Think about rationing

 Resources for health care be they people, knowledge, time or money are and always have been limited. Rationing seems to be a word not terribly much used in polite company. For the kidney community it has uncomfortable connotations harking back to our history of slow uptake of dialysis and hospital committees to decide who will be the lucky few.

I remember as a house officer presenting the clinical details of individual patients with end stage renal failure in the seminar cum coffee room. Followed by the nursing assessment of suitability and ability to cope, social work comments on employment and family circumstances and then a discussion about who would benefit most, what the implications for the dependents might be and how to allocate resource. Said another way, who should be started on dialysis, it was not really an offer, and who did not make the cut because of the limited dialysis space that we had available. Back then the acceptance rate was about 32 per million of the population per year compared to 110 PMP now. Peritoneal dialysis was just about to start. Occasionally, a space did become available when sadly; a dialysis patient died or someone was transplanted. It was a time, when uraemic frost and pericarditis were frequent clinical signs and the management of the intractable hiccups of renal failure were second nature to our ward sister who taught us  the ropes and kept us in line.

While those days are long gone, concerns about resources, choice for patients and the prospect of a return to rationing are again rising. The Nicholson challenge, to save £20 billion pounds over the next 4 years, has bought health care costs centre stage in England. Other western economies face similar financial challenges. In the USA for instance, the spending on health care is predicted to rise to 19% of gross domestic product by 2019. That is only 7 years off and it would be nearly double the UK cost. Our populations are also aging and the number of adults of working age  in the UK  to the elderly will  halve in my lifetime. The pattern of disease is changing from acute to long-term conditions; from single conditions to multi-morbidity and from health care managed to self-care.

So, “can you cut health care spending without undermining the quality of care?” yes, there are significant inefficiencies, yes, we can do things differently and yes, the “new technology” can help, but it is still the £100+ billion pound question. I am a believer that we can have a healthy population, deliver efficient and effective health care and support self-care with the resources we have as a nation. We need to tackle some of the wider determinants of poor health and outcomes- poverty, education, joblessness; be good stewards of the NHS and promote greater health literacy and self-management. There are many individual examples of high quality and high value care that costs less than traditional models of care in the kidney world and wider health economy. I do not know if we could deliver the Nicholson challenge by adopting all these practices more widely but I do know that the more people who do adopt them, the more likely we are to achieve our quality and financial goals.

To invest in higher value activity, we will need to disinvest in lower and no value activity. Therein lies the problem and perhaps lurks rationing. There are few things we do on purpose in health care that add no value to anyone.  Unsafe practice that causes harm is perhaps the exception- of course that is not done on purpose. Certainly unnecessary falls resulting in fractures, health care associated infection and drug errors are still common, and do cost an awful lot of money. I doubt we can save £20 billion pounds from better safety alone. 

So the publication Thinking about rationing by Rudolf Klein and Jo Maybin from the King’s Fund is certainly timely. The authors argue that rationing has been a fact of life for the NHS since its launch and that it is going to be a dominant issue in the hard times ahead. They carefully identify the different types of rationing- by denial, selection, deterrence deflection and perhaps most insidiously of all by dilution. Rationing by dilution refers to a situation where a service may continue to be offered, but its quality declines as cuts are made to staff numbers, equipment and so on. This form of rationing may be the least visible, but it may also be the most pervasive.

How should priorities be set? Who should be making the decisions about which patients should be treated and how? Can we reconcile a utilitarian approach to maximise the benefit for the whole population with the needs of the individual? Will the rights of the individual as laid out in the NHS Constitution provides sufficient safe guards? How much do we know about “bed side rationing”- the effects of decisions by clinicians determining who gets what? This well-written and thoughtful paper argues that geography should not determine the care people get as it currently does.

Debates about priorities and rationing place great emphasis on accountability, but exactly who should call commissioners and providers to account is less clear. The courts, clearly have a role. However, they cannot routinely scrutinize decisions, far less outcomes. In the future system there could be an important role for Health Watch, especially if it is linked to the Care Quality Commission and the analytical ability of local agencies is strengthen. The challenge, for both health watch and local authority scrutiny committees, will be to sound the alarm when efficiency saving become a euphemism for rationing by dilution. I would recommend reading Thinking about Rationing – it provides insights and a vocabulary that will be of use in the months ahead.