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Priorities and Rationing

Equality, Equity and Policy: Priorities and Rationing

Frameworks and theory

Prioritising some health care interventions over others (and some individuals over others) are difficult choices faced by most health care systems. There is no obvious set of ethical principles or analytical tools to determine what decisions should be made at which level of the health system, or how to allocate limited resources.

Beauchamp and Childress (2001) have outlined the Four Principles framework, one of the most widely used frameworks in decision making. In any given situation, the four different (and often competing) principles vie for
importance.

Table 1: Four Principles Framework

Beneficence

doing or bringing about good

Non-maleficence

the avoidance of doing harm

Autonomy

respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices.

Justice

distributing health care fairly and justly (However, as described in section. Need and Social justice, justice is a moral decision rather than an objective one)

However, the Four Principles are of limited use when making rationing decisions. Because there is no ‘quick fix’ for determining priorities, Klein (1993) argues that the prioritisation debate should focus on the processes and structure of decision making. Daniels and Sabin (1997) have proposed another four principles to be considered when prioritising health care, which they call “accountability for reasonableness”.

Table 2: Four principles of “accountability for reasonableness”

Transparency

Public visibility of ethnical framework/principles/rationale behind priorities.

Relevancy

Priorities should be set based on evidence, reasons and principles that fair-minded parties (including patients and clinicians) agree are relevant under the circumstances.

Appeal

Opportunity to review decisions in light of new evidence/circumstances. Mechanism for challenge and dispute.

Enforcement

Appropriate governance and accountability structures to ensure the above conditions are met.

Rationing takes place in all health care systems. While Daniels and Sabin argue for transparency in rationing, there is some debate about whether rationing should be explicit (in full view of the public) or implicit
(behind the scenes).

The case for implicit rationing (and against explicit rationing)
(Coast, 1997):

  • Practicality: explicit rationing is impractical because there are no clear criteria on which to base rationing.
  • The utility of ignorance: there are emotional consequences of explicit rationing:
    • Denial disutility: in explicit rationing, citizens that become involved in the process of denying care to particular groups or individuals may experience disutility (unhappiness/guilt/anxiety/disgust). I.e. Denying health care to others
      has the potential to make people unhappy.
    • Deprivation disutility: in explicit rationing, particular individuals may experience disutility when they are informed that their care is being rationed. I.e. People may become unhappy when they learn that their health care has been rationed.
  • Bureaucratic and political effectiveness: the administrative and bureaucratic processes of healthcare provision will run more smoothly in implicit rationing systems.

The case for explicit rationing (Doyal, 1997):

  • While there are no clear criteria on which to base explicit rationing, policy makers can, however, report the ethical principles on which rationing decisions are generally made.
  • Implicit rationing will undermine citizens’ moral commitments to democracy.
  • Any benefit derived from deception (avoiding denial disutility and deprivation disutility) will be sustained only while people are kept in ignorance.
  • If citizens are not informed of the principles guiding rationing, then rationing may be guided by only a few voices.
  • Informed democratic feedback can improve effectiveness of health care.

Prioritising in practice

Sabik and Lie (2008) reviewed priority setting in eight countries. They found two categories of priority setting approaches which they called “outlining principles” and “defining practices”.

Outlining principles:

The Netherlands: The Dunning Committee delineated four priority principles as a sieve for sifting out services that should not be publically funded—necessity, effectiveness, efficiency, and individual responsibility. The principles were
meant to be applied successively beginning with the principle of necessity (defined as capacity to benefit).

Sweden: The Parliamentary Priorities Commission outlined three platform principles—human dignity, need and solidarity, and cost-efficiency. Cost-efficiency should only be considered in comparing treatments for the same
condition.

Defining practices (explicit rationing):

The UK: In 1999 the National Institute for Health and Clinical Excellence (NICE) was established to appraise new health technologies, develop clinical guidelines, and assess interventional procedures. NICE makes decisions based on the “accountability for reasonableness” conditions described above and lists scientific rigour, inclusiveness, transparency, independence, challenge, review, support for implementation, and timeliness as its key procedural principles (NICE, undated).

The Oregon Plan: Starting in the early 1990s the Oregon Medicaid plan aimed to extend a basic bundle of services to all citizens living below 100% of the federal poverty line. The goal of the Oregon Plan was to ration services not people.  The Oregon Health Services Commission was established to produce a prioritised list of services that would make up Oregon’s basic Medicaid bundle of services. After considerable public consultation, initial rankings were decided based on a quality-of-well-being scale and cost-effectiveness. However, the rankings and ranking methodology were widely criticised and subsequently redrafted on the principles of clinical effectiveness and social value, with guidance from experts.  When spending levels were unable to cover all desirable services, those services with the lowest priority were eliminated from coverage. Each person’s eligibility for Medicaid was not affected. (Beauchamp and Childress, 2001; Sabik and Lie, 2008).

Economic evaluations (including cost-benefit analysis and cost-effectiveness analysis) are used by many countries in rationing health care. Value judgements are a key part of any economic evaluation, including the question of which costs, benefits and effects should be included (See module 4d: Health Economics section 8: The role of economic evaluation and priority setting in health care decision making). While economic evaluations provide a relatively quick and useful decision-making tool, prioritising health services based on economic evaluations alone serves a Utilitarian goal.  This may or may not be the desired principle of social justice (See section 1: The Concepts of Need and Social Justice), and may lead to public outcry (e.g. as caused by The Oregon Plan).

Rationing at a local level

Not only does prioritisation take place at a national level, local areas also face rationing decisions. In the UK, local primary care trusts (PCTs) are responsible for commissioning healthcare services for their resident population and are allocated a finite level of resources. PCTs generally commission a range of services from the NHS, Independent and Voluntary Sector Providers to meet the health care needs of their population. Patients who require services outside the normal range of services offered by a PCT (because, for instance, a new health technology has been developed) may apply to an Exceptional Treatment Panel (ETP).  Box 1 provides some examples of ETPs in England.

Box 1: Exceptional Treatment Panels

Islington PCT, London

If a patient's GP or other clinician feels that there are exceptional circumstances that must be considered for a treatment or drug to be provided, then they can refer the patient to NHS Islington’s Exceptional Treatment Panel (ETP). The ETP is a committee of experts who will consider each individual case on its merits, and decide whether
treatment can go ahead.

The ETP considers the following circumstances:

* Procedures covered by guidelines from the National Institute for Clinical Excellence  (NICE) for Islington that are high cost but low volume. Examples of such treatments are in vitro fertilisation and
surgery for obesity.

* Procedures such as cosmetic surgery, laser hair removal and varicose vein surgery.

* Some pharmaceutical treatments that are newly licensed but which don’t yet have NICE guidelines.

Source: http://www.islington.nhs.uk

 

Cambridgeshire PCT

The Exceptional Cases Panel is authorised by the Board to process requests for exceptional treatments (procedures, drugs or health care services) that are:

* Undertaken outside the criteria agreed locally for surgical thresholds

* Classified as low priority treatments

* Tertiary referrals ie. to a Consultant or a service not covered by contracts with local providers or not covered by the ‘Choice’ policy

* Drugs not funded for routine prescribing e.g. primary care red List or drugs outside secondary care contracts which practices may be asked to prescribe or support for your patients

Surgical Thresholds

The Cambridgeshire & Peterborough Public Health Network has produced surgical thresholds with the help of local primary and secondary care clinicians; and approved by PEC or PCT Board. The thresholds provide criteria to be used by GPs for referral and by providers before performing that surgical procedure. These surgical
thresholds are available on the Public Health Network website at: http://www.cambsphn.nhs.uk/default.asp?id=144

Low Priority Treatments

The low priority treatments are usually of unproven clinical effectiveness, poor cost effectiveness or of low overall priority, eg. cosmetic procedures or treatment for benign skin lesions. Policies for low priority treatments have also been developed by the Cambridgeshire & Peterborough Public Health Network. The low priority policies are
available via the following web link: http:/www.cambsphn.nhs.uk

Drugs not funded for routine prescribing

If a GP identifies a patient whom they judge may benefit from a treatment that we do not routinely fund which practices may be asked to prescribe or support for your patients e.g. primary care Red List or drugs outside secondary care contracts, then advice should usually be sought by contacting the locality medicines management team. They can advise on circumstances where red List and other restricted drugs may be funded.

Source: http://www.cambridgeshirepct.nhs.uk

 

References

  • Coast J (1997). “The case against”. BMJ, 314: 1118-22.
  • Daniels N, Sabin JE (1997). “Limits to health care: fair procedures, democratic deliberation and the legitimacy problem for insurers”. Philosophy
    and Public Affairs,
    26 (4):303–502.
  • Doyal L (1997). “Rationing within the NHS should be explicit”. BMJ,
    314: 1114-8.
  • Klein R (1993). “Dimensions of rationing: who should do what?”. BMJ,
    307:309-11.
  • NICE (undated). SOCIAL VALUE JUDGEMENTS: Principles for the development of NICE guidance. Second edition. http://www.nice.org.uk/media/C18/30/SVJ2PUBLICATION2008.pdf
  • Sabik L, Lie R (2008). “Priority Setting in health care: Lessons from the experiences of eight countries.” International Journal for Equity
    in Health
    , 7:4.

© Rebecca Steinbach 2009