Resource Allocation
2017: Either (A) now clear that impossible for NHS to provide free and comprehensive healthcare service and to eradicate health
inequaliites. As a result, NHS’s legal responsibility should be confned to provision of life-saving medical treatment. Discuss.
(B) Most signifcant challenge facing NICE is cost of new cancer drugs. Discuss.
2016: Either (A) NHS resources should be allocated to those who most deserve treatment. Discuss.
A lot of students answered this queston and most did it very well. Many answers were introduced by explaining why the
allocaton of NHS resources was necessary, with some teasing out the transiton from implicit to explicit ratoning, explaining the
role of NICE and QALY calculatons, as well as CCGs. Most answers then, quite rightly, spent the vast majority of their answer
unpacking what ‘most deserve’ might mean. The best answers proceeded on the basis that determining a criteria based on
‘most deserve’ was far from straightorward. Diferent ways of conceptualising ‘deservedness’ were based on some of the
following: clinical need, personal responsibility, social utlity, public percepton. The best answers problematied these
criteria, demonstratng how they would lead to arbitrary outcomes, or indeed outcomes which exacerbated e.g. societal
inequality. Other answers also nicely demonstrated how even something appealing like ‘clinical need’ would stll need
further clarifcaton, given the issue of limited resources, with very good answers using the example of the Cancer Drugs Fund to
demonstrate how illnesses are constructed diferently by society (i.e. that ‘clinical need’ is not necessarily an
objectve criteria). A few students cross-referenced the allocaton of other types of resources beyond money, partcularly organs,
notng how the allocaton system here prioritsed clinical need, but teased out how the allocaton of fnancial resources
potentally raise diferent issues given the range of treatment optons that are available. The very best answers gave specifc
examples to demonstrate their arguments, and related their analysis to things like the NHS Consttuton and the
founding principles of the NHS (especially equality). Others brought in recent proposals, especially in relaton to questons of social
utlity in making ratoning decisions. Those students who did not do so well on this queston generally failed to engage with
the second part of the queston, focussing only on how ratoning currently takes place in the NHS. This meant that answers were
fairly descriptve, without any real analysis directed to the more normatve porton of the queston.
2015: Free healthcare simply encourages ppl to make greater use of NHS than they would if they had to pay for medical treatment. AS a
result, UK should charge ppl full cost of all the treatment they receive, or insist they take out insurance to pay for it. Discuss.
2014: In making judgements about the relatve cost-efectveness of diferent treatments, NICE should give priority to the wider economic
benefts to society of treatng partcular patents.’ Discuss.
Good answers to this queston engaged specifcally with what it would mean to give priority to the economic benefts of treatng
patents, ie that this would favour the productve and mean a lower priority for the elderly, the disabled and other vulnerable
patents. Many people critcised this for being discriminatory and unfair.
Poor answers were just generic essays about ratoning. Some students simply interpreted ‘wider economic benefts’ to mean
general cost-efectveness, which resulted in rather circular answers that were more about ratoning than the specifc prompt in
the queston.
2013: Ratoning decisions should never be taken by doctors. If ratoning is inevitable, then NICE represents the best way to ensure that
decisions are fair.’ Discuss.
This queston was quite well answered. People discussed the pros and cons of doctors’ involvement in ratoning decisions, and the
pros and cons of NICE. Really good answers used the ‘hook’ of the Health and Social Care Act to frame their answers.
Diff Rationiong Straatrgigigi Trend towards explicit ratoningg Grounds for distnguishing patents
Rationiong ion trhegi NHSS CCGs, Role of NICE, Cost-Efectveness Appraisalsg End of Life Medicinesg Evaluatng NICE Efectveness
Cheallgiongiong Rational Dgici iion Judicial Rgivigiw: R v Cambridge DHA ex p. B, R v North West Lancashire HA ex parte A, R (Ann Marie Rogers)
v Swindon PCT, R on the Applicaton of Otley v Barking and Dagenham NHS PCT, R (on the applicaton of C) v Berkshire West PCTg Righetr tri
faia paicgi aond onitr agi ultr? R (SB) v NHS England [2017]g CP: S (A Child) v NHS Englandg Rgilgivaoncgi if HSR; R (on the applicaton of Condlif) v
North Stafordshire PCTg Righetr if Nion-Rgi idgiontr D v UKg ZT v The Secretary of State for the Home Department
Public HSgialtrhe Marmot Review Policy Objectves
Diff Rationiong - Atr traatr implicitr aationiongg Patgiontr Expgictration : patent tends to assume decisions taken in best interests +
Straatrgigigi unafected by cost consideratonsg (Syagit) Lower expectatons in serviceg Mi tr aationiong triik placgi uondgia civgia
if clionical judgmgiontr clinicians efectvely converted politcal decisions on resource allocatons into clinical
decisions, by internalising resource limits, provide justfcaton for denial on medical grounds; HSighe lvl if trau tr
bgitrwgigion dictria aond patgiontr that physician acted as dedicated patent advocates, and belief that they
possessed expertse and access to all medical resources neccg (+) ^ stable social relatons
- Niw gixplicitr aationiong; Bgiiong faaonk witrhe patgiontr patents need access to relevant info to make informed
, choices, relevant info incl existence of efectve treatment which NHS will not fundg Wgill-ionfiamgid public
(Sabion) ‘personal and computers and internet drive nails into cofn of implicit ratoning’g (+) Transparency
facilitates consistency and (Daonigil ) ‘accountability for reasonableness’g Fiua agiq fia agia ionablgi public dgici iion
makiong publicity, relevance, revisions & appeals, enforcementg Ensures decisions which are always going to be
unpopular nevertheless secure some level of public legitmacy + social acceptabilityg CP: Can be argued what
counts as relevant criterion not just proceduralg E.g. decision to take into acct person’s responsibility for ill-
health = controversialg CP: (Faigidmaon) Should add public partcipaton as a req too
- Faia Rationiong Straatrgigigi (Lima ky) Decisions taken in extreme conditons less ‘dreadful’ than ratonal,
considered choiceg Simgi gaiuond tri aulgi iutr cimplgitrgily 1. Unethical to take into acct patent’s likeability CP:
hard to eliminate personal sympathyg 2. Some patents more demanding and assertve than others, (Butrlgia)
Expressed concern about patent’s uneven ability to exert pressure, ofen atributed to less afuent, artculate
and educated patents, potental for social bias in innate responsiveness to pressure
- Simgi pitrgiontal gaiuond fia di tongui heiong 1. Equalitry; (Gutrmaonon) Equality of access means everyone with
equivalent health need should have equivalent access to careg (+) Places limit on market freedomsg CP: rich ppl
prevented from spending extra incomeg CP: What factors would justfy patents similar or diferentg E.g.
Alcoholism? CCP: Equality on its own does not tell us how to allocate scarce resources, only supplements other
ratoning criteria such a needg (Tgimkion) Health so central to ability to lead fourishing life, so concern for equality
might lead us to given priority to least healthy or least well-of
- 2. Ngigid (Jack ion) Need has much greater moral force than want / desire, appears simple and fairg CP (Lamm)
Medical need is an infnitely expandable concept, no end to what we can do to treat, can only operates as
ratoning criterion if able to construct a hierarchy of needsg CCP / Sil (Daonigil ) Applicaton of Rawls’ theory of
justce to distributon of healthcare, healthcare = primary social good, bcui of capacity to ensure fair equality of
opportunity, should rank competng needs acc to extent to which normal species functon is impaired g CCCP:
Paiblgim w atgimptong tri paiiait gi diff hegialtrhe ongigid by gixtrgiontr tri wheiche trhegiy iontrgiafgiagi witrhe oniamal pgicigi
fuonctioniong 1. Might seem like obj criterion but difcult to pin down: Aging: Do not want treatment of elderly
as low priority on grounds that some degree of ill-health ‘normal’ of them, Degree of Circularity: ‘Normal species
functoning’ depends in part on availability of healthcare servicesg 2. Difcult to construct obj populaton-wide
hierarchy of illnesses: E.g. Loss of vision in one eye worse for pilotsg 3. Exceptons to this classifcaton to accom
benefcial treatments that do onitr atempt to restore normal species functoning, E.g. Contracepton
- 3. Maximi iong HSgialtrhe Gaion (a) A gi iong Ci tr Effgictvgiongi Qualitry Adju trgid Lifgi Ygiaa (QALY ); so that
scarce NHS resources ‘do as much good as possible’g (William ) not only measure amt of extra life treatment
might generate but also qualityg assumpton: divert resources to treatments likely to ofer ppl longest periods of
healthy and actve lifeg Stages to Use of Test: 1. Just quality of life on scaleg 2. Multple life expectancy and
quality of life scores, both before & afer treatmentg 3. Dif between both = QALY Scoreg 1-CP: Nitr v u giful / faia
ion appaiache; 1. Logic of QALY is one that assumes icigitry i ongiutraal watr heiw hegialtrhe bgiongiftr aagi di traibutrgid
across societyg In practce, would prefer to fund treatment w srs conditons, as compared to those more cost-
efectve but trivial e.g. acneg 2. Emphasis upon maximising health gains explicitly utlitraaiaon, measures unit of
lifetme as if interchangeable, instead of treatng patents as separate indivs who value lifeg 2-CP: (Giaadaoni)
Digi onitr aly captruagi wheatr matgia tri ppl, not about no. of healthy life years the world contains, but no. of
health years they / ppl care about will haveg 3-CP: Tgiond tri gixacgiabatrgi di caimionation against elderly + disabled
(their QALY scores fairly low due to reduced life expectancy or lower pre-existng quality of life) + ppl unlucky to
sufer conditons expensive to treat (Double jeopardy - (HSaaai ) ppl unlikely to be srsly ill further disadvantaged
when competng for scarce resource)g CCP: QALY measures change in person’s health brought by interventon,
e.g. older ppl may actually have lower cost per QALY bcui greater risk of complicatons of illnessg 4-CP:
Ioncion i trgiontr witrhe Equalitry appaiache, (Mullgion) If access depends upon costs, systematc discriminaton could
result against those frm ethnic minority group that need translaton/interpretaton, or those living in poorer
housing req inpatent stays etc.g 5-CP May di ciuaaggi iononivation ion faviua if gi trabli hegid, cuaagiontrly chegiapgia
tragiatrmgiontr New treatments tend to be extremely at frstg 6-CP Nitr pi iblgi tri dgivi gi aon ibj, accuaatrgi
mgicheaoni m, Cannot reliably measure antcipated length & quality of person’s life, QALY too crude to capture all
variables: Quality of life judgments inevitably subjectve (e.g. some may think depression worse than chronic
back-pain)g Dr and Public can only speculate frm positon of relatve ignorance, will not know distress caused by
range of disabilitesg (b) Widgi / Naaaiw iontrgiapagitration if Ci tr-Effgictvgiongi (HSuontrgia) Has been estmated that
health services only afected 10% of principal indices for measuring health, Cost efectveness of new techs
should be judged not only against other medical treatments, but also against social measures e.g. welfare
paymentg Wheatr iuond a a bgiongiftr (Glivgia) Sometmes be legitmate to take into acct benefts to third partes
(e.g. dependent children)g CP: (HSaaai ) Prioritsing those w dependents would be ofensive discriminaton against
childless and friendless, Acquiring family may become cheap form of insurance against low priority ratngg CP:
Drs cannot be expected to predict accurately patent’s likely contributon to society or familyg CP: Giving priority
to patents whose loss might cause tangible harm to other ppl might involve tme consuming and intrusive
investgatonsg Possibility that social-utlitarian consideratons or bias / prejudice might creep into these
judgmentsg CP: (Baick) Taking into acct indirect non-health benefts can be legitmate on macai levelg
- 4. Aggi 1. ^ age, ^ likely to sufer from multplgi cimiabiditgi , also less cost-efectve treatmentg CP: While age is
, a variable that afects prognosis, not most impt oneg CP: Cannot make assumpton about older ppl’s frailtyg 2.
Older person likely to have a ‘faia iononiong’g i.e. seem to capture truity that not tragedy to die in old age but
misfortune to be cut of prematurelyg CP: (HSaaai ) Systemic devaluing of old ppl, corrosive efect on social
morality and community relatons
- (Walkgia, Aggiiong, ju tcgi, agi iuacgi allication) Argued that ^ chances of illness / losing functon, ^ age matersg
When we focus at group lvl, concerned with probabilites, but these group characteristcs cover wide range of
dif ageing paternsg Failure to rmb dif ageing trajectory can at indiv lvl lead to problematc outcomesg Potental
danger is assuming signs of confusion (due to ageing) as = lacking capacity, hence disrespect elder autonomy
- 5. Iondiv Rgi pion ibilitry fia Ill-HSgialtrhe 1. Might be argued that making access to treatment depend upon whether
sb responsible for illness could provide powerful incentve towards healthy behaviourg CP Being lower priority
will not necessarily be an incentve, since prospect of premature death / bad health alr don’t dissuade sb frm
engagingg 2. Fair and just to take indiv responsibility into acct, ‘distaste at having to pay for sb else’s bad habits’g
CP: In practce, impossible to devise fair system, e.g. skin cancer suferers who sunbathed too muchg Qnable
whether unhealthy behaviour always result of deliberate choice or outside of one’s controlg Bad choices tend to
correlate with socio-economic statusg At indiv level, impossible to isolate single causal factorsg 3. Ppl who cost
NHS a lot should take responsibility when behaviour has oppi cost for another, ( HSM Evaon ) sense of social
responsibility not to squander resources and disregard other’s needs, Adopted in NHSS cion ttrution does not
advocate denial of care, but lists taking care of one’s health as one of the obligs patents acquire for NHS careg
(Suaggiion atack plaon tri dgilay tragiatrmgiontr tri ibgi gi patgiontr aond mikgia ) In 2016, Valgi if Yiak CCG planning
to make ppl to wait for up to a year for treatment for non-life threatening conditons e.g. hip replacements if
BMI >=30, Adult smokers have electve surgery postponed for 6mths or untl stopped smoking for wksg Critcised
by both RCS and BMA for arbitrary scheme + ratoning on basis of povertyg Further evidence of postcode loteryg
- (Guaadiaon - Ti avgi NHSS, whey onitr cheaaggi trhei gi whei abu gi itr) Dispatches exposes unsustainable no. of ppl who
go to A&E who simply do not need tog Our lifestyle made us less self-sufcient and more-demandingg Few
patents are aware of the actual costs of NHS servicesg Charging for missed appts may not fll funding gap but
may trigger behavioural changeg However, must be careful to avoid penalising the wrongful people
- 6. Rgilgivaoncgi if Public Opioniion 1. Sgitong Paiiaitgi ; NHS funded thru taxaton + treatment deprivaton on cost
grounds controversialg vs. Disadvantages of relying too heavily on public opinion, leave unsympathetc groups
inadequately treatmentg (Ngiw) Respondents to one-of public opinion surveys ill-equipped to make complex
ratoning decisionsg Weaken accountability of decision makingg 2. Accgiptrabilitry if Fionaoncial Ioncgiontvgi Maj
of public appears to disapprove of giving incentves to ppl to smoke smoking / lose weightg Belief it ‘rewards bad
Thoughts: behaviour’ and corrode public goodwillg CP: Cost efectve in aligning unhealthy person’s ST interets w LT best
Fin incentves interests, (Paimbgiaggia) Public Opinion stem from prejudice and illegitmate value judgments, should not be
for vulnerable refected in policy decisions; ⇒ LINK TO PUBLIC HSEALTHS SECTION
groups? Note - 7. Abilitry tri Pay Let ppl be free to purchase healthcare + services be available only if consumer demandg 1-CP
that they Market forces may deter inappropriately use of health-care servicesg 2-CP: Always be ppl unable to aford
tend to work treatment / insurance, Insurance premiums set acc to risk rather than wealth, so cost of insurance would be v
more for high for those v ill & v poorg Even if use exempton or subsidies to help, scheme costs at cost since need to do
lifestyle means-testngg (+) might deter ppl from trivial complaintsg CP (HSualgiy) Ppl do not know in advance if symptoms
diseases trivial or signifcant, Reduce chance of early diagnosis and lead to subseq ^ in costsg 3-CP Problems with using
which are private insurance to cover healthcare costsg 1. Some health risks will be uninsurable, req state-funded safety net,
multfactorial problem of ratoning publicly funded care remainsg 2. Might drive premium of high-risk indivs up in long term, as
low-risk patents ofen will not want to purchase insurance if charged premiums higher than antcipated beneftsg
3. Insurance scheme tend to give healthcare providers incentves to over-treat, waste resource for no ^ health
gaing 4. Insurance insulates patents frm real costs of care, than in a simple free-marketg (2006 HSgialtrhe Sgilgictr
Cimmitgigi) Concluded that system of healthcare charges in England in mess, charges for prescriptons are
rather pigicgimgial agi pion gi tri ongigid tri aai gi miongiy, e.g. ppl with diabetes who req insulin receive free meds for
all conditons, vs ppl with diabetes controlled by diet don’tg Paaallgil paivatrgi gictria onitr ‘add-ion’ tri NHSS butr al i
iontrxtr witrhe NHSS NHS subsidises private sector, permitng NHS consultants to maintain private practces, NHS
trusts ^ capacity by purchasing private sector care, Health and Social Care Act 2012 bolsters private sector’s
ability to compete for NHS bii
- 8. Dgifoniong a Packaggi if Caagi Core package of essental svcs provided FoC + Non-essental avail only privatelyg
CP (Ciipgia) Not v successful atempts to devise packagesg In NZ, Comm could not fnd a treatment / area that
could be completely excludedg NHS said will not fund certain procedure like tatoo removal / sterilisaton
reversalg CP: Refusal to fund will not solve funding crisis since cost v litle compared to other svcs
- 9. Rationiong by Dilution Ofering less care than is ideal (vs Ratoning by Delay - wait to be treated)g (Lighetr) NHS
alr ratons on massive scale: ratons by delay to get on waitng lists, by dilution due to undersupply of staf and
diluton of tests done, also ratons by outright denial to even the chance to be waited or be treatedg (McPakgi)
Queuing should be regarded as ratoning deviceg CP Iongifcigiontr aond ionappaipaiatrgi, since true purpose is to
maximise efciency rather than ensure fair distributon of healthcareg CP (William ) Other costs, such as
patent's tme, used profigately by system
