Phillips / Health Economics Copy Editor: Paul George 0727918494_4_002 Final Proof page 32 28.7.2005 7:14pm
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Chapter 2
primarily concerned with promoting greater efficiency in service delivery. However, as demonstrated in Chapter 1 the drive for greater efficiency may result in equity in health having to be compromised. Limit service range The term prioritisation or its negative version, rationalisation, have become part of everyday usage within health care systems in recent years. As a process, it is an ‘elaborate and intricate issue’40 and also highly emotive. For example, the funding of the so-called ‘lifestyle drug’ Viagra became one of the major elements in debates surrounding the rationing of health care interventions. The government argued that the mechanisms of funding this type of intervention might even threaten the financial sustainability of current health systems, with the Secretary of State for Health making the case that, with regard to clinical need, impotence could not be regarded as a priority for any additional NHS expenditure compared with cancer, heart disease and mental health since, while it may result in psychological distress, it was not life-threatening or causing physical pain.41 Another example of the issues revolving around establishing priorities was found in the case of child B, a ten-year-old girl suffering from acute myeloid leukaemia. After a bone marrow transplant, the disease appeared to have been cured but the leukaemia returned and clinicians told the girl’s father that she had only a few weeks to live. He contacted a private practitioner who was willing to treat child B with a new treatment that would cost £75 000. The HA refused to fund the treatment or provide a second bone marrow transplant since expert opinion was that the chances of success were extremely slim. A high-profile legal battle ensued and eventually the Court of Appeal found in favour of the HA. An anonymous benefactor provided the funds for the treatment and the girl survived for another year before a further relapse led to her death. Although this particular example achieved national media attention, priority-setting decisions involving ethical and other costeffective considerations are at the heart of policies and local decision-making on an everyday basis. The establishment of NICE sought to address the problems associated with ‘postcode prescribing’, where services and treatments were available in one area but not in a neighbouring location. Before NICE the process of limiting the range of services made available had been ad hoc and not without considerable controversy, as evidenced in the two examples above, but the extent to which NICE has succeeded has yet to be proved.42 Additional funding The option favoured by most NHS staff and, according to opinion polls, by a large proportion of the general public would be to increase the level of funds going into the existing NHS. This could be done in a number of ways, such as levying charges, increasing taxation proceeds or shifting resources from other parts of the public sector. What is not evident, however, is the extent to