treatable. For example, premature babies who would once have died began to survive. Care for these babies is very expensive and many are handicapped, needing care for the rest of their lives.
It soon became obvious to the NHS's political masters that, because of these pressures, the NHS would be permanently faced with demands greater than the available resources. Charges were levied for some prescriptions (causing Aneurin Bevan's resignation from the Labour cabinet in 1951) as a means of reducing demand and increasing revenue. But the financing system remained open-ended, with the pressures on resources being met by supplementary estimates voted by parliament. Hospitals which ran out of money simply submitted claims for more. In 1950 a ceiling was imposed on NHS hospital expenditure within any one year. The fixed budget was born; to this day it forms the basis on which the NHS manages its financial affairs.
Hospital authorities had to work within their allocations. Those allocations remained based on inherited patterns of provision from the pre-NHS local health authorities, which favoured the better-off areas. Gradually, allocations became fairer, based on measures of population need. But the way in which resources were allocated by hospitals and health authorities remained largely implicit. Attempts by the centre to reallocate resources-in favour of the so-called "Cinderella" services for the mentally and physically handicapped, and the elderly-were often frustrated by the medical profession at the district health authority level. The centre's influence over rationing at the hospital unit level-for example, between acute specialities-was negligible. Such rationing mechanisms that did exist remained hidden from view. In a famous book by two Americans H Aaron and W Schwartz (The Painful Prescription, 1984), the British hospital was described as a "quasi-feudal enterprise, ruled largely by a peerage of consultants... who must parcel out the meagre rations allotted through the health district. British consultants are responsible, directly or indirectly, for the disposal of almost all the hospital's resources. The typical British hospital administrator, unlike his US counterpart, has little power or authority in his institution."
At the level of individual treatment, the waiting list remains the principal mechanism for reconciling demand and supply in the NHS. Individual consultants decide which patients are admitted, when, and for how long.
Rationing in practice in the 1990s
In the 1990s a series of NHS reforms were introduced which have had some impact on the nature of rationing. The distinction was made between purchasing agents (commissioning health authorities, general practioner fundholders) and providers (hospital and community health trusts).
The budget of the NHS in England in the early 1990s was approximately ?30 billion. This figure is allocated to the 90 or so commissioning agencies responsible for individual districts. The allocation is calculated by means of a formula reflecting the population characteristics in each district: for example, an area with a large proportion of elderly people will receive relatively more than an area with a younger population.
As well as this formal allocation, the department of health issues a range of directives and guidelines designed to influence the work of local agencies. For example, the patients' charter specifies a variety of maximum waiting times, such as 18 months for all in-patient treatment. Commissioning agencies thus have to balance a large number of central priorities with those they may identify themselves in the light of local circumstances. The result will be an allocation of the budget between various care groups. The health authority in Chichester had a budget of ?65m in 1993-94; the chart (right) shows how this budget was shared out between various hospital services (not including primary and community services). This money would have been passed on to various providers via rather loose contracts.
There will usually be a strong clinical presence in the sectoral allocation decisions shown in the chart, even though they are administrative in nature. At the hospital level, the money from commissioning authorities must be further allocated to particular services under the supervision of individual consultants. It is these consultants, and their management of waiting lists, who provide the final link in the rationing chain.
Waiting lists are like clothes pegs on a line from which the consultant chooses, rather than a queue operating on a "first come, first served" basis. As well as the wait for in-patient treatment, there are also waiting lists for those who have been referred by a GP but have not yet had their first meeting with a specialist. There are no explicit criteria for decisions about how long patients must wait, or about who gets referred and accepted for treatment and who does not. Along with decisions involving treatment, they constitute a doctor's "clinical freedom."
The above system is now evolving further. Here are some examples from different parts of the system:
The government: central government has specified waiting limits-for example, out-patient appointments (26 weeks), treatment (13 weeks) and emergency admissions (2-3 hours). In effect, "time waiting" is being promoted as an important criterion for rationing resources. Local commissioners must give priority to non-emergency treatments where people are waiting; service providers (consultants) should give priority to people who have waited a long time over those who joined a waiting list more recently. This is not as self-evidently reasonable as it sounds; it may encourage health authorities to allocate resources to long waiters, who are not seriously ill, thereby diverting resources from those more seriously ill. The president of the Royal College of Physicians suggested during the course of 1993 that this was indeed happening and that urgent cases were on occasion delayed admission.
The purchaser. During 1995, an internal memo from Berkshire Health Commission was leaked suggesting that 12 procedures would be removed from NHS provision in order to address a funding shortfall. These included in vitro fertilisation and tattoo removal. This caused a huge row because of the perceived abandonment of the NHS's comprehensive service. As a result of the protest, the Berkshire initiative was subject to "clarification." The authority stressed that it was not, in fact, proposing to withdraw services entirely and that where there was a clinical need they would still be provided.
The provider. In a hospital in Salisbury, consultants were asked about the criteria they used when deciding when to admit patients. The results were transformed into a points system under which patients were weighted according to their score in five categories. The five categories were: speed of progress of the disease, pain or distress, disability or dependence on others, loss of occupation and time waiting. Each could be scored from one to four points, depending on the condition and circumstances of the patient. The consultant who runs the scheme was quoted as saying that if there were only funds to treat patients who score two, three or more, then other patients with minor conditions would not be put on waiting lists.
What should be done?
The pressure on the NHS to deliver more health care, year after year, has been with it since its creation. An ageing population, developments in technology and more assertive consumers mean that the demands on the NHS are growing even faster. But so is its ability to respond. Spending in real terms has increased by approximately 100 per cent between 1974 and 1994. When this figure is adjusted to take account of the higher than average inflation rate for health care services, the increase is still 50 per cent. The number of operations and consultations, for every pound spent, is far higher now than in the past. So there is no strong evidence to suggest that the NHS cannot manage the demands which will be made on it.
But the pressure on the system of implicit rationing described above will grow. Implicit rationing has helped to perpetuate a benign deceit in the NHS. A doctor who says "there is no more that we can do" is often really saying "it is not worth the small benefit-and probable distress-which continuing this treatment will occasion when we only have limited resources." Furthermore, medical assessments are intimately tied up with a particular culture of resource constraints. Doctors, almost subconsciously, adjust clinical judgements in the light of what they know resources will allow them to do.
This system has worked remarkably well for the first 50 years of the NHS's existence, particularly in terms of sustaining public confidence. However, towards the end of the 20th century, a less acquiescent citizenry is beginning to question how health care is delivered. If the NHS is to continue to command public respect, progress is needed in a number of areas. First, the government must acknowledge the inevitability of rationing. The NHS will not continue to enjoy mass public support if it is perceived to be saying one thing and doing another. Second, the political centre should take responsibility for some rationing decisions. The NHS is predominantly a locally driven institution. This means that there are wide variations in the level of service in different parts of the country. Very often this is justified, but it is not appropriate that local health authorities should be free to decide what constitutes the range of NHS responsibilities. Fertility treatment, long-term nursing, cosmetic surgery, adult dentistry, sex change operations-all these services are increasingly patchy in their availability. It is patently inequitable that an individual's place of residence should determine whether he or she has any chance of receiving services on the NHS.
Third, more information is needed about how rationing decisions are currently being made by doctors. It may be that doctors are regularly using characteristics such as age, the existence of dependants, or lifestyle to discriminate between patients. If so, is this appropriate or should doctors only refer to characteristics such as the extent of ill health or the cost effectiveness of treatment?
Finally, there is a need to develop ways of involving ordinary citizens in making rationing decisions. Experimentation is already underway with citizens' juries. These juries consist of a small number of people randomly selected to represent their community. They are give a number of days to deliberate on decisions of public policy and are provided with evidence and allowed to cross-examine witnesses. The juries would seem ideally suited to the complex but fundamental issues of health care rationing.
