CURRENT ISSUES IN HEALTH AND SOCIAL CARE 2

Current Issues in Health and Social Care 2

Current Issues in Health and Social Care 2

UK spend less on health as a proportion of GDP than many other countries, but the results are just as good.' Such claims are common, but are it true to say that the NHS produces good results for patients? This study examines the impact of the NHS on the two main killer diseases. Among both men and women the biggest cause of death is diseases of the circulatory system, followed by cancer. Among diseases of the circulatory system, we focus on coronary heart disease and stroke (Tabloski, 2004, 627-638). We look at four cancers: breast cancer, the most common cancer for females; lung cancer, the most common for men; colorectal cancer, the second most common fatal malignancy in both sexes combined; and ovarian cancer, the fourth most common amongst women. Does the NHS ration provision for people suffering from these conditions? And if so, does it make any difference to the results for patients? Until recently, the existence of explicit rationing by the NHS was consistently denied. All decisions were supposed to be clinical rather than financial. There was 'priority setting' but not 'rationing'. Such claims have become increasingly implausible; however, as the number of doctors complaining about rationing has increased (Barroso, 1994, 96-121).

Just as the outright denial of rationing has become less tenable, so defenders of the NHS have tried to offer a more positive defense. Instead of claiming that all decisions are clinical, they argue that medical rationing is a virtue, so long as decisions are based on legitimate grounds. Typically they assert, not only that rationing exists, but also that it is unavoidable. Invariably they object to medical paternalism and suggest one of four main alternative (sometimes overlapping) rationales (Tabloski, 2004, 627-638).

One group argues that rationing should be given democratic legitimacy, through devices such as opinion surveys and citizen 2 DELAY, DENIAL AND DILUTION juries. A second group demands evidence-based medicine. Only medical procedures based on scientific evidence should be provided by the NHS. The National Institute for Clinical Excellence (NICE) is a consequence of this line of reasoning. A third group emphasises cost-effectiveness. In practice, they are closely linked to enthusiasts for evidence-based medicine, but not all champions of scientific evidence attach the same weight to cost minimisation. And a fourth group has urged that treatment should be made available according to the quality of life gained by patients. The Quality Adjusted Life Year (QALY) has probably been the most debated of such apparently technical devices.

These enthusiasts for openness and explicit rationing have in their turn come under strong criticism by writers such as David Hunter4 and Rudolf Klein,5 who have tended to debunk 'rational rationing (Barroso, 1994, 96-121)'. The purpose of the present study, however, is not to enter into that debate, but to form a clearer view about the extent of rationing on the two biggest causes of death in the UK, diseases of ...