Sunday, 8 January 2012

A rational debate about rationing?


The debate about the responsibilities of the NHS towards women who paid for poor quality breast implants privately has been fascinating to watch.

On Saturday, I just happened to catch an exchange on BBC news, when Bruce Keogh (Medical Director of the NHS) was interviewed straight after a lady who had had to have her breast implants revised after one them had ruptured. Bruce was subjected to what I thought was an unnecessary amount of ire, not just from the lady, but also from the interviewer, when he outlined that the NHS will replace any substandard implants that they put in and they will remove any ruptured implants, but they will not replace implants that were put in by private clinics.

Is this a ‘disgusting’ abandonment of responsibility by the NHS, or a reasoned decision based on the Utilitarian ideals that underpin the health service? I know where I stand on this issue, but I am not in the business of trying to get you to agree with me - what I would like to see is a world in which we can debate issues like this without accusing the individuals charged with making difficult choices of being evil when they outline their decisions and reasoning.

A consistent theme that I have  particularly seen on the TV has been the revealed assumptions by journalists and lay people interviewed that the NHS has a duty of care to all ladies who have these faulty implants, regardless of the circumstances in which the implants were fitted.

Furthermore, it has also been interesting to register the reaction among these same journalists and lay people, when someone from the health service challenges these assumptions and argues that all clinics that used sub-standard implants have a duty of care to correct their mistakes, and not just the NHS. Has anyone else noticed that the standards and expectations we have of the NHS differ from those we have of private health providers?

The beauty and the curse of the NHS is that it wholly separates the business of paying for the service from the business of using it. This affects the way we consume healthcare, and encourages us to use it like an all-you-can-eat buffet, and have more than we actually need.  This curse has also been politically compounded by the promise of better and more effective healthcare, and the frequent language of failure that is used when talking about the NHS.

Standards of care do vary, and not everyone receives the service they deserve, but as I have said before, overall, we get the health service that we deserve, and there is no use pretending it is something that it is not. Resources are finite, demand is potentially limitless, and we as a community have to be honest about what we can afford. Someone has to decide what we do and do not fund, or we all have to agree to pay a lot more - those are the simple choices we face.

Of course, it is all a lot more complicated than that, but the breast implant fiasco has revealed a couple of things that are likely to have increasing relevance in the future. Firstly, under the changes heralded by the health bill, we are likely to become a lot more familiar with having different treatments supplied by different providers in a range of different facilities. How good will the after-care for late-developing complications provided by private providers be, and who will be held responsible for correcting mistakes of the kind that we are currently dealing with? Given the financial imperatives, you can guarantee that providers will do their best to avoid responsibility, and the only people that will lose out will be the patients, while they wait for the different organisations to thrash out their arguments in the courts.

Secondly, the reality of health care is that it is a hungry beast, with an insatiable appetite. Remember the episode of The Simpsons when Homer gets sued for over-eating at an all-you-can-eat seafood restaurant? Marge is asked by the lawyer in the court what they did after they were thrown out of the restaurant, and the conversation goes something like this;

Marge: ‘We drove round Springfield for a couple of hours.’
Lawyer: ‘Why did you drive around Springfield for a couple of hours?’
Marge: ‘We were looking for another all-you-can-eat seafood restaurant.’‘
Lawyer: ‘You drove to another all-you-can-eat seafood restaurant?’, and turning to the court, ‘Are those the actions of a man who has had all he can eat?’

I use this rather self-indulgent reminiscence to make the simple point that it is unlikely that we would ever be prepared to spend so much on health care that everything that anyone needs or wants could be afforded. The obvious conclusion, therefore, is that the reach of our health service will be limited to what we decide should be paid for. Naturally, this means that there will be treatments and services that we withold.

The nature of any such rationing discussion is necessarily difficult, emotive, and potentially explosive, but we all need to start at the same point, which is the understanding that over time, and depending on the financial pressures the health service faces at any one time, we will have to exclude some levels of provision. The discussion, therefore, needs to be open, frank and responsible about what are the values that underpin such rationing.

And the breast implant debate is perhaps a good place to start: can we justify the £150 million it would cost to remove and replace all the faulty implants that have been used? If we do use the money in this way, what else are we foregoing?
Tax payers have no choice about whether or not they contribute to the health service - it is their obligation. Would it be fair to also say that we have an obligation to understand that the NHS will provide the best service it can, but that this will never cover everything? Is it fair to make the promise that the health service will be open, transparent and consistent about what it won’t do for you and be prepared to debate with you? Or would such a move merely represent an inevitable erosion of the level of provision offered similar to what we have experienced in dentistry?

I’m going to mull this over, but feel free to let me know what you think.

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