Critical Consumer Pat Sidley
SOUTH AFRICAN consumers should be getting used to the notion of debating critical issues around their health care. But one issue that needs a bit more attention is the rationing of health care. More precisely — who should live and who should die, a question facing hospitals and health maintenance organisations with scarce resources.
These decisions are effectively made every day, and different criteria are used depending on the type of institution, or the doctor.
There could be a public component to these decisions. If the United Kingdom is a good example, the public wants a say.
One case which made the international press fairly recently caused a public outcry against the policy of the hospital involved, which had rationed its care according to certain criteria.
It involved the sad case of Harry Elphick, who needed heart surgery but could not give up smoking. For a decade, the hospital had followed a policy of denying major heart surgery to heavy smokers because the chance of complications, hospital officials believed, was greater if patients smoked. Officials also believed there to be a smaller chance of a long-term benefit from the surgery. Unfortunately Elphick died waiting for his operation — after he had finally given up smoking.
A 73-year-old man, Johnny Gray, said he was denied physiotherapy in a UK National Health hospital because he was too old.
And in a case heard in a British court, a hospital was told that its decision to close a unit (thereby denying a three-year-old a bone-marrow transplant) should have been preceded by consultation with the local community.
All three decisions on policy, made by public bodies, affected individual lives and — at least in the last case — required some public input.
Some form of health care rationing seems inevitable. It arises when there is more demand for health care than there is money to pay for it — a neat summary of our own health care problem.
In this country it happens every day. Several managed health care systems (among them health maintenance organisations, or HMOs) which try to keep costs down by limiting certain services have set criteria for some of the more expensive procedures. Some will not provide intensive care unit facilities and major surgery to people over 70. Others try to spread the resources among those who could benefit most, trying to reach as many people as possible.
Conventionally-funded private hospitals and clinics, such as those owned by Clinic Holdings, are likely to ration much less than do other health care facilities. With profit the primary motive for their existence, and with medical aids, insurance companies and people with great deal of money or resources ready to pay for whatever is wanted, it is highly unlikely that a very old and sick patient who is a smoker will be told she cannot have heart surgery or use the expensive facilities in the ICU. Why should they? Those types of hospitals and doctors stand to gain hundreds of thousands of rands on some of these procedures.
State health institutions ration their care in a haphazard way at present, but if we get the promised streamlined system we all voted for, then we should expect a system will be introduced that includes policies on who can receive what type of care.
The Consumer Association’s magazine Which? in the UK surveyed its members on whether they believed the public should have a say in the formulation of these policies. Fully 75 percent believed the public “should be consulted about who gets what of limited health care resources”. Many people had feared that age or lifestyle considerations were being used to decide on access to health care resources.
Traditionally doctors have done the deciding. Classically, it is the general practitioner who will decide whether the patient should be referred to a specialist or admitted to hospital. Doctors would usually base this decision on what they believe to be clinical need with little reference to the patient’s preference or the affordability of the procedure, and often with disregard as to whether it is actually effective.
According to Which?, a law introduced in 1990 in the UK changed this way of operating. Says Which?: “It separated purchasers of health care from providers. Health authorities (and many GPs) have fixed budgets with which to buy in health services for local residents. Hospitals and other units provide the services that these groups choose to buy.
“This means that health authorities and GP fundholders have to decide their priorities and be far more explicit about exactly what services they are prepared to pay for and in what quantity. They must also be clear about the services for which they are not prepared to pay.”
For South Africans facing the introduction of a National Health Insurance scheme (see PAGE 27) these decisions are likely to be faced by all kinds of stakeholders, and the public really should have a say.
To set some criteria, doctors and health authorities will be measuring whether certain health care procedures are effective, both medically and financially. But other decisions will be much tougher: they’re in the God- playing area in which nobody will want to shoulder responsibility on his or her own. Communities need to make their voices heard, so that policies become broadly acceptable.
Which? describes some of the criteria used by health authorities and doctors. Some of them are in use here too:
* Concentrating on prevention rather than cure when allocating resources.
* Using cheaper drugs from a restricted list, cutting unnecessary tests and procedures and so on.
* Making the care more effective — which involves trying to weigh the benefits of a treatment, measured in increased quality of life and life expectancy, against the cost of the treatment.
* Making decisions on who NOT to treat (the God decision).
In the Which? survey 1 800 participants were given a list of different groups of people and were asked “if NHS treatment had to be restricted in some way, which of these groups of people should be given priority for treatment?”.
Most people assigned a high priority to babies and children (as has this government), people in pain and those who would be unlikely to survive unless treated. Only 17 percent of those surveyed gave priorities to people who needed expensive treatment and only 11 percent to “people whose habits or lifestyle may have caused their illness”.
In this country there are few obvious ways for the public to participate in this debate. Perhaps Health Minister Nkosazana Zuma will build an avenue in for public input on these issues. If not, perhaps the public could find one, or vote accordingly.