Thursday, November 24, 2005

The Economics of Healthcare

There's been a minor controversy recently about the decision of the NHS in East Anglia to refuse hip and knee replacement operations to those who are clinically classified as obese. The comments at Harry's Place have been particularly interesting: basically focusing upon who has the right to decide on these matters. The more provocative comments have pointed out that health treatments are routinely refused to those with what are deemed "unacceptable" lifestyles.

In the NHS there are already decisions made about life-style. Are you still drinking? Are you still smoking? Then no you can't have this transplant we'll give it to someone else. That's not a moral decision its just preventing a waste of time and resources (organs) on a treatment with a poor likelihood of success.

The problem with that argument is that we aren't really dealing with finite resources in the case of hip replacements, as we would be in the case of liver transplants. I don't think that anyone would deny in an ideal world it would be desirable for everyone needing one to have a suitable transplant. Yet when the physical reserves are scarce, priorities do have to be made - and ultimately it is justifiable that those with the lowest risk should be given some priority alongside need.

I use the word 'physical' in the last sentence deliberately. The reason that the Primary Care Trust has made the decision it has is that they need to cut costs. There isn't a material want that causes a need to prioritise, as in the case of 'flu jabs or organ transplants. Is it, therefore, fair for people to be denied a replacement knee on the grounds of obesity?

Ultimately, I think the decision is unjustifiable. The NHS rests on the principle that everyone is entitled to healthcare free at the point of access. When it is funded from tax money, that also has to mean everyone - it is a social good to have a healthy nation looked after by a health service. It is wrong for people to be expected to fund the healthcare of others if they have no access to the same treatment. The question should really be - is there a natural right to a hip or knee replacement on the NHS, or is it a superfluous treatment? Without being a medical expert, I couldn't comment, although I do know that treatments in one area can save costs in other related areas massively. If there is a right to the treatment, however, then it should be available to all. Similarly, if there is a cost issue relating to treatment, the decision must not be "who do we treat?" It must be "which treatments are most essential?"

The other question raised by the decision concerns the "postcode lottery" argument. It is already a worrying fact of the NHS that people in neighbouring cities can have significantly higher chances of death than others purely by accident of their location. We now have a clear-cut case of where the accident of location now restricts access to treatment. The problem with this is that it isn't a decision made by people who can be held accountable for their actions.

If decisions are going to be made on local variance in the health service, then there must be an accountable body through which local people can make their decisions known. Of course, it is vital to take into account the opinions of local doctors on where resources can be allocated most usefully and efficiently. But that should form part of an informed public debate, not a decision made behind closed doors that cannot subsequently be challenged through any effective process. For such strong local variance in the quality and quantity of treatment, democratic control is the only acceptable means through which this should be allowed.