IS HEALTHCARE RATIONING INEVITABLE?  SCARCITY AS SOCIAL INVENTION

Julian Tudor Hart, External Professor, Welsh Institute for Health & Social Care, University of Glamorgan

Paper presented to Colston Research Society Symposium on Rights and Rationing in Health Care, Bristol University, 15 April 1999

I’ve only a few minutes to introduce the rather light-hearted paper already circulated (Rationing for Contrived Scarcity). As at most conferences I attend, I’ve a problem.  I argue from entirely different assumptions than those currently dominating academic and political discourse, derived from entirely different experience.  So though I agree with many of the points made by Dr Callahan and Dr Holm, they’re mostly irrelevant to my purpose, which is to shift street wisdom from an old to an emerging new common sense, a new popular culture.  This new common sense differs as much from currently dominant ideas as the common sense of Adam Smith and Tom Paine differed from the ideas of Louis XVI and Burke.

Disguised as a visiting professor, I’ve been smuggled from time to time into some of the more peripheral boardrooms which manage our society.  I got my real work past academic censors by wrapping it up in good empirical research data, a technique I recommend.

What was this real work? The British NHS has an anomalous structure, wherein general practitioners still own and control most of primary care in a public service.  I was therefore a more or less autonomous primary health worker, in what used to be the South Wales coalfield.  I was a community generalist, a human biologist for poor people: first for people with jobs basic to all industry, then for a community discarded from society as unprofitable and therefore useless. My real work was to promote social change toward a society motivated by human needs, not private profit.  My profession allowed me to do this at a personal one-to-one level, as well as at community, national and international levels.  This work was, in a small way, fairly successful,[1] but compared with the changes brought about by virtual elimination of the coal industry and two decades of male youth unemployment exceeding 60%, and compared with the world retreat to social Darwinism, it was insignificant.

OVERPRODUCTION AND INAPPROPRIATE INVESTMENT ARE THE MAIN PROBLEMS

As we approach the third millennium, material scarcity of all kinds is indeed becoming social invention.  In most fields, the limits of commodity production are set not by scarcity of raw materials, nor scarcity of labour, nor scarcity of capital resources, but by availability of profitable consumers.  The globalised economy is reaching the limits of what economists call effective demand: that is, the wants of the minority rich enough to choose freely as consumers in the world market, rather than the needs of people simply because they are human.  In all advanced economies, we see the opportunities and problems of overproduction: opportunities for power-holders to transfer investment from high-cost labour, supported by a rising social wage, to low-cost labour unencumbered by taxation or trade unions.  These present as opportunities for expansion of capital into very profitable new markets, but as problems for communities like mine, losing expectations which more than a century of struggle seemed to have established as human rights, in dividing and disintegrating societies.[2]

If health care were simply a commodity, no question of scarcity or rationing would arise. For profitable consumers, we would see overproduction of healthcare, oversupply of all kinds of diagnostic and therapeutic resource, and overpromotion of medical science far beyond its real power to produce better health.  Rationing is on our agenda because health workers with integrity can’t accept this view of health care. They can’t avoid seeing the difference between market wants and human needs, the widening gap between what science could do for humankind, and what billionaire interests are willing to allow as unprofitable public service. 

The word “rationing” conceals retreat from past social commitments by implying justice and rationality.  It’s a pretty word for an ugly program, frequently used by delightful people for academic conversation, but completely useless in the street, where people are less easily deceived.

All advocates of rationing assume that health care is, more or less, a commodity.  In the private healthcare market there is no question of rationing.  Rationing is for the multitude, for people who receive this commodity as a gift paid from taxation.

Health care can’t produce health gain optimally as a commodity transmitted from active providers to passive consumers.  This is true both in profit-led markets, and in demand-led public services.  We need to recognise that unless populations work together with health workers as co-producers of health as a social product,[3] medical science can’t be effectively applied at affordable cost. 

This centers attention not on consumption, nor on planned limits to distribution, but on production and investment strategy.  Of course our societies need to plan redistribution of investments in health care, especially to move more resources to those most in need, and to address ill health in new ways closer to its origins.  If people want to call this “rationing” rather than “planning”, I can’t stop them.  The main need for us all is to think about health care as a productive process, to rethink the social relations surrounding it, and especially to open our minds to new social roles and new ways of applying human biology.[4]  This rethinking must center on participative democracy, the full use of every human brain for human ends: democratise or perish.

REFERENCES

1 Hart JT, Thomas C, Gibbons B, Edwards C, Hart M, Jones J, Jones M, Walton P. Twenty five years of audited screening in a socially deprived community. British  Medical Journal 1991;302:1509-13.

2 Greider W. One world, ready or not: the manic logic of global capitalism. New York: Simon & Schuster, 1997.

3 Hart JT. Two paths for medical practice. Lancet 1992;340:772-5.

4 Hart JT. Going for Gold: a new approach to primary medical care in the South Wales Valleys.  Third revision, March 1999. Available from WIHSC, Glyntaff Campus, University of Glamorgan, Pontypridd CF37 1DL.