Rational rationing - Personal Views

Professor Sir Michael Rawlins is the chairman of the National Institute for Clinical Excellence (NICE), the organisation charged with determining best medical treatments. Medical evidence is often contradictory and value laden; many decisions about treatments will be difficult. Healthcare professions and the public alike want Sir Michael and his institute to be rational, logical, and impartial in their decisions. Confidence in NICE will be dented if it shows signs of bowing to vested interests, whether commercial or political, or of pursuing its own agenda, immune to logical argument. Unfortunately, NICE is hindered by its chairman's stubborn refusal to accept that one purpose of NICE is to ration health care. Although some commentators believe rationing is not necessary, rationing by one means or another occurs in all healthcare systems.

The chairman of NICE is not a politician. He should not be afraid of telling the public the truth, which is that they cannot have all the health care they want, especially if they are not prepared to pay for it. So it is disturbing that he is so intransigent in accepting the reality of rationing: are there other arguments over which he is similarly immovable? And why?

Sir Michael's opinion is quite clear. He wrote in the Lancet in 1999, "The notion that the NHS has ever `rationed' health care is a gross misuse of the English language." In the same article he takes the definition of a "ration" from the New Shorter Oxford Dictionary as a fixed quantum of health care per person. This accorded with his personal experience after the war of a ration of food, clothing, or fuel; he claimed that something similar does not happen with health.

He is right, but as I pointed out in a follow up letter to the Lancet article it is not for this meaning that rationing is applied to health care. In the larger Oxford English Dictionary on CD-ROM the participle "rationing" is defined separately as "raising the price of a commodity so as to restrict the number of people who can afford to buy it. Similarly rationing by price." This is entirely analogous to health care. Before NICE's pronouncements health authorities rationed taxanes by price; now they will allow prescriptions.

Sir Michael's article about NICE was published in March 1999; my letter in response appeared in May. Yet a year later Sir Michael spoke at a meeting in which, complete with a slide of a photograph of a ration book, he repeated his assertion that rationing of health care was an incorrect use of the word.

I wrote directly to Sir Michael, drawing his attention to my letter, which I could only assume that he had not read. He replied within a few days, writing, "On the question of `rationing' I would suggest you go to something like the Oxford dictionary which, in its concise version, says, `fixed allowance of food etc for civilians in time of shortage'."

There was no comment about the definition of rationing that I had drawn from the much larger and authoritative dictionary (authoritative in the sense of recording usage, not of prescribing meaning). I could now only assume that he had indeed not read my letter, nor did he intend to read it. I wrote back to Sir Michael, asking whether he had seen that letter, and repeating the definition from the full Oxford dictionary. He has not replied, despite a gentle reminder two weeks later.

In a recent report, the Institute for Public Policy Research warned that the public trust in the NHS will collapse unless the government admits that health care must be rationed. Politicians have consistently refused to use the word. It is common parlance in medical journals. The BMJ published 45 papers between 1990 and 1999 with rationing in the title, and "healthcare rationing" is a medical subject heading in Medline (MESH term). By sticking to his belief that rationing has the strict meaning of a defined ration of care per person, Sir Michael risks accusations of using words for political ends. He also makes himself seem arrogant and dismissive of reasoned argument. This is not healthy for the chairman of NICE.

Neville W Goodman consultant anaesthetist, Bristol