Where are we in the rationing debate?

The papers on rationing healthcare (1) provide a good overview of the
present state of affairs. Daniels and Sabins’ Accountablility for
Reasonableness (2) provides some firm ground if you think that priority
setting is inevitable (and it is). Tough decisions are needed in priority
setting. Hard won experience suggests that Daniels and Sabins’ approach
around process and reasonableness is important if commissioners are to
gain legitimacy. The stability this approach should provide is needed to
help resist the legal, media and commercial challenges that sometimes
combine to provoke politicians to intervene. Although the rationing
papers are wide-ranging there are some important issues that are only
touched upon.

The lessons from the Herceptin affair are still there and the
commercial sector knows that using patient groups and the media can allow
pricing at what the market will bear. Donaldson et al (3) show that
health care is not a true competitive market. Health technology agencies,
such as NICE in England, often do not make a realistic connection between
making national decisions on behalf of local budget holders and the need
to balance the opportunity costs at that level. There is something odd
about having a rationing mandate but with no budgetary responsibility.
However, it is also true that the main budget holders in England, the
Primary Care Trusts (PCTs), have no direct public accountability for their
prioritisation decisions and this gap needs working on.

Public engagement work and debate will help this and there are also
mechanisms whereby PCTs could help to explain their annual budgetary
decisions to the local politicians. This might help to get behind the
technical nature of some priority setting decisions, which are often
difficult to explain fully in the media. However, the key missing element
is the overall political ownership of the need for priority setting and
leadership at the national level. We have seen politicians fudge
difficult rationing decisions and provide justifications that are too
simplistic whilst ignoring the opportunity costs. Politicians need to
support local decision makers, who are best placed to make everyday
rationing decisions. Politicians should set the strategic framework and
then stand back and hold their nerve in the face of media simplification
or commercial pressures. My judgment is that we still have some way to go
and much more work to do on the whole process of priority setting.

1. Goold SD, Baum NM. Where are we in the rationing debate? BMJ
2008;337:a2047, (and linked papers).
2. Daniels N, Sabin JE. Accountability for reasonableness: an update. BMJ
2008;337:a1850.
3. Donaldson C, Bate A, Brambleby P, waldner H. Moving forward on
rationing: an economic view. BMJ 2008;337:a1872.

Competing interests:
JH is involved in priority setting decisions for NHS commissioners.