In message <Pine.WNT.3.96.990310152439.-1038313D-
[log in to unmask]>, Dave Sackett <[log in to unmask]>
writes
>grand discussion; thanks.
>
>after working in the US, canadian, and UK health care systems, i've asked
>(but not answered!) 2 questions about NNTs and health policy:
>
>1. didn't rationing begin as soon as the first stone age shaman trephined
>the skull of the first schizophrenic in an attempt to let out the bad
>spirits (surely there were lots more schizophrenics than flint trephines
>or shamans), and haven't we been rationing ever since?
>
>2. if rationing decisions are made democratically and at a local level,
>don't variations in disease frequency and severity force NNTs to vary from
>place to place, and shouldn't (indeed, mustn't) there be differential
>"health care by postal code" on this basis, even when other elements of
>the decision (eg, values and preferences) are similar?
>
>erudite answers to these naive questions would be appreciated (but not
>necessarily understood).
>
>cheers,
>dls
As usual you ask the right questions but if you're sensitive, don't read
on! I've become interested in the health economists' view of these
matters. They make the point that rationing is inevitable because all
resources, including health care, are "scarce" (by which they mean
finite - although how finite depends on choices made by individuals and
governments). If resources are scarce, then they need to be allocated
efficiently and equitably (and economists have developed various methods
of economic evaluation which, although far from perfect, at least
clarify the issues and to some extent quantify the choices).
Gavin Mooney (Economics, Medicine and Health Care 2nd ed, chap 8, 1992,
Harvester, Wheatsheaf) writes about the ethical dimension of these
choices and suggests (like other economists) that justice and equity in
health care are interdependent with ethics and efficiency. So not taking
efficiency into account leads to inequity because every time you choose
a clinical intervention you incur an opportunity cost, and if you choose
inefficiently, the excessive opportunity cost deprives some other
patient of a potentially useful intervention.
Mooney argues that this is unethical, but that medical ethics, from the
time of Hippocrates, considers "virtue" and "duty" paramount, not the
"common good". Thus if we adhere to medical ethics, we place "virtue"
and "duty" (to the interests of each individual patient) above the
"common good" (society as a whole - all the other potential patients).
The GMC says that British doctors should take the NHS's limited
resources into account but that this is subordinate to the interests of
individual patients! This is illogical - if we are to allocate resources
efficiently and equitably, we must balance the interests of the patient
we are dealing with against the common good - and looking after the
common good is in the interests of the majority of patients.
I'd guess a lot of us do this but feel uncomfortable with it, while
other doctors bury their heads in the sand and bluster about "clinical
freedom". Our problem is compounded by the unwillingness of politicians
to be explicit about the choices that need to be made. Economists seem
to get a bit hot under the collar about the way doctors behave and
categorise us as "romantic" (we plough on regardless and behave as
though there were limitless resources) or "monotechnic" (we want to do
as many CABGs as possible, because that's what we're good at and like
doing).
There is also the issue of the patient's duty to society but maybe
that's another discussion (for example a patient who insists on a GP
home visit for a sore throat instead of attending the surgery or, better
still, taking some aspirin and not contacting a doctor at all, causes an
opportunity cost to the practice and deprives other patients of GP
time).
I've never understood why there seems to be such suspicion of EBM among
economists (perhaps they think we are both romantic and monotechnic!).
It seems to me that questioning, appraising evidence, using information
like NNTs leads us to at least consider both the effectiveness and
efficiency of what we do. But probably we also need to look at the
health economics viewpoint in more detail as it does offer useful
insights. (thinks: should we offer sessions on it at EBP workshops?)
Toby
--
Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel
0191-2811060 (home), 0191-2437000 (surgery)
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