The New Relevance of Rationing

By Ben Davies
Insofar as this is the reality of the NHS, it is surely preferable for difficult decisions to be made on justifiable grounds. That is the basic case for researchers in resource allocation to think about micro-level decisions, and to try to formulate ways to make them fairly. It is of no use to someone who faces a difficult micro-level decision to be told that they ought to have more colleagues, more beds, more time. What’s more, the head of the region’s hospital trust has urged people not to seek Accident & Emergency (A&E) hospital care unless their situation is “life-threatening”, a sentiment echoed elsewhere in the country. This is part of a longer-term trend that has seen A&E waiting times increase, which the King’s Fund has attributed to, among other things, increases in demand; staffing pressures; and possibly health improvements which mean people who previously would have needed to be hospitalised can now be treated without being admitted. This request might be seen as a form of ‘ultra-micro’ decision-making, where decisions about resource allocation are partly placed in patients’ hands as they are explicitly given a choice to seek less urgent forms of care, or not to seek care at all.
But it has always been important to keep one eye on the macro-level. The conundrum at this point comes if we think that the pressures on health services, and the increased need for micro-level and ultra-micro-level decisions, could be alleviated by different choices at the macro-level, such as additional spending, or greater efforts to stem declines in staff by compromising with healthcare unions. This is not to say that these decisions would make the pressure go away; but they might make it less severe.
Decisions about how to allocate healthcare resources can be divided, somewhat crudely, into macro– and micro-level choices. Roughly speaking, macro-choices are policy choices, often made outside any clinical setting, e.g., by government. For instance, it is a macro-level choice which treatments to fund to what degree, and how large the health budget should be as a whole. Micro-choices are the choices people make with a particular budget, generally in clinical settings. For instance, it is a micro-level choice which patients to admit to intensive care, and how to prioritise individuals for organ transplants.
However, it is also true that an increase in micro-level decision-making may not be a good thing. For one, it places much greater demands on medical professionals. Indeed, one criticism that applies to many proposed criteria for healthcare decision-making—including personal responsibility, or attempts to place greater weight on benefits for those who have been worse off across their lives—is that if such features have to be judged at the micro-level, this would cause significant administrative and other strains on the healthcare system.
But there is a clear risk here, of a failure to see the wood for the trees. In more political terms, there is a danger of simply accepting systemic factors which shape our reality, rather than critiquing and pushing back against them. At some point, the answer to “How do we choose between these patients?” is, ‘You must, but you can’t.”
All this raises a conundrum for those of us who work on resource allocation. In one sense our work might be seen as more relevant than ever; given strain on health services, it is no bad thing to think about how to make micro-allocation decisions fairly.
“We have patients having heart attacks who we don’t have trolleys or beds for, so they are sat waiting in chairs. We are having to ration care, having to decide who gets the next trolley with 20-30 people waiting for it”.
Macro-level decisions are taken at greater remove from the specifics of any individual patients. They work, by necessity, with a greater level of generality. Micro-level decisions are often shaped and constrained by macro-level decisions: for instance, it may be a macro-level choice that certain features of patients are not to be considered, or must be considered, at the micro-level. Some people may worry about macro-level decisions because of their tendency towards aggregation, and inability to see the patient as an individual. And there is certainly a case for medical professionals to ensure that they consider the individual before them, and how they might upend the assumptions contained in a policy set at the macro-level.
What’s more, an increase in micro-level rationing may be a sign of failures at the macro-level. The UK’s National Health Service (NHS) is currently undergoing an extraordinary confluence of pressures. For instance, a recent newspaper report from the north-western city of Liverpool had the following quote attributed to an emergency clinical support worker at a hospital in the area: