Rationing and Models

Why the NHS has to ration care: Nick Triggle in The Times 20th Feb 2013 reports:

What is health care rationing? ….The Kings Fund says to beware if it is not done by doctors… But they admit it has to happen (1999!!).. Rationing of services to patients is occurring but in a covert and post code manner different in different areas of the country. I would suggest that, if it is a National Health Service, that high end (expensive service) rationing should be universal and fair, but low end rationing could be local (and pragmatically but unfortunately unfair). Please let me have copy letters as examples of rationing – these will be listed at bottom of this post.

NHSreality welcomes suggestions to new links and articles regarding overt rationing around the world. Please contact me if you can make a contribution. The Nuffield Trust and the Kings fund are clear that we should be thinking about it, and if it has to be, that rationing should be overt. One of its foremost thinkers is John Appleby. If you would like to download the Kings fund document (2012) it is here.

The Nuffield Trust. Rationing health care: is it time to set out more clearly what is funded by the NHS? 27th February 2012

Too true it’s time. The professions have been waiting for many years for the politicians to address reality. The problem is that by saying what is funded, they will by implication be saying what is NOT funded, and outwitht he NHS – i.e. rationed. And they still dont want to use that word and fear that the first party to do so will be anathema. So it has to get worse…

Want to read more about deserts based rationing?

he House of Lords has a Committee to consider the impact of demograhic changes on Public Services. Its original background report  and “call for evidence” (also on You Tube) has been met, and the conclusion as reported in the BBC, is that we are woefully unprepared and that public services may disintegrate if we do not reconstruct and re-invent them.

There will be much debate about methodology once rationing is accepted. A suggested model comes from Holland.


Another country, which used to have an NHS like approach (Covert rationing by area and Post Code) has changed and for the last 20 years has controlled its costs much more effectively, whilst encouraging autonomy for high volume low cost items. This is New Zealand and this perspective by W. Edgar, director of the NZ National Health Committee makes the process overt. Discussion in journals such as Law Medicine and  Ethics has also been interesting.

Is it time to look abroad (The Times) for new models?

Holland has an insurance based system with obligatory state cover for those without means.

Germany has a tiered insurance system.

Australia as New Zealand has a mixed service with co-payments for entry.

The Italian Healthcare system has a small but definite disincentive when you first see a GP, and uses Insurance to provide a tiered service. Latest figures for spending on Wikipedia are 9.0% of GDP, but I expect this has caught up with us by now.

Canada’s system is based on the NHS but has a method of fiscal transfers (Health Canada is not responsible for the funding of Canada’s health care system. The federal government provides funding to the provinces and territories for health care services through fiscal transfers.)

The USA is a complex picture of mainly private provision (for adults) and state provision newly agreed for children under Mr Obama. Improvements in child and perinatal mortality and morbidity are inevitable, and so opponents are going to do everything they can to sabotage before the same improvements we had in the UK are universal in the USA. Proof figures should come out in 2-3 years time… Meanwhile Wikipedia is the best site I have found for US heath care. Try the official US government portal, but remember you will not be covered unless you take out special insurance for a visit.

A comparison between US and Canada is also available on Wikipedia.

The Chinese medical hybrid system (Economist April 27th 2013) is under continuous change and subject to great pressures. China – Feeling your pain. An excerpt is below:

“In theory the system should offer better care than before for patients with serious diseases, but in practice the opposite is often true. Patients with minor illnesses benefit, but hospitals, under pressure to control mounting costs, turn away the very ill. This is because of the caps that have been placed on how much insured treatment a hospital can claim back from the government. Hospitals fear that, if they exceed the caps, they will have to choose between paying the extra themselves or turfing out patients like Mr Qin.

As health-care coverage has broadened and deepened, so the government’s share of health spending has ballooned, from 16% in 2001 to 30% in 2011. Patients still directly bear more than a third of the total costs nationwide. Social and commercial insurance make up the rest. Over the past decade the country’s total health expenditure has grown almost fivefold, to an estimated 2.4 trillion yuan ($385 billion) in 2011. McKinsey, a consulting firm, expects it to reach $1 trillion by 2020, roughly 7% of GDP. The health-care system will have trouble absorbing the added costs. Preliminary estimates by the Chinese Academy of Social Sciences in Beijing suggest that many local state-run health-insurance funds across China will begin to run deficits in 2017.

As in America, inefficient and unnecessary care has contributed to the growing cost of Chinese health care. Hospitals are allowed to charge a 15% mark-up on the price of medicines, which inevitably encourages low-paid physicians to prescribe more expensive drugs. This is combined with a fee system, in which hospitals are reimbursed by the government for each service, regardless of the quality of care, thus giving doctors an incentive to perform unnecessary tests and treatments.”

The Irish Medical System has two leveover depending on means. The Irish dont try to pretend that everyone will have an equal service and so they ration healthcare effectively. Wikpiedia gives a non biased account. The Dutch and German models are also based on pragmatic reality.

Dutch GPs seem to be happier with their system and their lot: Why are Dutch GPs so much happier (BMJ articles 2016)

Examples of rationing.

  • Infertility treatment access differs in different regions.
  • Obesity surgery indicators differ in different regions.
  • Prescription charges.

Cancer treatment. In most European countries a diagnosis of Cancer prostate would invoke an immediate referral for radiotherapy if that was part of the treatment of choice. Even in low grade cancer prostate, the reassurance that treatment is not delayed is helpful to the patient. Here is a Radiotherapy Wait 6m 032013, and when the patient asked the likely waiting time for radiotherapy the answer was “at least 6 months”.

NHS NE Exceptional Treatment Policiesupdate and review Report.

This is an example, repeated across the country, of exceptions to treatment, this time in the North East. There are similar documents for all regions and PCTs LHBs. This is rationing, and simply obfuscatiing it under other names (exceptions, limitations, restrictions) hides the issue from the public, who only find out what is not available when they or their relatives need it.

In my own area, West Wales (Hywel Dda Trust minutes 27th Jan 2011), there is a “restriction” on second cataract operations, for which rules are unclear and subject to a “freedom of information” request.

Some Trusts have overt IFR (Individual Funding Requests) board rules. This is from Leeds.

Here is one from SE London.

IVF ‘postcode lottery’ to worsen, Lord Winston warns. 30th March 2013

IVF treatment will be down to a “postcode lottery” this spring when doctors take
control of NHS spending, Lord Winston has warned.  I too would be forced to ration IVF under the budgetary constraints PCTs and their boards are under, but NOT if I was allowed to ration high volume low cost items such as Paracetamol or nits or verruca treatments.

Please can managers and other staff, from all over the Uk, respond by sending me links to, and documents about, their particular Post Code rationing, and if I get enough I will open a special page which could act as a national resource. Remember that until we are asked for ID cards (and Passports for Wales/Scotland) you can register anywhere in the UK. Some areas are asking for proof of residency (a utility bill with your name on) but some are not.

Comment from Laurence Buckman..

…with declining standards, or pragmatic and ethically challenging rationing, but with solvency. I submit on this site that overt rationing, if done after a debate, and if this debate is ongoing in the media, is an ethical way to ration..

The Nuffield Trust has surveyed Doctors with regard to their attitude to rationing.

Update 17th October 2013

Several articles in The Economist reflect the problems of Health Reform in India ( The Economist India Health International) and China (Economist Health care in China) and (China Economist Health Care Reform) two of the fastest growing economies, and Brazil (Economist Health care in Brazil)and the threat of civil unrest in all these countries due to inequalities is real.

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