A middle way for rationing healthcare resources
http://www.100md.com
《英国医生杂志》
Technical analysis is indispensable but only the start
The great rationing debate has gone into one of its quiet phases. The occasionally angry controversies of the past decade or so on have ended in something remarkably like a truce between those who saw the future in terms of improved technical analysis and those who wanted better processes for decision making.1 It is becoming increasingly apparent—and accepted—that these are complementary rather than alternative ways of tackling rationing within whole systems of health care. The technocrats and the political realists are finding common ground in the realisation that, while more information and better analysis are indeed essential, there is no once-and-for-all formula or technical fix for resolving the question of how best to allocate scarce healthcare resources. The result seems to be less interest in the theology of rationing and more emphasis on developing the methodologies of analysis and decision making.
The focus of most of this activity is explicit decision making for whole systems on, for example, the use of specific drugs or procedures in a national service such as the NHS or in individual insurance schemes. At this level, there is a dual requirement for rationing.2 Firstly, decisions should be seen as legitimate by the actors—the medical profession and others—within the delivery system as well as by the public at large. Secondly, the two requirements point in different directions, and this presents the challenge of how to devise processes that satisfy both conditions. And this leaves aside, for the moment, how explicit rationing decisions are translated into usually implicit rationing decisions affecting individual patients.
The legitimacy of rationing within the healthcare system depends on better, more evidence based methods of analysis. The paper by Camidge et al in this issue (p 1382) documents both the controversies which continue to haunt the conventional methods of economic analysis that underpin most rationing decisions and suggests a new way forward.3 To attain legitimacy in the wider sense rationing processes need to command the confidence of a public who do not know, or care, about the profusion of acronyms generated by the technical literature—and cannot tell a LIG from a QALY or a PILY—but do want some assurance that decisions reflect social values and are taken in ways that are transparent.
The evolution of the United Kingdom's National Institute for Clinical Excellence (NICE), now transformed into the National Institute for Health and Clinical Excellence, illustrates the challenge of meeting both requirements. When first set up, NICE was widely seen as an attempt to depoliticise rationing decisions.4 Science, in the shape of cost effectiveness analysis, would guide its decisions and command assent. But this did not happen. Much of NICE's guidance was concerned not with rationing but with promoting good practice, which often meant extra spending. Many of the institute's decisions were contested and some were reversed, seemingly under pressure from politicians and the pharmaceutical industry. To build a basis for legitimacy in the wider sense NICE set up a Citizens Council, a body of 30 lay people representing a cross section of the population, to inform its decisions.
Most recently, in April 2005, the institute published a consultative paper that acknowledged the limitations of the technical criteria used in its cost effectiveness analyses and restated the importance of incorporating social value judgments.5 The institute conceded that "there is no empirical basis for assigning a particular value (or values) to the cut-off between cost effectiveness and cost ineffectiveness." In other words, a limit of ￡20 000 per QALY (quality adjusted life year) for the cost effectiveness of new drugs or procedures—or any other figure—is essentially arbitrary. More crucially still, NICE accepted that there were conflicting theories of distributive justice leading to different ways of framing decisions on rationing. From this flowed recognition of the importance of "ensuring that the processes by which decisions are reached have legitimacy" and that there should be "accountability for reasonableness."6
It remains to be seen how this new strategic emphasis will work out. There remains, however, the problem—already touched on—of how macrodecisions about rationing are translated into microdecisions at the delivery end of health care. Economic analysis depends on information about effectiveness produced by clinical trials. And the limitation of most clinical trials is that "they fail to reveal the potentially complex mixture of substantial benefits for some, little benefit for many, and harm for a few."7 This is why systems level rationing decisions almost invariably—across different healthcare systems—allow for clinical discretion in the interpretation of such guidance. But this leaves us with the so far unanswered question of how, and to whom, individual clinicians should be held accountable for "reasonableness" in the exercise of their discretion.
Rudolf Klein, visiting professor
London School of Economics, London WC2A 2AE
(Rudolfklein30@aol.com)
Education and debate p 1382
Competing interests: None declared.
References
Klein R, Williams A. Setting priorities: what is holding us back—inadequate information or inadequate institutions? In: Coulter A, Ham C. The global challenge of health care rationing. Buckingham: Open University Press, 2000; 15-26.
Garpenby P. The priority setting process. Linkoping, Sweden: National Centre for Priority Setting in Health Care, 2003.
Camidge R, Walker A, Oliver J, Nussey F, Maxwell S, Jodrell D, et al. Prognosis without treatment as a modifier in health economic assessments. BMJ 2005;330: 1382-4.
Syrett KA. Technocratic fix to the "legitimacy problem"? The Blair government and health care rationing in the United Kingdom. J Health Politics Policy Law 2003;28: 715-46.
National Institute for Health and Clinical Excellence. Social value judgments: guidelines for the institute and its advisory bodies—draft for consultation. London: NICE, 2005.
Daniels N. Accountability for reasonableness. BMJ 2000;321: 1300-1.
Kravitz RL, Duan N, Braslow J. Evidence-based medicine, heterogeneity of treatment effects, and the trouble with averages. Milbank Q 2004;82: 661-87.
The great rationing debate has gone into one of its quiet phases. The occasionally angry controversies of the past decade or so on have ended in something remarkably like a truce between those who saw the future in terms of improved technical analysis and those who wanted better processes for decision making.1 It is becoming increasingly apparent—and accepted—that these are complementary rather than alternative ways of tackling rationing within whole systems of health care. The technocrats and the political realists are finding common ground in the realisation that, while more information and better analysis are indeed essential, there is no once-and-for-all formula or technical fix for resolving the question of how best to allocate scarce healthcare resources. The result seems to be less interest in the theology of rationing and more emphasis on developing the methodologies of analysis and decision making.
The focus of most of this activity is explicit decision making for whole systems on, for example, the use of specific drugs or procedures in a national service such as the NHS or in individual insurance schemes. At this level, there is a dual requirement for rationing.2 Firstly, decisions should be seen as legitimate by the actors—the medical profession and others—within the delivery system as well as by the public at large. Secondly, the two requirements point in different directions, and this presents the challenge of how to devise processes that satisfy both conditions. And this leaves aside, for the moment, how explicit rationing decisions are translated into usually implicit rationing decisions affecting individual patients.
The legitimacy of rationing within the healthcare system depends on better, more evidence based methods of analysis. The paper by Camidge et al in this issue (p 1382) documents both the controversies which continue to haunt the conventional methods of economic analysis that underpin most rationing decisions and suggests a new way forward.3 To attain legitimacy in the wider sense rationing processes need to command the confidence of a public who do not know, or care, about the profusion of acronyms generated by the technical literature—and cannot tell a LIG from a QALY or a PILY—but do want some assurance that decisions reflect social values and are taken in ways that are transparent.
The evolution of the United Kingdom's National Institute for Clinical Excellence (NICE), now transformed into the National Institute for Health and Clinical Excellence, illustrates the challenge of meeting both requirements. When first set up, NICE was widely seen as an attempt to depoliticise rationing decisions.4 Science, in the shape of cost effectiveness analysis, would guide its decisions and command assent. But this did not happen. Much of NICE's guidance was concerned not with rationing but with promoting good practice, which often meant extra spending. Many of the institute's decisions were contested and some were reversed, seemingly under pressure from politicians and the pharmaceutical industry. To build a basis for legitimacy in the wider sense NICE set up a Citizens Council, a body of 30 lay people representing a cross section of the population, to inform its decisions.
Most recently, in April 2005, the institute published a consultative paper that acknowledged the limitations of the technical criteria used in its cost effectiveness analyses and restated the importance of incorporating social value judgments.5 The institute conceded that "there is no empirical basis for assigning a particular value (or values) to the cut-off between cost effectiveness and cost ineffectiveness." In other words, a limit of ￡20 000 per QALY (quality adjusted life year) for the cost effectiveness of new drugs or procedures—or any other figure—is essentially arbitrary. More crucially still, NICE accepted that there were conflicting theories of distributive justice leading to different ways of framing decisions on rationing. From this flowed recognition of the importance of "ensuring that the processes by which decisions are reached have legitimacy" and that there should be "accountability for reasonableness."6
It remains to be seen how this new strategic emphasis will work out. There remains, however, the problem—already touched on—of how macrodecisions about rationing are translated into microdecisions at the delivery end of health care. Economic analysis depends on information about effectiveness produced by clinical trials. And the limitation of most clinical trials is that "they fail to reveal the potentially complex mixture of substantial benefits for some, little benefit for many, and harm for a few."7 This is why systems level rationing decisions almost invariably—across different healthcare systems—allow for clinical discretion in the interpretation of such guidance. But this leaves us with the so far unanswered question of how, and to whom, individual clinicians should be held accountable for "reasonableness" in the exercise of their discretion.
Rudolf Klein, visiting professor
London School of Economics, London WC2A 2AE
(Rudolfklein30@aol.com)
Education and debate p 1382
Competing interests: None declared.
References
Klein R, Williams A. Setting priorities: what is holding us back—inadequate information or inadequate institutions? In: Coulter A, Ham C. The global challenge of health care rationing. Buckingham: Open University Press, 2000; 15-26.
Garpenby P. The priority setting process. Linkoping, Sweden: National Centre for Priority Setting in Health Care, 2003.
Camidge R, Walker A, Oliver J, Nussey F, Maxwell S, Jodrell D, et al. Prognosis without treatment as a modifier in health economic assessments. BMJ 2005;330: 1382-4.
Syrett KA. Technocratic fix to the "legitimacy problem"? The Blair government and health care rationing in the United Kingdom. J Health Politics Policy Law 2003;28: 715-46.
National Institute for Health and Clinical Excellence. Social value judgments: guidelines for the institute and its advisory bodies—draft for consultation. London: NICE, 2005.
Daniels N. Accountability for reasonableness. BMJ 2000;321: 1300-1.
Kravitz RL, Duan N, Braslow J. Evidence-based medicine, heterogeneity of treatment effects, and the trouble with averages. Milbank Q 2004;82: 661-87.