Health care prioritisation: no easy answers but plenty of difficult questions

Following a speech this week by the Secretary of State for Health and Social Care, Sally Gainsbury reflects on how there are no easy answers to questions about prioritising scarce health care resources.

Blog post

Published: 26/09/2024

Wes Streeting’s pledge this week to put “crack teams” into hospital operating theatres to “get sick Brits back to health and back to work” may sound like a bit of conference season puff (and one with no spending commitment attached to it at that), but the shift in emphasis is significant.

The Health and Social Care Secretary offers an answer to a question that politicians are often too scared to ask: just what is the purpose of the NHS? There is no missing the central argument made by the Labour government since taking power: the health and wealth of the nation move in lockstep and so the centrality of the government’s commitment to the NHS is affirmed.

There is also no missing that while health care – and possibly also health itself – has been put centre stage as a driver of economic growth, its value in these formulations seems to rest extrinsically – as a means to the end of that growth, rather than as an end in itself.

Right question, wrong answer?

This framing is unfortunate, not least because, as Nye Bevan found, the hope that the NHS could be made to pay for itself through higher economic productivity has been and will continue to be one that is destined for disappointment, not least because a very large proportion of health care is consumed by those who have completed the economically productive parts of their lives.

Framing health care as a means to economic growth also misses so much about what we want and value from health care (and perhaps even more so from social care), which goes far beyond the economic return it might bring us as individuals and communities. We want it to alleviate pain and suffering, to allow people to live more fulfilled and dignified lives, to extend life and reduce disability. 

Some of these things might have the lucky by-product of also boosting our personal and collective economic output, but that’s not at the forefront of most people’s mind when they sign petitions to save local neonatal care units, or join campaigns for expensive new dementia drugs to be made available on the NHS.

What’s at the forefront of thinking during those – arguably more dominant – moments is a notion of fairness and justice. And while these abstract concepts are never far from any discussion of what is at the heart of the NHS, they are rarely further scrutinised or unpicked. As Rudolf Klein puts it in his seminal book on the political history of the NHS since its inception: “The health care policy arena is characterised by the ambiguity of objectives and uncertainty about the means needed to achieve any given ends.”

Avoided questions

This studied refusal to lift the bonnet, scrutinise and be clear about values and objectives is perhaps not surprising: one individual’s vision of the world they want to live in, and of fairness or justice, may well not accord with another’s. Easier then to skate around the areas of potential disagreement, and leave the question of who, or what disease, gets prioritised to individual clinicians to determine, or to the vagaries of health care funding flows and staffing levels.

But avoidance of the issue is not a neutral position either. Health care resources are always scarce; most obviously during times of political and economic austerity, or when waiting lists are long. But relative scarcity is a constant beyond those times too, because outside a health care utopia, it will always be possible to do more with the science and practice of health care than there are actual existing health care professionals and facilities available to provide it.

In those real-life contexts, a lack of clarity over values and objectives results in a scramble for those scarce resources where, often, the most powerful and privileged prevail: those able to navigate the complex administrative burden of seeking an autism or ADHD diagnosis, those able to seek a timely elective referral and so trigger waiting time “clock starts” ahead of those who cannot, and those whose interests and values dominate public discourse and debate and so frame which diseases or forms of health care intervention or setting are prioritised

Amid this there is also the real risk of moral injury to clinicians – for example when overwhelmed health care staff are unable to provide the care to those they feel have the most pressing clinical need.

Right question, better answer?

So while clarity of purpose is welcome and needed, the emphasis in Mr Streeting’s particular health-care-as-driver-of-economic-growth formulation this week – on getting “sick Brits back to health and back to work” – will be problematic for some, possibly many. Does he intend to suggest that the suffering and disability experienced by people who are already retired – or who perhaps have such complex disabilities that they will never be able to work – is not also valuable, or a priority? We can very much doubt that is his intention or position.

Seen in the round, Mr Streeting’s formulation is more likely to reflect the appeal of utilitarian arguments where scarce resources need to be rationed (not least in the lead up to a government spending review). His argument appears to be that prioritising currently economically inactive working-age adults will bring the greatest benefit to society as a whole, and will ultimately provide additional resources to reinvest back into providing health care for all.

The formulation stands in sharp contrast to the misplaced yet widely held and comforting belief that health care resources are prioritised on the basis of some form of easily available and “objective” measure of “clinical need”. But the utilitarian argument here is also flawed by the distinct lack of evidence to back it up, and in how it reflects a moral double standard that commonly runs through UK health policy. 

This double standard is that the benefits that stem from health care are considered valuable in and of themselves when it comes to a diverse range of activities ranging from neonatal care to prosthetic hip replacements in the over-80s. But when addressing unmet health care need in deprived groups and parts of the country, the appeal needs to lie in a wider “economic benefit” or return on the investment.

An alternative principle underpinning Mr Streeting’s announcement this week (perhaps one he shares, outside negotiations with the Treasury) might be that scarce health care resources should be prioritised with a view to reducing the stark inequalities in healthy life expectancy that pervade this country. 

It is not a coincidence, but rather an avoidable feature of the economic choices and trade-offs we have made over time as a society, that the highest rates of economic inactivity Mr Streeting wants to target will, by and large, be found in areas with the shortest healthy life expectancies – the gap is almost 19 years for women and 18 years for men between the most and least deprived neighbourhoods in England.

Other answers are also available

Prioritising the closure of the healthy life expectancy gap is an ethical principle the author of this blog could get behind. But it is not a principle that will be universally agreed upon, or come without further questions, complications and potential moral dilemmas (what does it say, for instance, about health care for those who have outlived average healthy life expectancy?). Clearly, it may not be possible or plausible to select one single principle on which to prioritise scarce health care resources, and a transparent framework for working through and balancing different principles may be what’s needed.

The Health and Social Care Secretary admits the NHS is broken. To repair it sustainably, we must be clear on its purpose and guiding values – and not simply patch it up as an ornamental relic to admire. At this week's Labour conference, government ministers trailed a big national conversation on the NHS’s future to take place alongside the 10-year plan. This discussion must urgently involve public input on the values guiding the allocation and prioritisation of scarce health care resources.

These are high-stakes, complex and emotionally charged issues that can’t be resolved by focus groups or referendums. We often avoid these questions for a good reason: it hurts our brains to think of them. But help exists in the form of ethicists who can help navigate the implications of different approaches, with discussion informed too by the existing evidence on the costs and benefits of different choices. Patients, carers and clinicians must also share their experiences of health care rationing to inform this crucial debate. The conversation will be difficult – habitually avoided topics often are – but we cannot muddle on without it.  

Suggested citation

Gainsbury S (2024) “Health care prioritisation: no easy answers but plenty of difficult questions”, Nuffield Trust blog

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