How refreshing to read a correspondent who does not comply with the collusion of denial that most writers in the newspapers have with politicians. Perhaps Dominic Lawson can start the honest debate which Mr Stevens wants, and perhaps then we can debate if it should be covert or overt. I have a medical friend who genuinely believes rationing should be covert, and that citizens will only worry about what is rationed out. My answer is that rationing does not have to be of the same design for everyone. It can be means based, or income based, or a combination of both, but rationing by waiting list and post code is much worse. If this is agreed and is overt, we will have some sort of plan structure on which to base the new health service that emerges after Covid19.
Dominic Lawson opines in the Times 29th March 2020: All lives aren’t equal, but we still want them saved – Although the NHS favours youth, society will not abandon the old to Covid-19
The pathogenic micro-organism known as Sars-CoV-2 presents as an invisible but global Dick Turpin. Your money or your life. Here, opinion (in the media if not the nation as a whole) is fast dividing between those who think more of the loss of income and those who worry more about sparing lives.
This debate is intensifying as soaring unemployment (in America last week alone there were 3.3 million new benefit claimants) reveals the price of closing down all businesses dependent upon the interactions made impossible by anti-infection “social distancing”. In Britain, the astonishing measures of income support launched by the chancellor of the exchequer amount to a vast claim on future taxpayers (every pound of it is an addition to a national debt that must eventually be repaid).
But what amazes me is how few people seem to recognise that this dilemma — your money or your life — is a constant feature of the National Health Service. The coronavirus policy dilemma merely sheds a particularly harsh light on it.
As directed by the National Institute for Health and Care Excellence (Nice), the NHS will agree to fund non-palliative treatment for the seriously ill only if the drugs provided (for example) do not cost more than £30,000 in providing a further year of good-quality life. This is known as a Qaly (quality-adjusted life year). Since those with potentially terminal illnesses don’t have a good quality of life, that £30,000 limit would typically be cut to £15,000 per annum in their case — two of their years being regarded as of the same monetary value (in health accounting terms) as one year for an otherwise fit person.
As Sir David Spiegelhalter (who for decades ran the Medical Research Council’s Biostatistics Unit) put it to me: “It’s a myth that all lives are considered equally valuable in the NHS. The system already values years of remaining life given by treatment. So triage would be normal.” What Spiegelhalter means is that if the coronavirus crisis leads to a situation in which an older person is essentially left to die, in order to provide a scarce ventilator to someone with a greater life expectancy, that would be a graphic demonstration of the working model of the NHS.
This sort of calculation also governs expenditure on road-safety measures by the Department for Transport (DfT), under the formula known as the Value of a Statistical Life (VSL). The government will fund a new junction if it estimates that it won’t cost more than £1.3m per future life saved. Obviously, if your child gets killed because the DfT had worked out that the junction you and your neighbours had campaigned for was unjustifiable as it would cost more than £1.3m per likely life saved — well, you would not be consoled by the knowledge that they had dutifully followed the VSL guidelines.
But these calculations are the inevitable consequence of any system in which resources are centrally allocated according to need (rather than a market system in which individuals can pay any amount for what they want — which is not the same as need). This is especially true of the NHS, a centralised, free-at-the-point-of-use system unique in the western world, which can only function on the basis of rationing (since demand for healthcare is, in effect, limitless if “free”). Queuing is one form of rationing: on average, citizens are waiting four-and-a-half months for a hip replacement operation on the NHS. There is no measurable risk to their life expectancy with such a delay, even if the chronic pain of those on the waiting list may feel unendurable.
These are, by and large, the same old people whose lives are now at greatest risk from the coronavirus. The average age of the thousands killed by it in Italy is 79.5 years. This is what is driving many to say to our Dick Turpin pathogen: I’ll keep the money, please, if it’s all the same to you. Of course, they don’t mean that they are happy to die from the coronavirus and keep their money: only that they don’t want to see the nation’s economy suffer a hugely expensive shutdown in order to save the lives of people they don’t know and with not that many years left anyway.
Or, as one American health economist put it to me: “If the shutdown costs the UK 4% of GDP, that is equivalent to $104bn. If you didn’t shut down, according to your government’s advisers at Imperial College, that would cost about 230,000 more deaths from the coronavirus. I estimate those people who were saved would need to live for another 15 years on average to meet the Qaly limit of no more than £30,000: and given that the life quality of the unwell over-seventies is considered half that of a healthy younger person, that means they would on average need to live for another 30 years to justify the $104bn hit to the economy. If you spent all that money on NHS treatment across the board, you would save millions more life-years.” Besides, he added, if the UK had not pursued an economically toxic policy of enforced social isolation, the majority of those most vulnerable to the virus would be among the 620,000 anyway projected to die this year, from all causes.
But, I pointed out to my economist friend, if social exclusion had not been enforced by the government, the economy would still have taken a colossal hit, not just because of what was happening in other countries but also because of the public’s autonomous response to the risks of infection. And the first opinion polls taken on the matter show a remarkable 93% backing Boris Johnson’s latest, draconian measures.
It is not hard to understand why. None of us are creatures of pure reason. Logically, we should not put a high value on the last years of seriously ill relatives (or our own). But as the authors of a 2013 BMJ paper on Nice’s end-of-life criteria wrote, in some perplexity: “In a choice experiment . . . a gain in life expectancy without a gain in quality of life was preferred to an increase in quality of life with no gain in life expectancy, suggesting that focusing on extensions of life, rather than improvements in the quality of life, may be consistent with societal preferences.”
The government, since it comprises politicians, gets that. What it also gets is the likely reaction of the British people if a less dictatorial policy — combined with a gross insufficiency of ventilators — led to a situation akin to Italy’s, where thousands of old people have been abandoned to a horrible end, in effect waterboarded to death by the coronavirus as their lungs filled with their own blood and fluids.
In short, Boris Johnson would not just be suffering with the virus himself. He’d no longer be prime minister. The voters will accept only so much health rationing.