- Email: [email protected]
Can we restrict the health care menu?
Health Policy 27 (1994) 103-112
IRELAND
Can we restrict the health care menu?’ Rudolf Centre for
the Analysis
of Social
Policy,
Klein
Universitv
of Bath,
Claverton
Down.
Bath BA2
7A Y. UK
(Accepted 25 October 1993)
Abstract
The case of Britain’s National Health Service is used to illuminate the cross-national debate whether the availability of health care should be restricted and, if so, how this should be done. Traditionally, the NHS relied on implicit rationing by clinicians within budgetary constraints set by government. However, the logic of the 1989 reforms appeared to require explicit decisions about the packages of health care to be provided to local populations. In practice, purchasers have refused to define such packages. Explicit rationing remains very much the exception. Exploring the reasons for this suggests that defining a restricted menu of health care, by adopting a cost-utility approach and excluding specific procedures or forms of treatment on the Oregon model, is only one of many policy options. There is a large repertory of policy tools for balancing demands and resources, ranging from diluting the intensity of treatment to its earlier termination. Given that health care is characterised by uncertainty, lack of information about outcomes and patient heterogeneity, it may therefore be more ‘rational’ to diffuse decision-making among clinicians and managers than to try to move towards a centrally determined menu of entitlements. about
Key
words:
Rationing;
Britain’s NHS; Oregon
Introduction If the problem facing health care systems is defined as being how to meet rising demands, reflecting changes in technology, demography and cultural attitudes, without risking national bankruptcy, then Britain would appear to have found the answer. If one is seeking a model of parsimony, then Britain offers it. Health care expenditure, measured as a proportion of the national income, is lower than in most other European
countries.
Public
fRevised version of a paper presented Mission
Impossible?
0168-8510/94/$07.00 SSDI
0168-8510
held in Brussels, 0
support
for the National
at the 54th EHPF Meeting Belgium on 30 September -
1994 Elsevier Science Ireland
(93)00600-6
Health
Service remains
on Reducing Health 1993.
I October
Ltd. All rights reserved.
Care Benqfirs:
104
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Policy 27 (1994)
103-112
high. The controversy surrounding the reforms introduced in 1989 has tended to focus attention on the shortcomings of the NHS such as long waiting lists. This, in turn, has been reflected in public opinion surveys. But disgruntlement about particular aspects of the NHS has not undermined the national consensus about the principles on which the system is founded: a national tax-financed service which offers comprehensive coverage without any explicit limits on benefits. On the face of it, this is a remarkable achievement. This paper therefore asks what lessons, if any, there are for other countries. Specifically, it addresses the question of what British experience tells us about the scope for, and desirability of, restricting the health care menu. This is, as we shall see, a complex, multi-dimensional notion which requires to be carefully unpackaged. But before doing so, the current situation in the UK needs to be set in its historical context. 1. The British inheritance The NHS, as created in 1948, had a number of distinguishing features which helps to explain its ability to contain costs [l]. It was a paternalist system, based on the principle that health care would be distributed according to need as defined by the professional providers. It must therefore be sharply distinguished from insurancetype, demand-led systems where consumers have the right to specific services: in the case of the UK, the courts have always held that citizens have no entitlements to specific services, as distinct from a general right of access to health care. Central government determines the overall budget of the NHS, and its distribution to regional and local health authorities. The professional providers determine who gets what: i.e. the allocation of services at the point of delivery. The NHS also has a number of other characteristics which help to explain its ability to contain costs, most notably a system of primary care which copes with the great majority of doctor-patient contacts and which screens the demands on the secondary sector. But it is the fact that it is a need-led system which is central. This system, in turn, rests on two pillars: public deference and professional autonomy. The point about public deference is largely self-explanatory: the NHS has benefited from, some would say exploited, a general willingness to defer to medical judgments. The point about medical autonomy needs, perhaps, more elaborate explanation. The NHS, as originally devised, rested on an implicit contract between the State and the medical profession. The State determined the availability of resources to the medical profession, in return for conceding to doctors the right to determine how those resources would be used. Political decisions about resource levels were thus, in effect, transmuted into clinical decisions about the suitability of particular patients for treatment: rationing was, to a large extent, made invisible as a result. If doctors chafed at the limitations on the resources available to them, at least they enjoyed a remarkable degree of immunity from scrutiny. The reforms introduced in 1989 reflect the fact that both pillars sustaining the original NHS model are crumbling. Public deference has declined in an increasingly consumerist and better educated society. The transformation of the patient (someone who passively suffers things to be done to him or her) into a consumer (someone who is actively seeking out what he or she wants in the market place) - the new
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language of discourse about health care represents a semantic revolution. At the same time, the implicit contract between the State and the medical profession has broken down. The increasing emphasis of the Thatcher Government on strengthening management, evident throughout the 1980s threatened both the autonomy and the domination of the medical profession. In turn, the profession became increasingly resentful of, and openly hostile to, the Government’s attempts to contain costs. Moreover, the Government increasingly chafed at the ‘corporate stalemate’ [2] or ‘gridlock’ [3] within the NHS, the result of virtually conceding the right of veto to the medical profession, which inhibited adaptation to change. Both sides felt betrayed and the 1989 reforms, introduced despite extreme medical opposition [4], were the outcome. 2. The new system of health care The 1989 reforms maintained the financial and organisational framework of the NHS but introduced a number of significant changes. First, they represented a threat to medical profession’s traditional immunity from scrutiny. The new contract for general practitioners was much more specific than in the past: payments were increasingly related to the achievement of specific targets - notably in the field of public health [5]. Medical audit was introduced in all hospitals. Second, and most specifically relevant to the theme of this paper, a split between providers and purchasers was introduced. Whereas before health authorities were responsible for running hospital and community services, they have now become transformed into purchasers: i.e. they are responsible for buying the services needed by their populations from providers who, for the most part, have become independent trusts. In principle, though not often in practice, purchasers may also buy services from the private sector. The crucial point, from the perspective of this paper, is that purchasers, whose budget is determined by central government, via the regional authorities, on the basis of a weighted capitation formula, have to decide what services to buy. The logic of the change is that they should, therefore, explicitly determine what is needed and. by implication, what is not needed: i.e. that they should define the package of health care to be made available to their populations. Instead of the availability of services being determined, as in the past, by the accidents of history, i.e. the inherited distribution of facilities, now purchasers must decide how best to use their budgets with the freedom to switch providers. No longer therefore will developments be providerdriven: if the medical profession wants to introduce new procedures, or continue with old practices, it will have to persuade the purchasers that the products are worth buying. No longer, therefore, will priority setting or rationing be implicit, the result of a series of diffuse clinical decisions. Instead, it will be open and explicit. That, at any rate, is the theory. Practice has turned out to be rather different. In the outcome, there is not much competition between providers, except in London and the big conurbations. Similarly, purchasers were initially instructed by the Department of Health not to cause turbulence in the system by switching providers. In all these respects change is coming only slowly. Above all, and crucial for the theme of this paper, there is as yet no evidence that purchasers are defining explicit
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packages of care. Next, therefore, we turn to examining the reasons why the apparently irrefutable logic of the changes has not been translated into practice before moving on to speculating about the wider implications of the British experience, and what this tells us about the whole notion of restricting the health care menu. 3. Priority setting in practice In this section, we first look at the evidence of how the NHS purchasers have set about their task. This is based on two surveys carried out by the Centre for the Analysis of Social Policy at Bath and funded by the Nuffield Provincial Hospitals Trust, of the purchasing plans for 1992-93 and 1993-94, respectively [6-71. Financially, 1992-93 was a good year for the NHS, with a growth rate (in real terms) of about 3% in its budget; 1993-94, however, promises to be rather rougher, with a prospective growth rate of only about 1%. In 1992-93, therefore, purchasers were, to an extent at least, able to change their service package out of the dividends of growth; in 1993-94, conversely, any changes are more likely to be at the expense of existing commitments. By comparing the 2 years, it is thus possible to examine whether or not the approaches to determining the ‘NHS menu’ are affected by the degree of financial stringency. In the event, changes in the degree of financial stringency do not appear to have much effect. The common elements in the two sets of plans are much more pronounced than any differences. The NHS menu, in each of the purchasing authorities, is still overwhelmingly determined by history. The services available to their populations will be largely those which they have always had. There have always been considerable variations in these services seemingly unrelated to the characteristics of the local population: in, for example, the rates of hip replacement, by-pass and cataract operations. These are set to persist under the new purchasing plans, despite attempts to set national norms for the provision of certain procedures. The variations may be smoothed out at the edges. But there is very little evidence of health authorities asking themselves what the appropriate package of care should be: i.e. of moving towards what they consider the appropriate menu to be. Instead, the purchasing plans demonstrate a process of incremental adjustment: of adaptive changes at the margins. These reflect a variety of factors. In part, there is guidance from the Department of Health, nudging purchasers towards health prevention and the development of primary care. In part, there is local pressure to develop specific services: one of the most notable results of the NHS reforms has been to involve general practitioners in the priority setting exercise and their views have helped to shape purchasing plans. Overall, the effect has been to consolidate the existing pattern of health care delivery with the emphasis on remedying perceived local deficiencies in the services traditionally provided. Acute services, which account for 51% of all NHS spending, got 55% of the money available for new developments in the authorities surveyed in 1992-93 and 58% in 1993-94. These figures present, of course, a very crude picture at the aggregate level, which conceals many changes at the micro-level: thus much effort has gone into changing the configuration of existing services in order to make them more efficient and effec-
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Policy 27 (1994)
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107
tive, as distinct from changing the balance of spending between different sectors. However, the conclusion that the status quo has not as yet changed greatly is reinforced if we switch perspective and ask whether or not purchasers are explicitly striking services off the NHS menu. Explicit rationing, in the sense of making specific services or procedures no longer available, is very much the exception. In 1992-93, only 12 of the 114 purchasing plans surveyed explicitly announced that they would no longer buy certain procedures. In 1993-94, only four of the 100 purchasing plans surveyed did so (as a result of amalgamations there has been a diminution in the number of health authorities in the NHS). If anything, therefore, there appears to have been a retreat from explicit rationing a 1’Oregon. Equally significant, perhaps, is the nature of the procedures which were struck off the NHS menu. In 1992-93, tattoo removal topped the list (mentioned by seven health authorities), followed by GIFT/IVF (six), reversal of sterilisation/vasectomy and general cosmetic surgery (four each). Other procedures mentioned included: adult bat ears, breast augmentation, buttock lifting and cosmetic varicose veins. The numbers add up to more than 12, because most authorities mentioned more than one procedure. The much shorter list in 1993-94 includes many of the same‘items, but does not add to them. All the procedures appear to share two characteristics. They are marginal to the NHS’s activities in terms of their cost: they represent the small change in the NHS’s budget. And they tend to blur social and medical judgments: i.e. they raise questions about whether a national health care system should take responsibility for what might be seen as self-inflicted conditions and about the dividing line (if there is any) between what is socially desirable and what is medically necessary. The example of In Vitro Fertilisation, where purchasers are sharply divided, with some of them striking it off their menu, whilst others are putting more funding into this service, illustrates these points well [8]. The explanations for this apparentqimidity in the face of the challenge to be explicit about what is being purchased, and what is not, fall into two categories. There are those anchored in the particular circumstances of Britain’s NHS and there are those which have wider implications for health care systems in general. Taking the proximate or local reasons first, it is important to recognise that the NHS has been going through a period of turbulent change. The managerial and expert resources required to review spending priorities, to take a fundamental look at what should and should not be purchased, have therefore been largely absorbed by the need to get the new system going. For example, NHS purchasers have had to learn how to write and monitor contracts with providers: a totally new art form. Equally important, and of perhaps wider and more long-term significance, has been the problem of information, or, rather, the lack of it. Before deciding what should be on the menu, purchasers have first to discover what is on the menu already: i.e. who is getting what in the populations being served. And this is not always easy, particularly when he comes to relating clinical data to populations of different types or in different geographical areas. More crucially still, there is lack of information about the effectiveness of services or procedures. The purchasing plans typically make much of relating spending to effectiveness. They emphasise that spending should be geared to maximising ‘health gains’ and to ‘adding years to life and life to years’. But this is the tribute paid by ignorance to conventional wisdom, inevitably
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so given the lack of much of the relevant knowledge about outcomes and effectiveness. The notion that there would be no need to limit the menu of health services if only ineffective services were eliminated is betrayed, British experience confirms, in practice by uncertainty about precisely what is effective or not [9]. There would, indeed, be no problem at all if only procedures with demonstrated effectiveness were offered: the health care budget could be cut dramatically. But this is a very different matter from assuming that those interventions which are not supported by solid scientific evidence - 85% it is estimated [lo] - are necessarily ineffective. If only life were that simple, there would be no need to agonise over rising health care spending. This last point brings the argument to some of the more general issues involved in analysing the notion of the ‘health care menu’ or a ‘basic health care package’. Next, therefore, we explore the various dimensions of these terms, so often used as rhetorical shorthand for ways of limiting the burden of expectations and demands on health care systems but seldom defined with sufficient precision. 4. Unpackaging the concepts The metaphor of a ‘health care menu’ can, perhaps, be usefully illuminated by taking it at face value and seeing what it might mean if, instead of applying it to health care, we were to use it in its original context: i.e. that of a restaurant. Imagine a restaurant which was trying to cope with excess demand, and rising costs, but which was denied the option of raising its prices in order to discourage prospective customers. What sort of strategies might it adopt in response? One obvious response might indeed be to limit the menu: to offer only a table d’hote instead of an a la carte menu. It might further insist that it will only produce healthy dishes that are good for customers, low in fats and high in fibres, rather than those which they actually like. This might well stem the flood of customers, as they discover that they cannot get what they want. However, it might also provoke a rebellion among the cooks, anxious to demonstrate the full scope of their art and their ability to excel in producing new recipes (which would enhance their professional reputation and get them invitations to prestigious international gastronomic gatherings). So the restaurant might well turn to alternative strategies. It might, for example, decide that it would use cheaper ingredients or offer smaller portions in order to cut costs. It might make customers wait longer for their tables, in order to discourage them. It might try to rush customers quickly through their meals in order to increase the turn-over per table, whatever this might mean for their digestion. It might cut down on the decor and the frills: no white table cloths or candles. It might even delay ordering new equipment in order to discourage the cooks from inventing new dishes. Leaving our restaurant, and coming back to health care systems, it is evident that all these strategies are available if the aim of policy is to restrain the rise in spending. In short, the notion of restricting the ‘menu’ is only one of many available options. Furthermore, the experience of Britain’s NHS suggests that most of the options, usually in combination, can be used to ‘ration’ health care: i.e. that rationing by exclusion is only one, and not necessarily the best, way of coping with the problem of how to cope with technological inflation and demographic change without breaking the bank.
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Policy 27 (1994) 103-112
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To illustrate this point, let us translate the restaurant strategies into health care terms. There are, in effect, three main strategies for so doing [l 11. First, there is restricting demand by imposing time-costs on patients: i.e. rationing by queueing something for which Britain’s NHS (and other needed, budget-capped systems) is notorious. Second, demands on resources can be limited by dilution: i.e. by carrying out fewer tests, prescribing fewer drugs and generally limiting the intensity of treatment (the importance of this is underlined by the evidence that rising health care costs in the US are largely explained by the growing intensity of treatment offered). Third, demands on resources can be restricted by the termination of treatment: i.e. patients are turned out of hospital more quickly. All these are, of course, familiar. though seldom explicitly acknowledged. There may, in addition, be other tactics that can be pursued. Cutting down on environmental amenities is one such option. So could a more cost-conscious approach to quality: all too rarely does the debate about improving quality involve any mention of a price tag and there may well be a case for accepting that the aim should be to achieve minimum rather than optimal standards. There is, then, a whole repertory of policy tools available for dealing with rising costs, of which excluding items from the menu is just one. But it could still be that rationing by exclusion, i.e. defining a minimum health care package, should be the preferred option. The next, and concluding section, therefore addresses some of the intellectual arguments, as well as the evidence of the British experience, about the case for and against giving primacy to limiting what is available on the menu: what might be called the Oregon solution. In doing so, we also address the question of the relationship between political and clinical decision-making and between the State and the medical profession. 5. Concentrated or diffused decision-making?
The ghost of the Oregon model haunts all discussions about defining a set menu of health care rationing by the exclusion of certain procedures and activities, so at this point in the argument, let us flush it out into the open and (if possible) exorcise it. The case for this model is that it is both rational and democratic. It is rational because the methodology is based on cost-utility analysis: i.e. on the relative benefits yielded by different procedures. It is, democratic because the methodology also incorporates ‘community values’ derived from the participation of citizens in a series of deliberative meetings. But, of course, the model never worked as it was supposed to do [12]. The cost-utility analysis produced results that were considered to be counter-intuitive. The ranking list of procedures was accordingly revised to make it more acceptable in the light of professional and public opinion, so losing its methodological virginity. Reliable data about costs was ‘so difficult to acquire that ultimately costs were used only to make marginal adjustments in a small number of items on the list’[l3]. The meetings held to elicit the views of citizens were, in the event, dominated by health care professionals. As in the case of the UK experience, it can be argued that these problems reflected purely temporal factors. Only given a greater investment of effort in improving the methodology, only given a different approach to involving the public, and all would be well. We should be beware, it might be concluded, of drawing any conclusions
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for the future from pioneering experiments which, inevitably, draw attention to inadequacies and difficulties. But it may be that the flaws in the Oregon model are more deep-seated and that they cannot be remedied by methodological repair work. It may be that the definition of ‘rationality’ inherent in the Oregon approach is actually ‘irrational’. There are a number of reasons for taking this view. Like other models based on a costutility approach, the Oregon methodology assumes the availability of adequate and reliable information about outcomes and costs. But what if that information does not exist or, at best, is patchy and incomplete? Of course, it may be that the current investment of effort in outcomes research will, in due course, produce the missing data. But is it, in the meantime, ‘rational’ to base policy on a hope for the future which, conceivably, may never be fulfilled as changes in technology overtake and render obsolete yesterday’s data? There is a further flaw inherent in the Oregon model, as in any model which attempts to define the package of health care that is to be made available. This is the assumption that patients are homogeneous. This, of course, is a nonsense assumption. The same procedure that shows a low return for one patient may show a high return for another. In other words, limiting the health care menu, using a costutility approach, may be ‘irrational’ in its own terms: i.e. it may deny treatment to patients even in cases where intervention would be justified in terms of the benefits yielded by a specific form of treatment. To make this point is not to dismiss the cost-utility approach out of hand. It may well be that there are forms of treatment which yield a low benefit or none at all and which, once identified, can be dismissed from inclusion in any programme of service provision. It is to suggest, however, the inadequacy of such an approach for shaping the package as a whole. If we are concerned about using limited resources to the best effect, then inevitably we are driven to thinking about how to treat individual patients. In other words, the focus switched from macro-decisions by governments about the health care package to micro-decisions by clinicians about the use of the resources available to them. There are two dimensions, as already indicated, to such decisions. First, there are decisions about who should be treated, which involve judgments about the capacity of individual patients to respond to particular interventions. Second, there are decisions about how to manage the care of those patients. To quote an American commentator on the Oregon experiment [14]: ‘It takes no great talent to realize that appendectomy is worth funding, at least for a clear-cut diagnosis of appendicitis. The real issue is not whether to perform the appendectomy; it is whether to fund countless marginal interventions that are potentially part of the procedure - marginal blood tests and repeat tests; precautionary, preventive antibiotic therapy before surgery; the number of nurses in the operating room; and the backup support on call or in the hospital. Even more decisions about marginal elements will arise during the recovery phase: exactly how many days of hospital stay are permitted, how often the physician should make rounds, how many follow-up tests there should be, and so on. Many of these are predicted to offer more benefits than harm, but with margins so small that one could argue that resources ought to be used elsewhere.’
If it is accepted that it is such micro-decisions that largely determine the way in which resources are used, then it would seem that we are back to the kind of diffuse, largely invisible kind of rationing that has characterised Britain’s NHS. Govern-
R. Klein /Health
Policy 27 (1994)
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12
III
ments may decide the broad envelopes of expenditure for particular sectors of health care, such as the balance to be struck between spending on acute activities and care for the mentally handicapped. But within those envelopes, it is left to clinicians to decide on how to use the resources available to them. Moreover, as David Mechanic [ 151 has argued, this may be at least as rational as the Oregon approach: ‘Becausepatient populations are heterogeneous, many medical interventions involve uncertainty, and the clinical decision making process is iterative (using information obtained from the relationship between professional and patient), an effective health care rationing system must take into account the need for flexible physician response to numerous unprovided-for circumstances. Implicit rationing allows for needed sensitivity to variance by relying on clinical discretion.’ To return, in conclusion, to our metaphor: the evidence would seem to suggest that we should be less concerned with what is or is not on the menu, but with how the restaurant is managed. If uncertainty and inadequate information make it inevitable (and rational) to leave decisions to the cooks - i.e. the clinicians - then the challenge to policy is how best to devise a framework of appropriate incentives: including, of course, incentives to withhold services that are not efficacious. Instead of restricting the benefits offered by health care systems, we should perhaps concentrate on how services are delivered. Here the British experience would suggest that while capped budgets are a necessary condition, they are not a sufficient condition. It is quite possible to deliver an ineffective or inadequate service while keeping within one’s budget: indeed it was the realisation of precisely this point which led, as we have seen, to the reforms of the NHS in an attempt to make it less provider-driven. To acknowledge the decisive role of clinical decision making in any attempt to deal with the fiscal challenge of health care is therefore not to argue for the status quo. It is, rather, to direct attention to ways in which clinical decision making can be harnessed more effectively to the aims of public policy. It is to suggest that instead of attacking clinical autonomy head-on by introducing central guidelines about practices or benefits, a line of attack which might well have perverse policy effects by setting today’s conventional wisdom in concrete and thus discouraging experiment and innovation, we should be thinking more about making the medical profession accountable for the way in which it uses publicly provided resources. The Dunning Committee’s recommendation that the priority given to patients on waiting lists should be based on explicit and public criteria represents one step in this direction [16]. The insistence of some British purchasers that providers wishing to have new developments funded must demonstrate health benefits represent another. This last example may indeed provide a pointer to the future. There are a variety of intellectual and practical objections, as this paper has sought to argue, against national governments or their local agents restricting the scope of the basic health care package, i.e. against explicit rationing through the exclusion of specific benefits. And this is even without taking political factors into account: the pressure on politicians to maximise rather than minimise any defined benefits package, as evident in
President Clinton’s proposals, if not in the Oregon plan (no doubt because the latter only affects a politically weak minority). Instead, it would seem preferable to have a more diffuse process of decision making, but one where the currency of competition for limited funds between providers, including, of course, the medical profession, is the ability
to demonstrate
health
gains.
Instead
of governments
deciding
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what not to provide, an approach which assumes a delusory degree of omniscience, let the onus of proof be on the medical profession to show which of their activities will yield a dividend for society. In summary, then, policy making, if it is to be rational, must start by acknowledging that health care is characterised by a high degree of uncertainty and that the information required for central decision making will always be inadequate. The hope that ‘science’ will allow us to roll back the frontiers of ignorance to the point where it is possible to define a limited package of health care, which is defensible because it is based on demonstrated effectiveness, is therefore likely to prove delusory. From this flows the conclusion that both responsibility for dealing with uncertainty and for searching out information should be diffused throughout the system. In trying to reconcile growing demands and resource constraints, the best strategy may therefore be not to impose limits on what is on offer but to introduce incentives designed to encourage everyone working in the health care arena to make ‘best use’ (itself a contested notion) of the resources available to them, and to account for the way in which they are doing so. 6. Acknowledgements This paper draws on research funded by the Nuffield Provincial Hospitals Trust and was carried out in collaboration with Patricia Day and Sharon Redmayne. 7. References 1 2 3
I 8 9
10 11 12 13
14 15 16
Klein, R., The Politics of the National Health Service, 2nd. edn., Longmans, London, 1989. Klein, R., The Politics of the National Health Service, 2nd, edn., Longmans, London, 1989, p. 198. Enthoven, A., Reflections on the Management of the National Health Service, Nuflield Provincial Hospitals Trust, London, 1985. Day, P. and Klein, R., Britain’s Health Care Experiment, Health Affairs, lO(3) (1991) 39-59. Day, P. and Klein, R., Constitutional and distributional conflict in British medical politics: the case of general practice, 191I-1991, Political Studies, XL(3) September (1992) 462-478. Klein, R. and Redmayne, S., Patterns of Priorities, National Association of Health Authorities, Birmingham, 1992. Redmayne, S., Klein, R. and Day, P., Sharing out resources, National Association of Health Authorities, Birmingham, 1993. Redmayne, S. and Klein., R. Rationing in practice the case of in vitro fertilisation, British Medical Journal, 306 (5 June) (1993) 1521-1524. Blustein, J. and Marmor, T.R., Cutting waste by making rules: promises, pitfalls and realistic prospects, University of Pennsylvania Law Review, 140(5), 1543-1572. Smith, R.,“Where is the wisdom. . ?” British Medical Journal, 303 (1992) 798-799. Parker, R., Social administration and scarcity, reprinted in E. Butterworth and R. Holman (Eds.). Social Welfare in Modern Britain. Fontana, London, 1975. Fox, D.M. and Leichter, H.M., Rationing care in Oregon: the new accountability, Health Affairs. Summer (1991) 7-27. Garland, M.J., Rationing in public: Oregon’s priority-setting methodology. In M.A. Strosberg. J.M. Wiener, R. Baker and I.A. Fein (Eds.), Rationing America’s Medical Care: the Oregon Plan and Beyond, The Brookings Institution, Washington, D.C., 1992, p. 49. Veatch, R.M., The Oregon Experiment: Needless and Real Worries. In Strosberg et al. op. tit p. 88. Mechanic, D., Professional judgment and the rationing of medical care, University of Pennsylvania Law Review, 140(5) (1992) 1713-1754. Dunning. A.J. (chairman) Report of the Government Committee on Choices in Health Care, Ministry of Welfare, Health and Cultural Affairs, Rijswijk, Netherlands, 1992.
IRELAND
Can we restrict the health care menu?’ Rudolf Centre for
the Analysis
of Social
Policy,
Klein
Universitv
of Bath,
Claverton
Down.
Bath BA2
7A Y. UK
(Accepted 25 October 1993)
Abstract
The case of Britain’s National Health Service is used to illuminate the cross-national debate whether the availability of health care should be restricted and, if so, how this should be done. Traditionally, the NHS relied on implicit rationing by clinicians within budgetary constraints set by government. However, the logic of the 1989 reforms appeared to require explicit decisions about the packages of health care to be provided to local populations. In practice, purchasers have refused to define such packages. Explicit rationing remains very much the exception. Exploring the reasons for this suggests that defining a restricted menu of health care, by adopting a cost-utility approach and excluding specific procedures or forms of treatment on the Oregon model, is only one of many policy options. There is a large repertory of policy tools for balancing demands and resources, ranging from diluting the intensity of treatment to its earlier termination. Given that health care is characterised by uncertainty, lack of information about outcomes and patient heterogeneity, it may therefore be more ‘rational’ to diffuse decision-making among clinicians and managers than to try to move towards a centrally determined menu of entitlements. about
Key
words:
Rationing;
Britain’s NHS; Oregon
Introduction If the problem facing health care systems is defined as being how to meet rising demands, reflecting changes in technology, demography and cultural attitudes, without risking national bankruptcy, then Britain would appear to have found the answer. If one is seeking a model of parsimony, then Britain offers it. Health care expenditure, measured as a proportion of the national income, is lower than in most other European
countries.
Public
fRevised version of a paper presented Mission
Impossible?
0168-8510/94/$07.00 SSDI
0168-8510
held in Brussels, 0
support
for the National
at the 54th EHPF Meeting Belgium on 30 September -
1994 Elsevier Science Ireland
(93)00600-6
Health
Service remains
on Reducing Health 1993.
I October
Ltd. All rights reserved.
Care Benqfirs:
104
R. Klein/Health
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high. The controversy surrounding the reforms introduced in 1989 has tended to focus attention on the shortcomings of the NHS such as long waiting lists. This, in turn, has been reflected in public opinion surveys. But disgruntlement about particular aspects of the NHS has not undermined the national consensus about the principles on which the system is founded: a national tax-financed service which offers comprehensive coverage without any explicit limits on benefits. On the face of it, this is a remarkable achievement. This paper therefore asks what lessons, if any, there are for other countries. Specifically, it addresses the question of what British experience tells us about the scope for, and desirability of, restricting the health care menu. This is, as we shall see, a complex, multi-dimensional notion which requires to be carefully unpackaged. But before doing so, the current situation in the UK needs to be set in its historical context. 1. The British inheritance The NHS, as created in 1948, had a number of distinguishing features which helps to explain its ability to contain costs [l]. It was a paternalist system, based on the principle that health care would be distributed according to need as defined by the professional providers. It must therefore be sharply distinguished from insurancetype, demand-led systems where consumers have the right to specific services: in the case of the UK, the courts have always held that citizens have no entitlements to specific services, as distinct from a general right of access to health care. Central government determines the overall budget of the NHS, and its distribution to regional and local health authorities. The professional providers determine who gets what: i.e. the allocation of services at the point of delivery. The NHS also has a number of other characteristics which help to explain its ability to contain costs, most notably a system of primary care which copes with the great majority of doctor-patient contacts and which screens the demands on the secondary sector. But it is the fact that it is a need-led system which is central. This system, in turn, rests on two pillars: public deference and professional autonomy. The point about public deference is largely self-explanatory: the NHS has benefited from, some would say exploited, a general willingness to defer to medical judgments. The point about medical autonomy needs, perhaps, more elaborate explanation. The NHS, as originally devised, rested on an implicit contract between the State and the medical profession. The State determined the availability of resources to the medical profession, in return for conceding to doctors the right to determine how those resources would be used. Political decisions about resource levels were thus, in effect, transmuted into clinical decisions about the suitability of particular patients for treatment: rationing was, to a large extent, made invisible as a result. If doctors chafed at the limitations on the resources available to them, at least they enjoyed a remarkable degree of immunity from scrutiny. The reforms introduced in 1989 reflect the fact that both pillars sustaining the original NHS model are crumbling. Public deference has declined in an increasingly consumerist and better educated society. The transformation of the patient (someone who passively suffers things to be done to him or her) into a consumer (someone who is actively seeking out what he or she wants in the market place) - the new
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language of discourse about health care represents a semantic revolution. At the same time, the implicit contract between the State and the medical profession has broken down. The increasing emphasis of the Thatcher Government on strengthening management, evident throughout the 1980s threatened both the autonomy and the domination of the medical profession. In turn, the profession became increasingly resentful of, and openly hostile to, the Government’s attempts to contain costs. Moreover, the Government increasingly chafed at the ‘corporate stalemate’ [2] or ‘gridlock’ [3] within the NHS, the result of virtually conceding the right of veto to the medical profession, which inhibited adaptation to change. Both sides felt betrayed and the 1989 reforms, introduced despite extreme medical opposition [4], were the outcome. 2. The new system of health care The 1989 reforms maintained the financial and organisational framework of the NHS but introduced a number of significant changes. First, they represented a threat to medical profession’s traditional immunity from scrutiny. The new contract for general practitioners was much more specific than in the past: payments were increasingly related to the achievement of specific targets - notably in the field of public health [5]. Medical audit was introduced in all hospitals. Second, and most specifically relevant to the theme of this paper, a split between providers and purchasers was introduced. Whereas before health authorities were responsible for running hospital and community services, they have now become transformed into purchasers: i.e. they are responsible for buying the services needed by their populations from providers who, for the most part, have become independent trusts. In principle, though not often in practice, purchasers may also buy services from the private sector. The crucial point, from the perspective of this paper, is that purchasers, whose budget is determined by central government, via the regional authorities, on the basis of a weighted capitation formula, have to decide what services to buy. The logic of the change is that they should, therefore, explicitly determine what is needed and. by implication, what is not needed: i.e. that they should define the package of health care to be made available to their populations. Instead of the availability of services being determined, as in the past, by the accidents of history, i.e. the inherited distribution of facilities, now purchasers must decide how best to use their budgets with the freedom to switch providers. No longer therefore will developments be providerdriven: if the medical profession wants to introduce new procedures, or continue with old practices, it will have to persuade the purchasers that the products are worth buying. No longer, therefore, will priority setting or rationing be implicit, the result of a series of diffuse clinical decisions. Instead, it will be open and explicit. That, at any rate, is the theory. Practice has turned out to be rather different. In the outcome, there is not much competition between providers, except in London and the big conurbations. Similarly, purchasers were initially instructed by the Department of Health not to cause turbulence in the system by switching providers. In all these respects change is coming only slowly. Above all, and crucial for the theme of this paper, there is as yet no evidence that purchasers are defining explicit
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packages of care. Next, therefore, we turn to examining the reasons why the apparently irrefutable logic of the changes has not been translated into practice before moving on to speculating about the wider implications of the British experience, and what this tells us about the whole notion of restricting the health care menu. 3. Priority setting in practice In this section, we first look at the evidence of how the NHS purchasers have set about their task. This is based on two surveys carried out by the Centre for the Analysis of Social Policy at Bath and funded by the Nuffield Provincial Hospitals Trust, of the purchasing plans for 1992-93 and 1993-94, respectively [6-71. Financially, 1992-93 was a good year for the NHS, with a growth rate (in real terms) of about 3% in its budget; 1993-94, however, promises to be rather rougher, with a prospective growth rate of only about 1%. In 1992-93, therefore, purchasers were, to an extent at least, able to change their service package out of the dividends of growth; in 1993-94, conversely, any changes are more likely to be at the expense of existing commitments. By comparing the 2 years, it is thus possible to examine whether or not the approaches to determining the ‘NHS menu’ are affected by the degree of financial stringency. In the event, changes in the degree of financial stringency do not appear to have much effect. The common elements in the two sets of plans are much more pronounced than any differences. The NHS menu, in each of the purchasing authorities, is still overwhelmingly determined by history. The services available to their populations will be largely those which they have always had. There have always been considerable variations in these services seemingly unrelated to the characteristics of the local population: in, for example, the rates of hip replacement, by-pass and cataract operations. These are set to persist under the new purchasing plans, despite attempts to set national norms for the provision of certain procedures. The variations may be smoothed out at the edges. But there is very little evidence of health authorities asking themselves what the appropriate package of care should be: i.e. of moving towards what they consider the appropriate menu to be. Instead, the purchasing plans demonstrate a process of incremental adjustment: of adaptive changes at the margins. These reflect a variety of factors. In part, there is guidance from the Department of Health, nudging purchasers towards health prevention and the development of primary care. In part, there is local pressure to develop specific services: one of the most notable results of the NHS reforms has been to involve general practitioners in the priority setting exercise and their views have helped to shape purchasing plans. Overall, the effect has been to consolidate the existing pattern of health care delivery with the emphasis on remedying perceived local deficiencies in the services traditionally provided. Acute services, which account for 51% of all NHS spending, got 55% of the money available for new developments in the authorities surveyed in 1992-93 and 58% in 1993-94. These figures present, of course, a very crude picture at the aggregate level, which conceals many changes at the micro-level: thus much effort has gone into changing the configuration of existing services in order to make them more efficient and effec-
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tive, as distinct from changing the balance of spending between different sectors. However, the conclusion that the status quo has not as yet changed greatly is reinforced if we switch perspective and ask whether or not purchasers are explicitly striking services off the NHS menu. Explicit rationing, in the sense of making specific services or procedures no longer available, is very much the exception. In 1992-93, only 12 of the 114 purchasing plans surveyed explicitly announced that they would no longer buy certain procedures. In 1993-94, only four of the 100 purchasing plans surveyed did so (as a result of amalgamations there has been a diminution in the number of health authorities in the NHS). If anything, therefore, there appears to have been a retreat from explicit rationing a 1’Oregon. Equally significant, perhaps, is the nature of the procedures which were struck off the NHS menu. In 1992-93, tattoo removal topped the list (mentioned by seven health authorities), followed by GIFT/IVF (six), reversal of sterilisation/vasectomy and general cosmetic surgery (four each). Other procedures mentioned included: adult bat ears, breast augmentation, buttock lifting and cosmetic varicose veins. The numbers add up to more than 12, because most authorities mentioned more than one procedure. The much shorter list in 1993-94 includes many of the same‘items, but does not add to them. All the procedures appear to share two characteristics. They are marginal to the NHS’s activities in terms of their cost: they represent the small change in the NHS’s budget. And they tend to blur social and medical judgments: i.e. they raise questions about whether a national health care system should take responsibility for what might be seen as self-inflicted conditions and about the dividing line (if there is any) between what is socially desirable and what is medically necessary. The example of In Vitro Fertilisation, where purchasers are sharply divided, with some of them striking it off their menu, whilst others are putting more funding into this service, illustrates these points well [8]. The explanations for this apparentqimidity in the face of the challenge to be explicit about what is being purchased, and what is not, fall into two categories. There are those anchored in the particular circumstances of Britain’s NHS and there are those which have wider implications for health care systems in general. Taking the proximate or local reasons first, it is important to recognise that the NHS has been going through a period of turbulent change. The managerial and expert resources required to review spending priorities, to take a fundamental look at what should and should not be purchased, have therefore been largely absorbed by the need to get the new system going. For example, NHS purchasers have had to learn how to write and monitor contracts with providers: a totally new art form. Equally important, and of perhaps wider and more long-term significance, has been the problem of information, or, rather, the lack of it. Before deciding what should be on the menu, purchasers have first to discover what is on the menu already: i.e. who is getting what in the populations being served. And this is not always easy, particularly when he comes to relating clinical data to populations of different types or in different geographical areas. More crucially still, there is lack of information about the effectiveness of services or procedures. The purchasing plans typically make much of relating spending to effectiveness. They emphasise that spending should be geared to maximising ‘health gains’ and to ‘adding years to life and life to years’. But this is the tribute paid by ignorance to conventional wisdom, inevitably
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so given the lack of much of the relevant knowledge about outcomes and effectiveness. The notion that there would be no need to limit the menu of health services if only ineffective services were eliminated is betrayed, British experience confirms, in practice by uncertainty about precisely what is effective or not [9]. There would, indeed, be no problem at all if only procedures with demonstrated effectiveness were offered: the health care budget could be cut dramatically. But this is a very different matter from assuming that those interventions which are not supported by solid scientific evidence - 85% it is estimated [lo] - are necessarily ineffective. If only life were that simple, there would be no need to agonise over rising health care spending. This last point brings the argument to some of the more general issues involved in analysing the notion of the ‘health care menu’ or a ‘basic health care package’. Next, therefore, we explore the various dimensions of these terms, so often used as rhetorical shorthand for ways of limiting the burden of expectations and demands on health care systems but seldom defined with sufficient precision. 4. Unpackaging the concepts The metaphor of a ‘health care menu’ can, perhaps, be usefully illuminated by taking it at face value and seeing what it might mean if, instead of applying it to health care, we were to use it in its original context: i.e. that of a restaurant. Imagine a restaurant which was trying to cope with excess demand, and rising costs, but which was denied the option of raising its prices in order to discourage prospective customers. What sort of strategies might it adopt in response? One obvious response might indeed be to limit the menu: to offer only a table d’hote instead of an a la carte menu. It might further insist that it will only produce healthy dishes that are good for customers, low in fats and high in fibres, rather than those which they actually like. This might well stem the flood of customers, as they discover that they cannot get what they want. However, it might also provoke a rebellion among the cooks, anxious to demonstrate the full scope of their art and their ability to excel in producing new recipes (which would enhance their professional reputation and get them invitations to prestigious international gastronomic gatherings). So the restaurant might well turn to alternative strategies. It might, for example, decide that it would use cheaper ingredients or offer smaller portions in order to cut costs. It might make customers wait longer for their tables, in order to discourage them. It might try to rush customers quickly through their meals in order to increase the turn-over per table, whatever this might mean for their digestion. It might cut down on the decor and the frills: no white table cloths or candles. It might even delay ordering new equipment in order to discourage the cooks from inventing new dishes. Leaving our restaurant, and coming back to health care systems, it is evident that all these strategies are available if the aim of policy is to restrain the rise in spending. In short, the notion of restricting the ‘menu’ is only one of many available options. Furthermore, the experience of Britain’s NHS suggests that most of the options, usually in combination, can be used to ‘ration’ health care: i.e. that rationing by exclusion is only one, and not necessarily the best, way of coping with the problem of how to cope with technological inflation and demographic change without breaking the bank.
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To illustrate this point, let us translate the restaurant strategies into health care terms. There are, in effect, three main strategies for so doing [l 11. First, there is restricting demand by imposing time-costs on patients: i.e. rationing by queueing something for which Britain’s NHS (and other needed, budget-capped systems) is notorious. Second, demands on resources can be limited by dilution: i.e. by carrying out fewer tests, prescribing fewer drugs and generally limiting the intensity of treatment (the importance of this is underlined by the evidence that rising health care costs in the US are largely explained by the growing intensity of treatment offered). Third, demands on resources can be restricted by the termination of treatment: i.e. patients are turned out of hospital more quickly. All these are, of course, familiar. though seldom explicitly acknowledged. There may, in addition, be other tactics that can be pursued. Cutting down on environmental amenities is one such option. So could a more cost-conscious approach to quality: all too rarely does the debate about improving quality involve any mention of a price tag and there may well be a case for accepting that the aim should be to achieve minimum rather than optimal standards. There is, then, a whole repertory of policy tools available for dealing with rising costs, of which excluding items from the menu is just one. But it could still be that rationing by exclusion, i.e. defining a minimum health care package, should be the preferred option. The next, and concluding section, therefore addresses some of the intellectual arguments, as well as the evidence of the British experience, about the case for and against giving primacy to limiting what is available on the menu: what might be called the Oregon solution. In doing so, we also address the question of the relationship between political and clinical decision-making and between the State and the medical profession. 5. Concentrated or diffused decision-making?
The ghost of the Oregon model haunts all discussions about defining a set menu of health care rationing by the exclusion of certain procedures and activities, so at this point in the argument, let us flush it out into the open and (if possible) exorcise it. The case for this model is that it is both rational and democratic. It is rational because the methodology is based on cost-utility analysis: i.e. on the relative benefits yielded by different procedures. It is, democratic because the methodology also incorporates ‘community values’ derived from the participation of citizens in a series of deliberative meetings. But, of course, the model never worked as it was supposed to do [12]. The cost-utility analysis produced results that were considered to be counter-intuitive. The ranking list of procedures was accordingly revised to make it more acceptable in the light of professional and public opinion, so losing its methodological virginity. Reliable data about costs was ‘so difficult to acquire that ultimately costs were used only to make marginal adjustments in a small number of items on the list’[l3]. The meetings held to elicit the views of citizens were, in the event, dominated by health care professionals. As in the case of the UK experience, it can be argued that these problems reflected purely temporal factors. Only given a greater investment of effort in improving the methodology, only given a different approach to involving the public, and all would be well. We should be beware, it might be concluded, of drawing any conclusions
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for the future from pioneering experiments which, inevitably, draw attention to inadequacies and difficulties. But it may be that the flaws in the Oregon model are more deep-seated and that they cannot be remedied by methodological repair work. It may be that the definition of ‘rationality’ inherent in the Oregon approach is actually ‘irrational’. There are a number of reasons for taking this view. Like other models based on a costutility approach, the Oregon methodology assumes the availability of adequate and reliable information about outcomes and costs. But what if that information does not exist or, at best, is patchy and incomplete? Of course, it may be that the current investment of effort in outcomes research will, in due course, produce the missing data. But is it, in the meantime, ‘rational’ to base policy on a hope for the future which, conceivably, may never be fulfilled as changes in technology overtake and render obsolete yesterday’s data? There is a further flaw inherent in the Oregon model, as in any model which attempts to define the package of health care that is to be made available. This is the assumption that patients are homogeneous. This, of course, is a nonsense assumption. The same procedure that shows a low return for one patient may show a high return for another. In other words, limiting the health care menu, using a costutility approach, may be ‘irrational’ in its own terms: i.e. it may deny treatment to patients even in cases where intervention would be justified in terms of the benefits yielded by a specific form of treatment. To make this point is not to dismiss the cost-utility approach out of hand. It may well be that there are forms of treatment which yield a low benefit or none at all and which, once identified, can be dismissed from inclusion in any programme of service provision. It is to suggest, however, the inadequacy of such an approach for shaping the package as a whole. If we are concerned about using limited resources to the best effect, then inevitably we are driven to thinking about how to treat individual patients. In other words, the focus switched from macro-decisions by governments about the health care package to micro-decisions by clinicians about the use of the resources available to them. There are two dimensions, as already indicated, to such decisions. First, there are decisions about who should be treated, which involve judgments about the capacity of individual patients to respond to particular interventions. Second, there are decisions about how to manage the care of those patients. To quote an American commentator on the Oregon experiment [14]: ‘It takes no great talent to realize that appendectomy is worth funding, at least for a clear-cut diagnosis of appendicitis. The real issue is not whether to perform the appendectomy; it is whether to fund countless marginal interventions that are potentially part of the procedure - marginal blood tests and repeat tests; precautionary, preventive antibiotic therapy before surgery; the number of nurses in the operating room; and the backup support on call or in the hospital. Even more decisions about marginal elements will arise during the recovery phase: exactly how many days of hospital stay are permitted, how often the physician should make rounds, how many follow-up tests there should be, and so on. Many of these are predicted to offer more benefits than harm, but with margins so small that one could argue that resources ought to be used elsewhere.’
If it is accepted that it is such micro-decisions that largely determine the way in which resources are used, then it would seem that we are back to the kind of diffuse, largely invisible kind of rationing that has characterised Britain’s NHS. Govern-
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III
ments may decide the broad envelopes of expenditure for particular sectors of health care, such as the balance to be struck between spending on acute activities and care for the mentally handicapped. But within those envelopes, it is left to clinicians to decide on how to use the resources available to them. Moreover, as David Mechanic [ 151 has argued, this may be at least as rational as the Oregon approach: ‘Becausepatient populations are heterogeneous, many medical interventions involve uncertainty, and the clinical decision making process is iterative (using information obtained from the relationship between professional and patient), an effective health care rationing system must take into account the need for flexible physician response to numerous unprovided-for circumstances. Implicit rationing allows for needed sensitivity to variance by relying on clinical discretion.’ To return, in conclusion, to our metaphor: the evidence would seem to suggest that we should be less concerned with what is or is not on the menu, but with how the restaurant is managed. If uncertainty and inadequate information make it inevitable (and rational) to leave decisions to the cooks - i.e. the clinicians - then the challenge to policy is how best to devise a framework of appropriate incentives: including, of course, incentives to withhold services that are not efficacious. Instead of restricting the benefits offered by health care systems, we should perhaps concentrate on how services are delivered. Here the British experience would suggest that while capped budgets are a necessary condition, they are not a sufficient condition. It is quite possible to deliver an ineffective or inadequate service while keeping within one’s budget: indeed it was the realisation of precisely this point which led, as we have seen, to the reforms of the NHS in an attempt to make it less provider-driven. To acknowledge the decisive role of clinical decision making in any attempt to deal with the fiscal challenge of health care is therefore not to argue for the status quo. It is, rather, to direct attention to ways in which clinical decision making can be harnessed more effectively to the aims of public policy. It is to suggest that instead of attacking clinical autonomy head-on by introducing central guidelines about practices or benefits, a line of attack which might well have perverse policy effects by setting today’s conventional wisdom in concrete and thus discouraging experiment and innovation, we should be thinking more about making the medical profession accountable for the way in which it uses publicly provided resources. The Dunning Committee’s recommendation that the priority given to patients on waiting lists should be based on explicit and public criteria represents one step in this direction [16]. The insistence of some British purchasers that providers wishing to have new developments funded must demonstrate health benefits represent another. This last example may indeed provide a pointer to the future. There are a variety of intellectual and practical objections, as this paper has sought to argue, against national governments or their local agents restricting the scope of the basic health care package, i.e. against explicit rationing through the exclusion of specific benefits. And this is even without taking political factors into account: the pressure on politicians to maximise rather than minimise any defined benefits package, as evident in
President Clinton’s proposals, if not in the Oregon plan (no doubt because the latter only affects a politically weak minority). Instead, it would seem preferable to have a more diffuse process of decision making, but one where the currency of competition for limited funds between providers, including, of course, the medical profession, is the ability
to demonstrate
health
gains.
Instead
of governments
deciding
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what not to provide, an approach which assumes a delusory degree of omniscience, let the onus of proof be on the medical profession to show which of their activities will yield a dividend for society. In summary, then, policy making, if it is to be rational, must start by acknowledging that health care is characterised by a high degree of uncertainty and that the information required for central decision making will always be inadequate. The hope that ‘science’ will allow us to roll back the frontiers of ignorance to the point where it is possible to define a limited package of health care, which is defensible because it is based on demonstrated effectiveness, is therefore likely to prove delusory. From this flows the conclusion that both responsibility for dealing with uncertainty and for searching out information should be diffused throughout the system. In trying to reconcile growing demands and resource constraints, the best strategy may therefore be not to impose limits on what is on offer but to introduce incentives designed to encourage everyone working in the health care arena to make ‘best use’ (itself a contested notion) of the resources available to them, and to account for the way in which they are doing so. 6. Acknowledgements This paper draws on research funded by the Nuffield Provincial Hospitals Trust and was carried out in collaboration with Patricia Day and Sharon Redmayne. 7. References 1 2 3
I 8 9
10 11 12 13
14 15 16
Klein, R., The Politics of the National Health Service, 2nd. edn., Longmans, London, 1989. Klein, R., The Politics of the National Health Service, 2nd, edn., Longmans, London, 1989, p. 198. Enthoven, A., Reflections on the Management of the National Health Service, Nuflield Provincial Hospitals Trust, London, 1985. Day, P. and Klein, R., Britain’s Health Care Experiment, Health Affairs, lO(3) (1991) 39-59. Day, P. and Klein, R., Constitutional and distributional conflict in British medical politics: the case of general practice, 191I-1991, Political Studies, XL(3) September (1992) 462-478. Klein, R. and Redmayne, S., Patterns of Priorities, National Association of Health Authorities, Birmingham, 1992. Redmayne, S., Klein, R. and Day, P., Sharing out resources, National Association of Health Authorities, Birmingham, 1993. Redmayne, S. and Klein., R. Rationing in practice the case of in vitro fertilisation, British Medical Journal, 306 (5 June) (1993) 1521-1524. Blustein, J. and Marmor, T.R., Cutting waste by making rules: promises, pitfalls and realistic prospects, University of Pennsylvania Law Review, 140(5), 1543-1572. Smith, R.,“Where is the wisdom. . ?” British Medical Journal, 303 (1992) 798-799. Parker, R., Social administration and scarcity, reprinted in E. Butterworth and R. Holman (Eds.). Social Welfare in Modern Britain. Fontana, London, 1975. Fox, D.M. and Leichter, H.M., Rationing care in Oregon: the new accountability, Health Affairs. Summer (1991) 7-27. Garland, M.J., Rationing in public: Oregon’s priority-setting methodology. In M.A. Strosberg. J.M. Wiener, R. Baker and I.A. Fein (Eds.), Rationing America’s Medical Care: the Oregon Plan and Beyond, The Brookings Institution, Washington, D.C., 1992, p. 49. Veatch, R.M., The Oregon Experiment: Needless and Real Worries. In Strosberg et al. op. tit p. 88. Mechanic, D., Professional judgment and the rationing of medical care, University of Pennsylvania Law Review, 140(5) (1992) 1713-1754. Dunning. A.J. (chairman) Report of the Government Committee on Choices in Health Care, Ministry of Welfare, Health and Cultural Affairs, Rijswijk, Netherlands, 1992.