The rational case for rationing health care

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Few words are as contentious in healthcare as rationing. The ‘r’ word conjures up emotive images of inequality, discrimination, cuts to services and avoidable suffering. Unsurprisingly, policy makers, clinicians and consumers shy away from the concept, and during election season it becomes an anathema.

And yet rationing is an integral and inevitable reality in every healthcare setting. Even in relatively wealthy modern societies, the demand for services will likely always exceed existing resources. Rationing is already a fact of life, but it is expertly disguised by more palatable pseudonyms and processes. We accept triage and referral criteria, we tolerate a plethora of wait lists and we support programs like Choosing Wisely to reduce low value care. Organisations have to meet ‘efficiency and productivity dividends’, have ring-fenced budgets and continue to function despite recruitment freezes.

The question is not whether we should be rationing healthcare – we should, and we are. Australia already has rationing processes like the Pharmaceutical Benefits Advisory Committee and the Medical Services Advisory Committee in place.

The Deeble Issues Brief (Deeble Institute for Policy in Healthcare)  lists the following methods that are used to ration healthcare in Australia: restricting access to specific services through eligibility thresholds; selecting particular patients who are most likely to benefit; deflecting would-be consumers to other government services; imposing barriers; delaying access and diluting the level of services on offer.

A recent review found evidence that rationing is applied at four main levels: policy-makers; managers; healthcare providers; and patients.

The real questions are how we ration our precious and finite resources and how we ensure they provide the greatest good? To answer these questions, we require much more research to understand and clearly articulate the purposes, influencing factors, mechanisms and outcomes of rationing.

For now, there may be a clue in the word itself. Ration and rationing are derived from rational, an adjective that means to be sensible, agreeable to reason, having sound judgement and good sense. It will also require integrity, honesty, respectful communication and close collaboration between all stakeholders.

General practice has survived and even thrived despite the harsh and explicit rationing of the last decade. We have the necessary attributes and the ‘lived experience’ to initiate and contribute to a rational dialogue about rationing.

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