Feature

‘Growing old is like being increasingly penalised for a crime you haven’t committed̵

So wrote Anthony Powell in his novel Temporary Kings — and his words ring true in the wake of revelations that some NHS patients are being denied treatment solely on grounds of age. Here, John Brazier, Paula Jones and Adam Darkins examine aspects of the
relationship between elderly people and health care

Recently a man in Brighton was denied physiotherapy because he was over 65. Tory ministers argued that discrimination by age was not widespread, but other examples were found by the media. The Labour Party were quick to seize on this, and other cases, as examples of the ‘obscene internal market’, yet as the more astute commentators observed, all the market is doing is making such practices more explicit. But should scarce resources be rationed by age?

We can take it as read that there are not enough resources to meet every health care need. This problem is not unique to the poorly resourced NHS, but exists in every health care system. Health authorities and other purchasers must ration care — so why not use age? Such a rationing device is cheap and easy to administer, and, at least until now, the NHS has always got away with it. For example, until the mid 1980s it was extremely difficult for someone over 65 to get kidney dialysis.

It is often claimed that health care is more effective for younger people. There is some truth to this. A younger person is better able to recover from surgery, and is likely to live longer. Equally, there are other treatments — of which physiotherapy may be one — where recuperative powers are not an issue, and benefits may be immediate. What does determine effectiveness here, as in most treatments, is the appropriateness of the intervention for the type and severity of the condition being treated, and age is a very poor proxy for these more medical criteria.

Some would argue that it is fairer to give priority to younger people. In Brighton the physiotherapy manager argued that ‘people below 65 are more likely to be at work, and need to get better more quickly’. On the same grounds, then, we would discriminate in favour of white, middle class males — hardly a priority care group in the NHS.

Yet there are circumstances where it is considered legitimate to discriminate in favour of younger groups. A classic example is children with terminal illnesses. Here society, often through highly publicised charitable campaigns, is prepared to spend large sums on treatments with little chance of success. In contrast, many elderly folk, who may be in considerable pain and discomfort, are made to wait for up to two years for comparatively cheap procedures of proven effectiveness. We seem to have some sense that people deserve all their chances early in life — and that the elderly have already had theirs.

In most circumstances, we should use the need for health care as our guiding principle, and not some poor substitute such as age, with its ethically dubious overtones. By ‘need’ is meant the ability to benefit from the care — i.e. those who are likely to benefit most from the use of resources should be given priority. It sounds simple, but how can it be done?

The most notorious attempt at such an explicit method of rationing on the basis of ability to benefit was in Oregon. The affluent classes in the US have a heavily subsidised insurance system which has, until recently, not been concerned with costs. As is often the case in the US, the poor are not very effectively covered. The Oregon reforms were designed to extend the health care coverage for the very poor by rationing treatments.

The proposal was that only treatments above a ‘plimsoll line’ would be funded. The benefit to cost ratio of each treatment was determined by a panel of experts, who used the opinions of local people to value various health states. There was an enormous reaction against the scheme, albeit often from professional vested interests concerned to see their own treatments funded. It was easy to ridicule because the basis on which benefits were assessed was weak. Uncertainty over the benefits of medical treatments is widespread, and is reflected in wide variations in medical practice from place to place.

The Oregon experiment also raised the question of how to value improvements in the quality and quantity of life. Respondents were asked such questions as: ‘On a scale of one to a hundred, where would you place “not being able to climb the stairs?”’. Such questions seem far removed from the highly politicised world of contracting in the British NHS.

To some, it is not possible to weigh up whether to fund a heart transplant centre or provide more hip replacement procedures. But such choices simply will not go away. It may be obvious when the benefits for certain patients are great, but in other situations it is extremely difficult. As a person with an unfashionably rationalist view, I would like to see these issues debated openly and honestly in public. Unfortunately, no political party is ready to admit that rationing is necessary or desirable. In the meantime, professionals and managers are forced to make the choices, and patients have to accept the consequences.

Health care rationing should be on the basis of expected health benefit, not on the wholly arbitrary criterion of age. When we know people are being denied health care which has proven and substantial benefit, then we are forced to reconsider our priorities as a society, and the adequacy of NHS funding.

This is an edited version of a talk given by Paula Jones and Adam Darkins at the Health Rights AGM.