Rationing Priority setting Ann Winter

Definition A fixed quantum of health care per person (New Shorter Oxford Dictionary) Raising the price of a commodity so as to restrict the number of people who can afford to buy it. Rationing by price (Oxford English Dictionary)

Accountability for Reasonableness Publicity – decisions must be publicly accessible Relevance – rationales for decisions must rest on evidence that for minded parties agree are relevant Appeals – there is a mechanism for challenge and dispute resolution Enforcement – there is regulation of the process to ensure the first three conditions are met Daniels N & Sabin J (1998) The ethics of accountability in managed care reform, Health Affairs, 17: 303 - 50

Explicit rationing Why not? Confused criteria – cannot deny it just because its messy Deprivation utility – scarce resources to fund treatment incur distress (perceived deprivation) Effectiveness, visibility & clinical decisions

Implicit rationing Happens at the bedside or consultation between patient and doctor Clinical decision making Benefits knowledgeable patients

Macro Resources allocated to local popn. on basis of needs assessments Divided proportionally between different types of disabling and treatable illnesses within pop Specific illnesses should not be discriminated against due to popularity/social worth Rationing within not between eg triage waiting lists Informed /influential public

Utilisation management managed care Precertification for admission Concurrent review of length of stay Case management of high cost cases Second surgical opinions Decisions often made by administrators

UK Quasi explicit rationing Medical discretion Block purchasing Waiting lists Getting on waiting lists Undersupply of doctors, staff, machines, facilities etc

Rationing Agenda Group Real ethics of rationing is to minimise the need to ration by eliminating ways that entrenched institutional, political and professional interests lock in waste. Eg Over testing Inappropriate prescribing Follow up organisation Utilising doctors when nursing skills Budgets and contracts that protect hospitals, consultants and GPs from integrated and more effective contracts If all this waste is eliminated waiting lists would disappear and never return Hancock C Rationing – not the spice of life, Health Service Journal 1997 June 26:26

Muir Gray J (1997) Evidence Based Health Care – How to make health policy and management decisions The NHS must shift from maximising the number of episodes to maximising the number of effective interventions and beneficial outcomes Critical to reducing such waste and the need for rationing is the strong implementation of EBM

Probability of particular outcomes Valuation of the outcomes Degree of risk Outcomes can only be expressed as probabilities applying to populations eg Glue ear surgery is often unnecessary and is less effective if the hearing loss is <25 dB, but some children with lower levels of hearing loss do benefit Probability can be applied to populations not individuals

New Zealand 1992 – National Advisory Committee on Core Health and Disability Support Service now national Health Committee Higher priority patients attract higher points severity of illness, treatment effectiveness, ability to work, ability to care for dependents Level of funding dictates the points at which patient can expect treatment

Sweden Priorities Commission report – ethical principles Human dignity – all people have equal dignity and the same rights regardless of their personal characteristics and function in the community Needs and solidarity- direct resources to those whose needs are greatest but also pay special attention to those less able to voice needs/exercise rights Cost efficiency – there should be a reasonable relation between cost and effect

Forms of rationing Denial – threshold of eligibility is raised/lowered to exclude Selection – of beneficiaries/deserving cases Dilution – reduction in scale and depth of services – everyone gets less – order fewer tests, less time with patients – quality reduced Delay – long exchange of letters/discouragingly long waits for appointments/waiting lists Deflection – beneficiaries are steered towards another programme – education problems are redefined as housing problem which in turn is re defined as a social security problem – dumping the problem in someone else's lap Deterrence - barriers/costs of entry into system receptionists/ incomprehensible forms/long queues in dismal surroundings Termination – discharging patients, closing lists CLOAK OF INVISIBILITY

Decision analysis Structure tree Assess probability Attach utilities /values to tree Identify option that maximises expected utility Lanza & Bantley (1991) Decision analysis makes explicit those often implicit considerations in making the best possible choice in difficult or complex situations Lanza M & Bantley A (1991) Decision analysis. A method to improve quality of care for nursing practice. J of Nursing Care Quality 6.1. 60-72