The UK Faculty of Public Health has recently taken ownership of the Health Knowledge resource. This new, advert-free website is still under development and there may be some issues accessing content. Additionally, the content has not been audited or verified by the Faculty of Public Health as part of an ongoing quality assurance process and as such certain material included maybe out of date. If you have any concerns regarding content you should seek to independently verify this.

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 1: Concepts of 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).
  • Deprivation disutility: in explicit rationing, particular individuals may experience disutility when they are informed that their care is being 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 they are a relatively quick and useful decision-making tool, prioritising health services based on economic evaluations alone favours services that deliver the greatest benefit to the most people and at the lowest cost, which is a Utilitarian approach. The public may identify more with other principles of social justice (See section 1: The Concepts of Need and Social Justice), and object to decisions made on the basis of economic evaluations, as was the case with 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 England, local commissioning bodies are responsible for purchasing healthcare services for their resident population and are allocated a finite level of resources. They 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  (because, for instance, a new health technology has been developed) may make an Individual Funding Request (IFR).  Box 1 provides some examples of  IFRs in England.

 

Box 1: What is an Individual Funding Request?

 

This is National Health Service (NHS) funding for drugs, operations or other care that is not routinely funded by the NHS. Normally this is because they:

  • are clinically not effective or effectiveness has yet to be determined
  • are not cost effective in comparison to all the competing demands on NHS funding
  • have a low clinical priority and offer little health gain
  • are largely cosmetic in nature.

Clinicians can make an individual funding request for a treatment if

  • it is a very new treatment or drug and has no commissioning policy available
  • there are exceptional reasons why the treatment or drug should be available to an individual patient.

A treatment may be funded on an individual basis if

  • The patient has a set of circumstances that are very different from anyone else meaning they will derive greater benefits from the intervention than others who are in a similar position

AND

  • There is good evidence to suggest that they would be healthier after the treatment or operation. 

 

- See more at: https://www.bristolccg.nhs.uk/about-us/what-we-fund/what-individual-funding-request/#sthash.Rq2lOytZ.dpuf

 

 

References

 

                                                  © Rebecca Steinbach 2009, Rachel Kwiatkowska 2016