RATIONING FOR CONTRIVED SCARCITY

Paper presented to Bristol University Symposium on NHS rationing, 1999

Viagra has brought so-called “rationing” back to the agenda, this time in ways that can no longer be evaded.  Once a week for the “lucky” ones, whose erectile failure can be attributed to one of a short list of specific causes.  For the rest, more than half of the roughly 10% of men under 65 who have this problem, this treatment is not to be available through the NHS.  Lovemaking is an undeniably normal and important function.  It commands high priority for most of us, probably higher than most other non life-threatening health problems, partly because it entails not just personal loss, but damages relationships to the point of marriage breakdown or even suicide.  That it’s useful for second-rate comedians to raise belly laughs would be irrelevant, if we could be sure cabinet discussion never sank to the same level.

It has fallen to politically uneducated GPs to defend the dignity of their patients, to appreciate the complexity of their lives, to weed out occasional patients in search of a new recreational drug (there have in fact been few of these) and to defend basic principles of the NHS.

With a few more prudent and sometimes surprising exceptions, most health economists, senior NHS managers, and think tanks on health policy ranging from pink to black, have been pressing for “rationing” ever since this word began to be misused in the early1980s. In dictionaries we find rations are fixed allowances made to specified groups of people.  Within those groups, rations are equal.  Apart from the one erection a week granted to men with erectile failure arising from one of the minister’s list of approved causes, there’s nothing equal about personal medical care, other than access.  People’s needs for care are diverse and unequal, in line with the diversity and complexity of problems from which their needs arise, and contexts within which they must be solved.  This is why the NHS can’t function efficiently as an inhuman machine, why it needs to become more rather than less labour-intensive, a productive system in which doctors, nurses, and an army of other health workers can interact with patients in co-operative, joint production of health gain.[1]

So why does anyone call amputation of particular services “rationing”, and why do so many people honestly believe it’s essential if the NHS is to survive?  Many of its supporters are frankly opposed to the NHS as a public service outside the market, and recognise it as a useful tactic for returning most of the NHS to commerce, leaving only a barebones emergency service for the indigent.  If they were our only opponents, we’d have no problem seeing them off.  They have virtually no support among the general public.

Our problems lie not with these, but with good men fallen among Fabians, as Alick West said of George Bernard Shaw.  They see the central problem well enough.  Useful scientific knowledge is growing exponentially, and so are its useful applications to human biology, some through medical care, many more through other changes in the ways we live.  The taxes hitherto used to pay for an NHS collectively funded, and collectively distributed according to need, are falling in relation to costs of an expanding service.  Being unable to conceive of any way to make more of the gross social product available for social purposes, and easily persuaded (without empirical evidence) that the NHS faces infinite demand[2] with finite resources, something must go.  Large parts of the NHS must be amputated, but amputations are an unpleasant aspect of war.  “Rationing” is a more comforting word, evoking sentimental recall of our lost solidarity.  It implies that, as in 1940-45, we all face the same enemy.  We must share privation and each of us take less, because the alternative is to lose the war and be left with nothing.

The medical profession is divided.  Top brass in the Royal Colleges, the medical schools, and editors of liberal journals like the Lancet and British Medical Journal endorse appeasement.[3]  If government will frankly admit that some parts of medical care must go, perhaps the enemies of corporate taxation will be satisfied, and populist politicians who promise better services as well as lower taxes will stop lying.  Then doctors can know where they stand, and get on with what’s left of their jobs. They hope their less eminent colleagues, who are actually responsible for patient care, will assist them in this, by abandoning their traditional role as patients’ advocates, recognising that personal advocacy is anti-social, irresponsible, and intellectually outmoded.[4]

I’m glad to say that this entire edifice, the mighty product of endless conferences, learned papers, BMA conference decisions, verbatim transcripts of colloquia and inspired media agonising by ethicists, all constructed at immense cost to all kinds of Establishment foundations and well-heeled advisory bodies, is about to crash to the ground.  Peace has not been bought, and cannot be bought, through capitulation to the enemies of progressive taxation, who have never had majority support from the public, or empirical support from good data, but have enough money to buy an army of incestuous opinion-formers. BMA chairman Ian Bogle, and General Medical Services Committee chairman John Chisholm, have wisely endorsed what was bound to happen anyway.  Regardless of regulations, which simultaneously insist that GPs do their best in principle but withhold their best in practice, thousands of GPs will continue to do what they can for their patients, and by hook or crook get them as much as possible of what they need and medical science can provide.  They will do this because if GPs (or any other workers in primary care) are not advocates for their patients, they’re nothing.  They know we’re not at war against misery and disease, but retreating from responsibility for public services to accommodate the supposed needs of big business. We do not share equally in adversity.  Every task we perform within the`pinchpenny limits of the NHS economy has its spacious counterpart in a black market approved by law, where anyone can have anything they like as long as they have enough money, and clinical interventions are promoted as profitable commodities.  This even includes NHS hospitals, whose pay beds now account for over 16% of all private medical care.[5]

Faced by what he calls “possibilities for the endgame” of the NHS, BMJ editor Richard Smith asks us to think more about reducing expectations.[6]  However, when he gets down to specific expectations, his suggestions are that we accept that “death is inevitable; most major diseases cannot be cured; antibiotics are no use for ‘flu; artificial hips wear out; hospitals are dangerous places; drugs all have side effects; most medical treatments achieve only marginal benefit and many don’t work at all; screening tests produce false negative results; and there are better ways to spend money than on more healthcare technology".  With two exceptions, these are appeals not for rationing, but for rational practice.  In which case he might generously agree that when Lois Quam said exactly that in 1989,[7] she was right. The exceptions are artificial hips which eventually wear out (if that were a good reason for not doing them, I couldn’t attend this conference), and “better ways to spend money than on more healthcare technology.”  That depends on the alternatives.  There are indeed a few better ways (if such choices are necessary) but there are many other worse ways.  These include the millennium dome, nuclear missiles, and an approaching swarm of worthless satellite television channels.

Returning to treatment of erectile failure, there seem to be few reasons for amputating this particular part of the NHS.  I can think only of one: Viagra costs a lot of money.  In a constructive spirit, which he deserves as a fundamentally decent man constrained by obscene priorities, I offer Frank Dobson a dignified path for retreat from what will otherwise become an untenable position.  Viagra costs the NHS £5.00 for each tablet.  Why?  Our Minister should put this question to Pfizer, the multinational corporation which fortunately discovered the unexpected properties of this relatively simple variant of nitroglycerin (which we’ve been using for the last hundred years to treat angina, as well as to make bombs).  More Viagra is being sold in USA now than any drug in previous history, so Pfizer and its shareholders are virtually printing their own money.  They, not men with the misfortune of erectile dysfunction, should be asked not to sink the NHS.

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