Rationing the evidence

The rationing debate is profoundly unscientific. The problem it seeks to address is assumed rather than expressed in any refutable form, and the literature is dominated by assertion, political analysis, and ethical debate. In other areas of public health, assertions must be supported by data. For example, the case for a national concern with the health implications of obesity in childhood would not be accepted were it based on haphazard sightings of fat children; representative data describing body mass index would be required, drawn from samples adequate to support robust population estimates. In contrast the discussion of rationing is largely free of appropriate data. Any particular instance of failure is taken as evidence of a global shortfall in provision, which is the epidemiological equivalent of pointing at the occasional fat person as sufficient justification for an antiobesity programme.

In the clinical context the ideas of bias and representativeness are now accepted to the extent that selected observations are disparaged as anecdotal and thus not generalisable to the wider population. The epidemiological naivety that suffuses discussions of health policy can be illustrated in the context of current patterns of provision and in relation to trends in utilisation.

The longstanding failure to satisfy the demand for a number of effective and high volume procedures has been the benchmark of demand mismanagement in the NHS for many decades,2 but a more intimate examination may not support the common interpretation of a global mismatch between supply and demand. For example, in general surgery in England, about 110 000 people were waiting for day case treatment in December 1999, of whom some 21 000 had waited over six months. This is not, however, a general problem. In a few parts of the country there are serious shortfalls, but in most there are none (fig 1). If most centres satisfy demand successfully while a few do not, which group is representative: the 10% who account for 35% of the problem or the 10% who have no problem at all? This question is not asked, but the conventional, implicit interpretation is that centres that fail to satisfy demand are representative of a global pattern of failure. This is the equivalent of taking a few fat individuals as a proxy for a problem in the population.

Fig 1.

Proportions of NHS trusts in England that had patients waiting more than six months for day case general surgery, December 1999

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When demand for health care is assumed to be increasing it is more common to express concern about this trend than to question it. In the United Kingdom high rates of bed occupancy lead to inevitable bed crises during periods of raised demand.3 These periodic problems are interpreted as expressions of inexorable increases in demand that arise from an ageing population. The reality is that emergency admission rates are certainly increasing in some areas4 while in others supposed increases are largely artefacts of re-counting those individuals who are moved between consultants within a hospital. 5 6 This is less an instance of a global and inexorable problem than an issue requiring more contextual inquiry. It is interesting to note that in the United Kingdom, population based measures of utilisation, such as the proportion of the population admitted to hospital each year, have remained remarkably constant for the past 15 years.7 The “increase” in total ordinary admissions in the Oxford area between 1988 and 1993 was −0.3%.6 In primary care, consultations increased by only 2.4%, from 33 961 to 34 785 per 10 000 person years at risk during the entire decade from 1981–2 to 1991-2, hardly an insurmountable challenge for the NHS.8

The epidemiology of indications

It is difficult to justify the conventionally unfavourable forecasts of the relation between demand and supply in terms of overall epidemiological trends, as these are broadly favourable. Among the main disease groups that underlie demand, the rates of coronary heart disease and stroke have been declining since the 1970s. Trends in cancer differ between younger and older people. Rates of cancer among men younger than 70 years have decreased but have increased among those who are older. For women an equivalent change occurs at age 50. As these cohort effects work through the population the overall outlook is therefore encouraging.9 This broad approach, however, is of little value since legitimate demand on the NHS reflects not so much incidence of disease as the incidence of indications for worthwhile forms of care.10

Changing patterns of demand and supply

The question of whether we can catch up with today's problems may seem irrelevant when the current adverse balance is seen as deteriorating under the burden of the three commonly cited adverse pressures: increasing life expectancy, new technologies, and raised public expectations.1 What is the justification for portraying this triad in such pessimistic terms when each could otherwise be seen as a hallmark of desirable progress?

The social construction of pessimism

The scale of legitimate demand will therefore be moderated over time by this range of factors. If an informed prediction of the balance of the outcome is so uncertain, why does the pessimistic interpretation predominate? One answer is that healthcare experiences are constantly being examined informally,30 are given continuous media attention, and provide the seasoning to much political debate. This discourse reflects a number of moral and political undercurrents.

Modern health systems resolve or ameliorate many problems with illnesses that until recently were insoluble and they may provide reassurance to those who are well, but their predominant concern is with a tide of pain, fear, indignity, and death. A happy health service is therefore something of an oxymoron. Many of the problems that prompt debate about rationing have more to do with an unwillingness to acknowledge that some disease processes are inexorable rather than reflecting an inadequate health service. The child B case, in which a health authority denied further treatment to a child with non-Hodgkin's lymphoma, was a public example of this,31 but there are numerous such cases in which informed comment is restrained by sensitivity to the feelings of ill people and their families or to the bereaved. Such a denial of mortality and of the irreversibility of much morbidity is accentuated by prosperity, and this may underlie the otherwise odd association between the wealth of a country and its preoccupation with rationing.

There is also a strand of professional self interest in the common focus on failure. The NHS is one of the largest employers in the United Kingdom. Evidence of unsatisfied demand is not necessarily disinterested. Bidding for extra resources is a competitive process for which ordered coping is rarely rewarded. Surgical waiting lists still offer the potential for abuse that is inherent in an arrangement which offers financial incentives for selectively low productivity. The NHS still draws on an impressive fund of altruism, but it would be naive to assert that the interests of staff always coincide with those of the public. These undercurrents to the flow of information make a balanced assessment of the system's capacity to meet demand less likely. It can be difficult to understand why the NHS should be seen as drowning when the pool is so shallow (fig 2). In Ophelia's case the explanation is that

her garments, heavy with their drink,

Pull'd the poor wretch from her melodious lay

To muddy death.

Fig 2.

Ophelia drowning, like the NHS

(Credit: OPHELIA BY JOHN EVERETT MILLANS/TATE GALLERY, LONDON)

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For the NHS this social construction of pessimism adds unacknowledged weight to the demand side of the scales where the possible future influences of age, technology, and expectations are judged.

Finite demand, infinite supply?

Even in its underfunded state, the capacity and productivity of the NHS are prodigious. In England over 11 million hospital episodes are managed each year. Within this capacity there is considerable discretion. For example, up to one quarter of admissions cannot be justified on clinical grounds, implying flexibility for reducing any apparent mismatch between supply and demand. 6 32

The demand for health care must be finite: the population is finite and only a proportion of the population can benefit from and want treatment.33 Care is offered at all levels within society, from the most specialist provision to the most informal support within the neighbourhood or family. Slogans about healthcare capacity should have no place in serious analyses, but as there is a tendency to oversimplify these issues it may be wiser to encompass this informal sector, invert conventional assumptions, and think in terms of finite demand and infinite supply.34 The working hypothesis should be that selected services can be expanded in the expectation that legitimate demand will be satisfied. This is a proposition that can be tested empirically. The establishment of programmes to test whether demand will be satisfied has been inhibited by the wrong assumptions that are conveyed by conventional metaphors such as the “iceberg of morbidity.” In many areas of the NHS's failure to meet demand this metaphor may be strained by the fact that key NHS icebergs are carrying all, or almost all, of their bulk above the surface. Often we are dealing with an iceflow of morbidity that can be as readily melted as allowed to deepen; but in a world dominated by the language of rationing, where every solution has a problem, it can be difficult to attract attention to the fact that much of the failure to meet demand is unnecessary. Instead the rationing gaze wanders restlessly towards other deficiencies or takes refuge within the safety of “dilution,”35 although the fact that some aspects of care could be offered more agreeably is a platitude.

Misunderstanding, vested interests, and parsimony are greater problems than the potential level of demand. The conventional null, or nihilist, hypothesis that demand always exceeds supply within a public health system reflects neither hope nor experience. The proposed expansion in investment in the NHS, including the targeted use of resources to address the politically serious issue of waiting lists,36 provides an opportunity to establish whether, after over 50 years of equivocation, it is possible to counter the professional37 as well as the intellectual barriers to satisfying demand. This programme must be ordered to allow us to judge the merits of the alternative hypothesis: that the limits to demand for key categories of health care lie within the capacity of a properly resourced NHS.

Demand is problematic

In the first place the concept of demand is rather more problematic than the authors allow. For goods and services rationed by price, demand is “satisfied” because the price rises until no additional people come to the market. Similarly, in a system that is not rationed by price, demand can be “satisfied” by a number of other techniques including, to use some of the authors' words, setting “agreed criteria,” estimating “requirements,” or establishing “legitimate demand.” There may, however, still be unsatisfied demands for which benefits could be provided.

Discussing legitimate demand introduces the need to make a judgment about costs and benefits—that is, a decision about when the provision of a wanted thing no longer warrants the cost to others. This is the language of rationing. Unless there is unanimity about what constitutes legitimate demand, then agreeing what this level of demand should be will involve denying some people things that they believe will benefit them. These denials should not be hidden behind technical language but defended openly. It seems to me that those who use the NHS will settle for nothing less.

Secondly, the authors criticise the rationing debate for being selective: “any particular instance of failure is taken as evidence of a global shortfall.” This is certainly not a valid inference, although I would point out again that rationing does not necessarily imply a failure or even a shortfall. But neither does the reverse apply: instances of (potential) success do not imply the possibility of a global avoidance of rationing. The examples of hip replacement and cataract surgery are used as a means of demonstrating “the flaws belying the health economists' hegemony,” but the argument falls foul of the authors' own criticisms.

To borrow their analogy, choosing these two cases is a bit like pointing out that there are a number of thin people (or people who could be made thin if we concentrated resources on them) and then using this fact as a means of showing that the whole population could be thin. This does not follow, and it is certainly no more scientific a means of using evidence than indicating that there has never been a time when all demands have been satisfied in the NHS. However, the authors go on to accept that “at the macro level, choices must be made in the use of scarce resources.” This is confusing: why should admitting that rationing occurs at the macro level, rather than at the micro level, be acceptable? Furthermore, surely it must be acknowledged that global rationing directly implies that micro rationing occurs somewhere in the NHS? In fact, on closer examination Frankel and colleagues seem to be arguing that rationing is currently done rather badly, not that it should not happen at all. In this case the need for a debate about rationing seems all the more important.

The third point relates to the authors' narrow understanding of what rationing means, as revealed by the phrase: “The demand for care must be finite: the population is finite.” This suggests that each individual is limited to a discrete package of demand and that the degree to which their needs should be satisfied is not problematic. In fact the concept of rationing by dilution is crucial. It refers to the possibility that the degree, intensity, or quality of an intervention can be varied endlessly so as to marginally change the overall level of health improvement gained by a patient. It is often a matter of probabilities: just how small of a risk of an adverse incident do we wish to achieve? Adding to these small but real benefits will inevitably bring health systems up against resource constraints even in countries that spend much more on health care than the United Kingdom. The fact that it is sensible to avoid trying to exhaust these benefits should not lead us to pretend that they do not exist. (I am unclear why this type of rationing is considered to refer only to the possibility of offering care “more agreeably.”)

A matter of belief?

Any discussion about rationing must be unscientific in one sense because it is impossible to test whether a society can ever have all its desires satisfied, in health or anything else. Nevertheless, many of those who argue that rationing is inevitable would support much of this paper; it produces an excellent catalogue of evidence opposing the view that the NHS is incapable of coping and it also complements less epidemiologically based work that makes the same case.1 But surely all experience of health care over time, not to mention the experience of economic exchange in general, is that new wants are continually developing and that human ingenuity will continue to strive to meet, but never exhaust, them. Perhaps this comes down to a matter of belief, but for those who support an open debate about rationing this is not an admission of failure but an attempt to sustain the NHS by being brutally honest about its inevitable limitations as well as its considerable capabilities.