Be afraid, be very afraid. That is the message to current and future patients following an extraordinary decision, since rescinded, by a clinical commissioning group in Yorkshire. But the very fact that administrators in the region felt able to put forward a nakedly discriminatory health policy says something of the funding pressures on health systems across the western world.
The plans by Vale of York Clinical Commissioning Group (CCG) could have meant that patients who exceed a body mass index (BMI) of 30 would face delays of up to a year in receiving surgery on the National Health Service (NHS).
And smokers would also have had non-emergency surgery delayed until they gave up smoking. Effectively, it would mean denying smokers and people who are obese hip and knee replacements until they amended their lifestyles.
The CCG said it had taken the decision because it was the “best way of achieving maximum value from the limited resources available”. In other words, it proposed rationing healthcare on discriminatory grounds.
Responding to the plan, NHS England pointed out that it went against the NHS constitution and asked the CCG to review "its proposed approach before it takes effect to ensure it is proportionate, clinically reasonable, and consistent with applicable national clinical guidelines". So the proposal is off the table – for now.
Controlled distribution
Defined as the controlled distribution of scarce resources, rationing is not a new concept in healthcare. The Republic’s national healthcare budget is under as much strain as that in Britain, with service reductions now obvious across all sectors. We are moving from a period of cost-containment to one of effective healthcare rationing.
There is an urgent need to ensure that rationing does not occur in a haphazard fashion; factors such as a person’s age or where they live must not become the determining considerations in whether they receive a particular treatment or not.
While the CCG proposal is nakedly discriminatory – ignoring the fact that smoking is an addiction and that many people who struggle with their weight do so for valid medical reasons – other forms of rationing can be so subtle they don’t attract headline condemnation.
Take the current difficulties people are having in accessing homecare packages. We know that in Waterford, a ministerial announcement of an additional €40 million notwithstanding, applicants were told that no further applications for homecare were being processed.
Unlike the CCG proposal, no announcement of this decision was made by the Health Service Executive (HSE) either regionally or nationally. Instead, operating under the smokescreen of additional funding for the sector, the HSE, for reasons as yet unexplained, decided to continue rationing homecare packages.
A double dishonesty ensued, creating the ultimate camouflage for a subtle rationing of resources.
Unfortunately the HSE has “form” when it comes to not announcing its rationing decisions. Its behaviour lacks leadership: surely the HSE should be the organisation calling for a healthcare rationing debate?
We urgently need to engage in a national debate about the controlled distribution of scarce resources – and one that is wider than the headline issue of approving expensive new drugs.
Part of the debate must be about the rational use of current treatments and interventions. As former Minister for Health, Leo Varadkar, noted: "Universal healthcare systems involve waiting lists in some form, telling people they have to wait because there is somebody with higher priority ahead of them or that they cannot receive some drug or treatment because it is not considered to be cost-effective.''
What he didn’t say was how those rationing decisions should be made. By politicians? By doctors – having cardiologists going head-to-head with oncologists? By patient advocacy groups? But who is more deserving – the person with severe arthritis or someone with advanced Crohn’s disease?
These are not pleasant choices. We can continue to run away from debating them but we most certainly cannot hide from rationing.
mhouston@irishtimes.com