1. Rationing Priority setting
Ann Winter

2. 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)

3. 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:

4. 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

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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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