If it can be accepted that there is a limited level of resources within the NHS, then we

should also accept that there must be some sort of rationing system in place to be able
to allocate the available resources in the most efficient and effective way. While there is
an argument about where the funds are obtained from, or the way in which they are
obtained, I will not be exploring this within this essay.

The current system in the UK involves many different bodies making decisions. The
Health Secretary along with the Department of Health make general decisions about the
acceptable levels and availability of treatments, while locally Primary Care Trusts
(PCTs) are able to make decisions about which treatments will receive funding based
on the spread of their population and recommendations by the National Institute for
Health and Clinical Excellence (NICE).

There is always going to be a need for resources to be distributed in a system which will
seem unfair or unjust to some. Unless we the NHS was able to be designed on the
basis of Rawlsian Justice, where the allocation of resources was placed in the hands of
someone who had no personal feelings towards the subject,​2​ it may be impossible to
come to a completely ethical, moral, rational and just solution.

As mentioned by Edwards and Kirchin an important idea comes from John Harris,
whose first principle suggests that “we should help those who are under an immediate
threat to their life”.​ 3 ​If we were to extend this argument to the extreme, then despite
most people accepting that research is a major necessity to provide tomorrow’s patients
with the best possible treatments, today’s patients should always take president over
tomorrow’s. If this is so, then all funding which is currently being spent on training,
research and development should be curtailed and redistributed to the current needs of
the country. This is obviously an irrational decision, but can be theoretically justified by
the Universal Declaration of Human Rights, Article 3 – “Everyone has the right to life”,​4
such that we are taking that right away in preference of a life which does not yet exist.

“​Actions are morally correct if they are conductive to the greatest happiness of the
greatest number of people”.​5 ​ This definition of utilitarianism suggests that the rationing
agenda can be approached from a morally correct standpoint if each decision is made
in order to maximise the good being done. This could be translated into modern practice
by the use of Quality-Adjusted Life Years (QALYS) which has been explored by Phillips
and Thompson 6​ ​This theory would allow the NHS to generalise the treatment being
received by patients all over the country and any new treatments could be added to the
scale. A threshold would be made and any treatment above the cost threshold would
not be offered on the NHS.

An alternative mortal standpoint would be to consider the argument in terms of Justice,

where each individual should be treated equally. The basis on this treatment can be
split into Procedural Justice - in the NHS example it would be whether everybody who
has completed the same basic requirements has the same opportunity to receive
treatment as everybody else in that situation; e.g. a cancer patient who has already
been through two courses of alternative drugs being put on a treatment list for an
experimental drug. This may not mean certain treatment, but all patients on this list
have the same chance of receiving the new treatment. Alternatively there is Distributive
Justice - the NHS example would display this as all patients receiving the same care so
all cancer patients should receive the same care, and if this is not available to all, it
should not be offered to anyone in preference over others for any reason other than lack
of resources. This was the rationale behind the decision made by the High Court in the
case of Ann Rogers, where the judges held that “trusts will be able to choose between
patients as long as they make cost a factor in their decision.”​7

When some patients are faced with the decision from their PCT, that funding will not be
given for their treatment, it is commonplace for this not to be accepted, but for the
patient to bring their situation to the attention of the media in order to change the
funding decision. I believe that the media should not be involved in the NHS agenda,
even when the cause of their involvement is due to being approached by the individuals
who are not being denied potentially beneficial health care services.

It is the type of cases which are brought to the attention of the media which causes such
public concern and feeling. Diseases such as Cancer and Multiple Sclerosis, which are
constantly being researched and new technologies and treatments being made
available continuously, are often at the core. Many of these new drugs and treatments
are very costly, being developed by the private sector and sold to the NHS with the sole
purpose of making a profit. Unfortunately the NHS simply does not have enough funds
to pay for these treatments for everyone, especially considering the lack of research to
suggest the effectiveness of the treatments.

A good example of this is the outrage at the ruling out of the use of drugs to treat
advance forms of bowel cancer. Treatments claim to extend the lived of sufferers by up
to 6 months when combined with chemotherapy treatments, however there is a
staggering price tag attached to these drugs, with Avastin, potentially increasing
lifespan of a patient by around 5 months costing £18,000 for a 10 month course, and
Erbitux slowing down disease progression by at least 4 months, but costing £11,200 for
a course lasting 16 weeks, it is no surprise that there are doubts to whether the supply
of these on the NHS budget is a suitable use of resources.​8

The media often encourages patients to take their cases to court. This process in itself
causes huge problems for the NHS. In many examples the NHS backs down to the
pressure and agrees to pay for the treatment, but the evidence suggests that it is due to
the patient being “wronged” in any way or that they should receive the drugs, but simply
that the cost of going to court, and the negative PR which results is far more destructive
to the NHS as a whole than paying for the treatment. In the case of Ann Rogers’ appeal
against being denied the breast cancer treatment Herceptin Swindon PCT paid in
excess of £50,000 in legal costs, while the full treatment of the drug is estimated to cost
approximately £30.000.​9​ In these situations, it appears that any attempt at cost
allocation made by PCTs is fruitless as they will be required to provide services or pay
for defending their decisions at a later date if any treatments are denied to patients who
go on to complain.

While I believe that patients should not be attracting the attention of the media to obtain
the treatments they require, this does assume that the rationing decision itself is being
made correctly and that the systems in place are working efficiently. It appears that this
is not the case. The Channel 4 production of Dispatches claimed that there were
massive differences between PCTs within the UK. This is understandable considering
the difference in population dynamics in different locations; however what is not
acceptable, is the legal requirements being made by NICE being ignored by local PCTs
and nothing being done about it.​10​ This is where the media do have justification for
getting involved, as this is not a rationing decision, but an illegal act.

If the issue about people not receiving treatment is about the uncertainty of whether
their PCT is acting rationally and efficiently, then surely this is the issue which should be
raised and not the media intensive activity which is currently being undertaken by
frustrated patients.

There is already some evidence that the Department of Health has taken this seriously,
and the level of spending by individual PCTs in different areas is now being monitored
in a programme launched in 2002 called National Programme Budget Project (NPBP).​11
This initiative allows the PCTs to be tracked and their efficiency ensured. Additionally
many PCTs are making their spending budgets, both historical and predicted publicly
available. Swindon PCT for example, displays their forecasted breakdown of spending
on their website in an attempt to remove any uncertainty about its policies and
efficiency.​12

While there are inefficiencies within the NHS system, there is no place for the media in
such cases where there is no lawful wrongdoing. If the rationing decision is going to be
placed within the hands of PCTs then it must be made explicit that there will be
occasions in which people are denied treatments based on the decisions made by their
PCT. It is the job of the Department of Health and NICE to ensure that the guidelines
are being followed and if necessary take the necessary actions. It is only if these
regulatory boards fail to complete their tasks that the media or alternative sources of
pressure should be applied to the situation.

References

1. http://www.rpsgb.org.uk/pdfs/preregnhsbrief.pdf

2. Chryssides and Kaler, 1993, p181.

3. http://jme.bmj.com/cgi/reprint/28/1/20.pdf

4. http://www.un.org/Overview/rights.html

5. Chryssides and Kaler, 1996, p33.

6. http://www.jr2.ox.ac.uk/bandolier/painres/download/whatis/QALY.pdf

7. http://www.guardian.co.uk/frontpage/story/0,,1752835,00.html

8. http://www.guardian.co.uk/medicine/story/0,,1854892,00.html

9. http://www.irwinmitchell.com/PressOffice/PressReleases/herceptinappeal.htm

10. Channel 4 Productions, 2007.

11. http://www.kingsfund.org.uk/resources/briefings/local_variations.html

12. http://www.swindonpct.nhs.uk/about_the_pct/our_aims/our_aims.htm