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Rationing health care                                    constrained the application of a solution which just
                                                         might work. I contend that the way is clear for the
                                                                                                                      exotic and quixotic organisational behemoth that
                                                                                                                      presently towers over us.
SIR,-Professor Rudolf Klein kindly gives us the          BMA and the Department of Health to open                        A considerable part of the load from cold surgery
sociologist's overview of the Oregon experiment.'        discussions about such a project and how it could            could be "contracted out" en bloc, tenders being
Unfortunately his review disappoints a coal face         be applied in Britain.                                       submitted by suitably supervised private facilities.
doctor, seeming excessively academic.                                                              GRANT KELLY        Terminations of pregnancy would be well suited
                                                         Chichester                                                   to this approach in that it would obviate the
   I would argue contrary to Professor Klein that it
is precisely the experiment's attempt to give a                                                                       possibility of these women being in beds next to
                                                         1 Klein R. On the Oregon trail: rationing health care. BMJ   pregnant, recently delivered, or infertile women.
public aspect to the basis of health care rationing          1991;302:1-2. (5 January.)
that is its most important feature. The reason it has                                                                                                            STEVEN FORD
come about is not hard to fathom and is broadly the                                                                   Haydon Bridge,
same in- all medical systems-namely, too many            SIR,-Recently I conducted a correspondence                   Northuamberland NE47 1HJ
demands chasing too few resources-and to see it          with Westminster on broadly similar issues
as a purely American answer to an American               to those covered in Professor Rudolf Klein's                 1 Klein R. On the Oregon trail: rationing health care. BMJ
problem is to miss the point.                            editorial,' though I chose to express the options for            1991;302:1-2. (5 January.)
   In Britain we are now trying to pursue a tax          action in terms of what the NHS does not need to
based health system with the added problem of a          do. The response was characteristically opaque
balanced budget. In that, we are in the same             and evasive. The quality of response on this and             SIR, -Will any attempt be made to repeat the
position as Oregon but have a much larger tax base       other health related topics causes me to question            Oregon experiment in Britain? Professor Rudolf
to rely on and decades more experience with              the firmness with which ministers and their                  Klein does not think so,' but proponents of the
the cushion of a relatively large system, yet we         acolytes grasp and comprehend the issues with                quality adjusted life year (QALY) school, led by
still contrive to have recurring fiscal crises. The      which they grapple.                                          Professor Alan Maynard of York, would dearly
transatlantic difference is simply that we start from       Rationing of health care should not be thought            love to try.
a lower level of public expectation and financial        of solely in terms of angst ridden decisions about              The concept of QALYs lies at the heart of the
input, are unbalanced by changing expectations or        restricting high tech options for groups of patients         Oregon plan; it was the basis on which the
technology moving the baseline, and as a result          -as it were, trimming the blossom on the top.                preliminary priority list of treatments was pre-
achieve de facto health care rationing.                  Much could be achieved by hewing off whole                   pared. It, together with other defects, produced so
   This rationing is never acknowledged as such          branches close to the ground.                                many anomalies that it will have to be modified or
but can usually be flushed out from behind the              From a general practice perspective, I submit             even abandoned before the final list is ready. But
smokescreen of waiting lists and seen to arise           that there is a group of conditions for which                that will not deter devotees of the QALY concept;
from costly surgery for the elderly, or "related         patients should no longer expect the NHS to                  they will continue to advocate its use here whether
conditions" for dialysis at any age. So we already       provide resources. Not only would this release               the Oregon experiment is duplicated or not.
ration care-by that most random of all processes,        resources but it would simultaneously unclot                 British readers would benefit from a detailed
the decree of a single doctor or administrator.          the nation's waiting rooms, allowing general                 analysis of the Oregon plan, and I hope to have one
    This is where the sense of the Oregon experiment     practitioners more readily to discern the wood               published soon.
lies. It is an attempt to confront an intractable        from the trees.                                                 My paper will show how difficult it is to
problem with method and as such should be                   The "limited list" of drugs could have been               construct a priority list that covers the whole
roundly applauded for trying to bring order to           rendered and presented in a way that would help              spectrum of medical, mental, and dental health
chaos. As such it is also bound to have gross flaws      general practitioners rather than antagonise them.           care. The data needed are not available-nor are
in its first applications. Similarly, the results will   The constricted referral patterns that will soon be          they ever likely to be-and too many subjective
never please everybody as the process is too honest      upon us could likewise have been a powerful                  judgments are involved for just decisions to be
for comfort, but there is little excuse now for the      instrument for refreshing the resource consump-              made or an acceptable consensus to be reached.
medical paternalism of the past. In an informed          tion profile instead of simply being another tiresome        What would Christy Brown have made of a tech-
democratic society there should be no need for           bureaucratic burden for the punchdrunk NHS to                nique that measured the quality of life simply by
doctors to have to bear the responsibility for           stagger over.                                                the degree of physical dexterity displayed?
deciding who shall not receive treatment on                 Why retain any "cough bottles," vitamin prepa-               Rather than list 1685 procedures according to
economic grounds. By the same token, any in-             rations, indigestion preparations, wart nostrums,            the cost of a QALY it makes more sense to
centive to pass the responsibility to the populace or    fibre supplements, anorectics, minor analgesics or           concentrate on the more costly and less useful
its representatives should be encouraged. As             antipyretics, benzodlazepines, or hypnotics                  procedures, particularly those that deal with
doctors we are not ethically equipped to adjudicate      except (approximately respectively) for terminal             terminally ill patients. If rationing by procedure is
over health care rationing, but we could equip our       illness, objectively defined deficiency states, objec-       to come that is where it should begin.
populace to do so and should consider how best to        tively defined upper gastrointestinal disease, ob-              Because of the difficult clinical judgments needed
do this.                                                 jectively defined lower gastrointestinal disease,            it may be wiser- provided that safeguards for
   As Professor Klein says, this would entail            long term painful conditions, and psychiatrically            patients are erected - to leave the decisions to
developing partners in dialogue. We would serve          defined necessity?                                           doctors. In Oregon conditions and procedures are
both our patients and ourselves well if we begin            Patients should not expect minor, self limiting,          reduced to solitary concepts and the cost-benefit
this before the politicians take it upon themselves      or self inflicted conditions to be endlessly provided        ratios are based on averages for the treatments
 to do it for us. The 1990 general practitioner          for. A government sponsored and professionally               used. But illness may come in a mixture of forms,
 contract gives us a good example of what can            supported move along these lines to define the               and the progress of conditions like cancer can
 happen in this direction if we do not do so, and it     lower limits of NHS provision would be a mere                be difficult to predict. Patients will have to be
 would be a great shame if academic concerns             bagatelle to implement in comparison with the                protected from medical bias or misjudgments by

 288                                                                                                                     BMJ      VOLUME         302     2 FEBRUARY 1991

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