Calling the shots on health: With Viagra , a politician has for the first time come out and admitted that the National Health Service rations treatments.
DAVID WALKER
01/26/99
The Guardian
VIAGRA is the headline, but the real story is power. Who calls the shots? During the past few days Frank Dobson stepped over a boundary and the clinicians (and drug manufacturers) are upset. They've clashed before but this time there's a newcomer - the public. Viagra isn't going to be the last controversial new therapy for a condition that criss-crosses between 'really ill' and 'lifestyle'. In future allocations of money and treatment are going to be much more explicit. The question is what happens now that rationing is out of the closet. Can Mr Dobson agree a procedure for new therapies that won't bust NHS budgets, but does accommodate doctors' professionalism and sustains the belief of the British public in the national religion, the NHS.
The NHS has always been 'an institutional device for rationing scarce resources' (the phrase was coined by Bath University's Rudolf Klein). To do it, the political problem of finite money was translated into a clinical one - it was doctors who did the rationing. The bargain was that doctors didn't complain too loudly about quantities while ministers respected clinical freedom (the myriad practices of doctors which as successive audit reports show rarely bear inspection).
But Tory health reforms started to break things up: the 'purchaser-provider' split has made things more transparent. Now the British Medical Association is saying, we will not be made scapegoats for limited budgets, we'll prescribe Viagra as we see fit. Frank Dobson (with some political courage though the issue would be the same if Ann Widdecombe Tory were sitting in his seat) says: here are the clinical guidelines for when and where doctors can prescribe Pfizer's A4.84 per shot blue tablets. Meanwhile, on the sidelines, the pharmaceutical industry is beside itself; threatening law suits. The ex-Guardian journalist Chris Mihill was recently recruited by the Association of the British Pharmaceutical Industry to write about the 'scandal' of concealed rationing. There is 'an invisible patchwork of deprivation across the country, where the rules [on prescribing] are set largely in secret and the basis for the judgments is never made explicit'(1). The patients' lobbies kick in. Before Viagra there was beta interferon, an expensive treatment for multiple sclerosis. It is not uniformly available. Peter Cardy of the MS Society comes close to urging people with MS to move house (for example to Liverpool and Manchester) to areas where beta interferon is available from NHS doctors.
Viagra is thus not the first treatment to open the wound of rationing. What's new is explicitness. The other day the Prime Minister backed Frank Dobson's move into making what are in effect clinical judgments: the drug should go only to delineated groups, anything else would not be a 'sensible use of resources', Mr Blair said(2). Many welcome this new openness about triage. It gets them off the hook. According to Stephen Thornton of the NHS Confederation, 'such value judgments must be made by the Government. It is not the job of the health service to determine who deserves the drug - our job is to treat people in need. If it is left to the health service locally, there will be different decisions in different parts of the country, leading to so-called 'post-code prescribing', which is fundamentally unfair'. But not peculiar to Britain. All health regimes ration. Americans ration by income; American doctors' clinical freedom is increasingly circumscribed by insurers.
CHRIS Heginbotham of the East and North Hertfordshire health authority speaks for many health managers in warmly embracing rationing. Its inevitability will be 'a spur to identifying genuinely inappropriate care, reducing inefficiencies and eliminating proven ineffectiveness'. He belongs to the school which says: throw the surgery windows open wide. Let the auditors and the accountants in, picking up on their way the American evidence which suggests that only 15 per cent of clinical interventions are fully supported by good scientific evidence, noting that famous table comparing per capita spending on health in different western countries and male life expectancy - there isn't a correlation.
But will patients, their families, the public and the headline writers take to rationing as eagerly? NHS pessimists point to the pace of technological and pharmaceutical change. The graphic on the right shows some likely developments during the next couple of decades. Meanwhile, patients expect more, their self-awareness as health consumers grows, they are more likely to reach for lawyers or lobbyists to assert their right to treatment. Julian Le Grand of the London School of Economics borrowed the phrase 'legitimation crisis' to capture the problem of imploding public confidence.
But optimists respond that the NHS has successfully dealt with the onrush of technology and tight resources ever since 1948. What matters to patients, they say, isn't getting a specific treatment, it's being told. The phrase here is procedural rights - a patient's right to be consulted, be heard, to be given reasons. The assumption is that doctors are going to share power and give up chunks of their autonomy.
PUBLIC participation in decisions about rationing has been earnestly pursued by the Institute of Public Policy Research and the King's Fund. The think tanks have worked in Somerset, Cambridgeshire and Huntingdon and East Sussex on giving the public a bigger say. Should, for example, treatments be available across a health authority area or concentrated to greater effect in a single centre? People were found to agree that you can't provide everything everywhere; they were capable, in other words, in trading off quality of care against local access. There is some evidence on public acceptance of the principle of rationing from overseas. The Dutch government and American authorities asked people to assess different conditions and whether the state should pay for them. In the Netherlands, physiotherapy and dental care for adults lost out. An elaborate exercise was conducted in the state of Oregon that produced a league table of conditions/treatments, as the graphic shows(3). But theory is one thing, practice another. Putting these findings into administrative effect has proved very difficult.
Do people really want to engage so directly with their destinies and their mortality? Has Frank Dobson, with his admission that the NHS does ration, let a genie out of the bottle, confronting people with something they had only dimly perceived before and, more important for his own future as Secretary for Health, shown clearly that responsibility for decision making lies with Richmond House, the DoH headquarters? David Hunter of the Nuffield Institute for Health argues that inexplicitness has its virtues, that in health there is such a thing as too much knowledge. The public has been known to speak with forked tongue over its willingness to be taxed to pay for public spending; what people may say to interviewers isn't always the same as how loud they will shout when a relative is ill and might benefit from expensive care. Ignorance about how the NHS works is rife; it's easy to whip up a campaign against cuts. But the 'information rationalists' persist. If the public are 'properly informed' they will be able 'to participate in decisions about rights and rationing, at local and national levels'(4). The IPPR has pursued citizens' juries, which are panels given intensive briefing about money and medicine. It reports that people feel strongly, whether it's cancer or impotency, that they should have a say, not necessarily the last word, so that decisions are not left entirely to 'boffins in white coats'. NHS optimists say there's really no choice but to rationalise rationing: the alternative cedes the field to vocal lobbies, self-interested drug manufacturers and doctors who want to turn the clock back - and this at a time when there has been an explosion of both therapies (stemming from the application of the new genetic knowledge) and information, thanks to the Internet. Health resources are finite, but the market for health information knows no bounds.
THE information revolution does cut two ways, say the optimists. Women carers, for example those with dependent relatives with Alzheimer's Disease, seem to be energetically using the Internet to exchange information, which may cut the overall cost of care(5).
The optimists agree that what's needed - and Frank Dobson has pushed the boat out - is clear articulation of national standards and priorities. Chris Ham of the University of Birmingham has seen his proposals for a national committee on health care priorities taken up in the form of the National Institute for Clinical Excellence (NICE) that will be established later this spring(6). This official body will comprise NHS managers, doctors and representatives of patients and users. It will produce guidance on what treatments work and (the Viagra point) 'assess new interventions for their clinical and cost effectiveness'; it will work in conjunction with a new commission for health improvement which will audit clinical practice - count the dead bodies some surgeons leave on the operating table.
The point, says Professor Ham, is that decisions about care and medicines are recognised as more than just technical issues. They embody value judgments. 'NICE provides a focus for the first time'. Will the public prove mature enough? Sources: (1) Hard Rations, ABPI, January 1999; (2) Department of Health guidelines - now out for consultation - allow NHS to fund Viagra for men who have had pelvic or prostrate surgery and those with spinal injuries, diabetes, multiple sclerosis or single-gene neurological disease; (3) Alan Maynard and Karen Bloor, Our Certain Fate: Rationing in health Care, Office of Health Economics, November 1998; (4) Jo Lenaghan, Rationing and Rights in Health Care, IPPR, November 1996; (5) Jo Lenaghan ed, Rethinking IT and health, IPPR 1998; (6) Chris Ham, The Sir Charles Carter Lecture, NIEDC 1998.
Graphics: Finbarr Sheehy.
Research: Matthew Keating.
David Walker edits Analysis.
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