Rationing and rationality

When I first started work as a journalist, Virginia Bottomley was health secretary, GP fundholding was the big new idea, and the alliterative headline that all health journalists reached for at the drop of an expensive cancer drug was ‘postcode prescribing.’

All of which makes me feel really old and a bit depressed. Not at the onward march of time (OK, a bit), but at the squealing noise of the brakes being slammed on, and the engine thrown into reverse, of one of the best ideas the last government ever had.

There were many things I disagreed with about Labour’s health policy, but establishing the National Institute for Health and Clinical Excellence was not one of them. Finally, someone had the bright idea of looking at the really difficult decisions around which treatments were funded on the NHS, and handing the job to the experts. Not the overworked GPs (who look like getting the task under the new proposals), or tabloid newspapers, or  the specialists, keen to prioritise their own expensive bit of the health service over the less glamorous bread-and-butter care. Real, expert clinicians, supported by lay people, with access to the best research evidence available.

Working in the BMJ’s Evidence Centre, I’ve come more and more to realise what a genius idea this was. My day to day work involves weighing up and assessing the merit of newly published clinical papers, to see where they fit into our accumulated knowledge about a particular condition and its treatments. I know how tough this is – and I don’t have patients banging on the door to distract me, and I don’t have to consider the cost of treatments. If I had to weigh up not only the effectiveness of Drug X (which may or may not prolong Mrs Y’s life by some weeks, which may or may not be miserable and filled with pain), but whether to pay for Drug X for Mrs Y, or to fund physiotherapy for Mr Z, who can’t work because of his back pain… well, I’d hardly know where to start.

As it is, I’d simply look at the NICE guidelines. I may agree or disagree, but I do know that if NICE says a drug is not effective enough to be worth the cost, it has looked at the evidence, done the maths and come up with a reasoned, measured answer. It sounds cold, and to an extent it is. That’s why tabloid newspapers hate it so much – what price a calculating machine, weighed against a young mother’s life? Yet the very absence of emotion allows NICE to be fairer and more just than an ad-hoc committee of local politicians and doctors, which was how decisions were taken under the old ‘postcode prescribing’ regime.

Rationing was the word that every politician used to weasle their way out of saying. It’s not rationing, it’s prioritising, it’s the decision of the local health authority, it’s about ensuring value for money, they used to say. Finally, a government had the sense to hand the whole can of worms over to the experts, who did a fine job, despite all the ordure thrown their way.

Every health system in the world has to ration treatment. You can ration it by what individuals can afford to spend themselves, or by what taxation will bear, or by what the tabloids think should be the priority. Personally I’d rather have rational rationing, done by the people who do it best. If the government really is minded to make NICE ‘irrelevant’, I suspect the rationing debate will soon be back to haunt them.

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