Rationing health care

2009-08-11 00:00

IT is common cause that the public health services are in disarray. The government has been caught unawares by the exponential escalation in health-care costs over the past few years and the resultant chronic underfunding is now seriously jeopardising the ability of the health services to provide adequate and effective care to the general public.

Our government is not alone in this predicament. In the United States, the richest country in the world, President Barack Obama has said that the U.S.’s current system of health-care provision is not sustainable and that he is going to propose a radical reorganisation of the system at a cost of trillions­ of dollars­.

The United Kingdom’s minister of Health Lord Darzi and his chief executive have resigned after intense criticism of his proposed reforms to give the country a health service that will provide quality, safety and that which is equitable.

What then are the cost-drivers, which worldwide have resulted in this exponential rise in health- care costs? Paradoxically, the main cause of the burgeoning health care costs is the success of modern medicine in keeping people alive. The older the population, the greater the need for medicines and medical services for the treatment of cancer to cataracts, cardiac surgery, new hips and new knees, to name but a few, but which are all available and are now being demanded by an increasingly well-informed public.

For example, if there are 30 000 patients on ARV treatment for HIV infections in our area, this imposes an ongoing financial obligation for the next 20 years or so. While the rate of new infections may be going down, the overall number on treatment must inevitably increase on an annual basis. Coupled to which are the concomitant risks of tuberculosis, malignancy and the other complications that require treatment in this cohort of the population. Furthermore­, add in diabetics and hypertensives, all those who are on chronic medication for years and one can easily understand the enormous future financial commitment which the Department­ of Health is obliged to assume. There is no way that this can be catered for within the current health budget.

The other potent cost-driver is the rapid increase in medical technology. The advent of intensive care units for newborn babies, children and adults has resulted in a growing gap between what is possible and what is affordable. Medical aids are also under stress as they are experiencing what they term “selective lapsation” which means the reduction in the number of the young and healthy joining the schemes, while the remainder of their members grow older and consume more expensive medical modalities.

It is essential for the future of health care in this country that tertiary centres of medical excellence such as Grey’s Hospital are adequately funded, for they are the training ground for all our future specialists. It is no good appointing a neurosurgeon if there are insufficient ICU beds to enable the surgeon to operate, and likewise to commission a cardiac catheter unit if the hospital is unable­ to afford sufficient catheters to make the unit cost effective. Grey’s Hospital has not been able to come out within its budget for years, not due to any maladministration, but purely as a result of patient demand for its specialist services.

The rationing of these scarce and expensive resources is a reality but brings in its wake many ethical dilemmas. Many decisions are literally ones of life or death for a patient. These decisions are made under ethical guidelines and protocols that are intended to maximise the use of these scarce resources for the greatest number of patients but nonetheless which are difficult to make and emotionally draining. Who gets the last ICU bed, the 20-year-old bullet- ridden bandit or the elderly bishop­? You decide.

Sudden cash-flow crises have a deleterious effect on the whole hospital, often with unintended collateral damage, such as the closure of the paediatric intensive care unit that only now has been restored. There is no greater stimulus for a dedicated young doctor to emigrate than to stand by helplessly and watch a young child die through a lack of facilities. Indeed, it is this lack of basic facilities that was behind the recent doctors’ strike just as much as their poor renumeration.

Rationing health care has to be done rationally to ensure optimal use of the available funds on an ethical, equitable and sustainable basis. One cannot begin to ration anything unless one knows the relative costs of the services that are provided. The first step must be to compute the expanding costs of chronic health care and escalate it annually in the health-care budget.

Secondly, currently there are no cost centres in the clinics and hospitals, so the cost of individual services are unknown. As a result budgets are imposed from the top and hospitals are not remunerated according to the volume and complexity of the services they provide.

The exhortation to cut costs but not services is an exercise in futility­. There is currently a mal-distribution of available funds. The administrative costs are too high in relation to the cost of the medical services provided. Devolve administrative responsibility to those who are actually involved with the work and empower them to do so, for only those directly involved can ration health care with compassion and equity.

Our public health service is in need of intensive care. Only a massive transfusion of money will restore it to its former glory. Unless this happens, the gulf between private and public health care will grow ever wider and any prospect of introducing a national health service will fade into obscurity.


• Dr T. J. Rockey is vice-chairman of the Grey’s Hospital board and a member of the Grey’s Hospital ethics committee .

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