Elsevier

Social Science & Medicine

Volume 47, Issue 10, November 1998, Pages 1555-1564
Social Science & Medicine

The ethics of resource allocation: the views of general practitioners in Lincolnshire, U.K.

https://doi.org/10.1016/S0277-9536(98)00256-1Get rights and content

Abstract

Concerns about the intrusion of economic and financial considerations into patient management have increased in the United Kingdom, largely as a result of the passage of the 1990 National Health Services Act. Based on an agenda set by the British Medical Association, a questionnaire was designed to reveal general practitioners' attitudes to potential ethical problems posed by rationing and resource allocation. The questionnaire was issued to each of the 105 practices in Lincolnshire and 70 replies were returned for analysis. The survey revealed that, in certain areas, there existed a wide divergence of opinion amongst physicians. Examples included the extent to which the government was to be held responsible for full health care funding, the legitimacy or otherwise of general practice budgets and the extent to which service provision should be dependent on upon personal remuneration. On the other hand, relatively high degrees of consensus appeared to exist with respect to issues such as rationing by deterrence and service dilution. Additional, qualitative, evidence suggests that practitioners perceive themselves to be under increasing pressure from patient demand and that morale in the profession is falling. The results of the present study appear consistent with those obtained in other countries. In view of recent policy initiatives with respect to public sector health care, it is likely that the debate over the ethical dimensions of resource allocation in the U.K. will become more vigorous.

Introduction

The British Medical Association (BMA) is the professional association of U.K. physicians and traces its origins back to 1832. Since the formation of its Committee on Medical Ethics in 1849, the BMA has explicitly concerned itself with the “ethical implications of all matters concerning the relationship between the medical profession, the public and the State...” (British Medical Association, 1988, p. v). Naturally, the focus of the BMA's attention within the realm of medical ethics has varied over the years although, since the formation of National Health Service (NHS) in 1948, one particular item has risen to prominence on its agenda. The NHS was intended to make health care available to all at zero or only nominal prices, with most of the costs being met from public funds, principally taxation. Since 1948, patient demands on the NHS have generally out-weighed its capacity to supply, with the result that rationing by means of quantity adjustment (waiting lists for treatment) has emerged. In consequence, a potential conflict between the strictly-finite availability of public health care resources and the “ideal” management of patients from a clinical point of view has become apparent.

In its first formal handbook of medical ethics, published in 1980, the BMA advised its members of two specific duties entailed by the scarcity of NHS resources. First, physicians should “explain the position to the patient” (that is, explain that overall resource constraints may preclude immediate treatment) and offer “an assessment of any medical implications of the delay”. Second, “it is clearly the ethical duty of the doctor to use the most economic and efficacious treatment available” (British Medical Association, 1981, p. 39) This second duty is owed to the taxpayer and other beneficiaries of the national health care budget, rather than to the patient per se and underlines the need to maximise the simple, technical efficiency of overall resource use in a world of scarcity.

By the next revision of the BMA handbook in 1988 (British Medical Association, 1988), the discussion of the ethical implications of resource allocation had grown from three short paragraphs to three pages whilst, by the third and most recent revision (Sommerville, 1993), the coverage has risen to a chapter of seventeen pages, plus repeated references to the issues throughout the book. Even if judged only in terms of the quantity of advice offered by the BMA to practising physicians, it is evident that concern about the consequences of the intrusion of economic and financial considerations into the clinical management of patients has increased dramatically in recent years.

Section snippets

Re-structuring of incentives

Much of the current concern over the economic aspects of medical ethics has undoubtedly been prompted by the passage of the 1990 National Health Services Act. As a result of this Act, public sector health agencies were divided into financially-autonomous purchasers and providers of health care. The latter effectively gain revenue from selling care services to the former, who receive pre-specified and cash-limited budgets from the government for this purpose. The flow of care services is

General practitioners' views

In 1992, the BMA “recognised the inevitability of rationing of health services as an unfortunate fact of life” (Sommerville, 1993, p. 303) and resolved to involve itself actively in the debate over how rationing and resource allocation should take place. It argued that rationing decisions would, of necessity, involve full and complete consultation involving all parties. Rather than commit itself to any one allocation model, the BMA put forward a number of alternatives for debate. A recent

Results

Seventy completed questionnaires were returned, implying a response rate of exactly two-thirds. The survey results are presented in Table 1, the statements appearing in the same order as on the original questionnaire. The statement reference code (denoted “Ref.” in the table) refers to the section of the BMA ethics handbook (Sommerville, 1993) in which this issue is raised, the two exceptional propositions being denoted “W”. For each statement, response frequencies are reported, together with

Discussion

The survey evidence presented thus far suggests that, in some areas, GP opinion appears reasonably homogeneous whilst, in others, opinions are more sharply divided. The highest degrees of consensus, measured as the lowest standard deviations, were evident with respect to opposition to rationing on the basis of either deterrence (Q25) or dilution (Q10), recommending drug purchase if this avoided the patient incurring higher prescription charges (Q6), prescribing decisions not being influenced by

Acknowledgements

The authors gratefully acknowledge the financial and research assistance provided by Lincolnshire Health. The views expressed in this paper are those of the authors alone and do not necessarily reflect those of Lincolnshire Health.

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