It seems that commentators (health economists, politicians, academics et al) have argued endlessly about the principles of health care in modern societies. “Is it just?” they ask. The moral argument is never satisfied. Those who argue for ‘equality’ believe that everyone is entitled, irrespective of age, gender, ethnicity, or income for example, to the same benefits. Others argue for ‘equity’ or ‘fairness’ intending that each person should have what they need, rather than necessarily the same as everyone else. But then, who decides what is needed?
One school of thought is that a ‘minimum’ standard of care should be provided to all, and what should that minimum be? Should it be greater for those who have the worst starting position? The underprivileged, or those with the poorest health? Alternatively, should the provision of care be determined as that which brings the greatest measurable health gain?
All very interesting, I hear you say, but what’s that got to do with me? From 1948 until 2006, broadly, statefinanced dental care leaned towards the first of these objectives: provide the most for those with the least. Financing more treatment for those who needed it (the ‘fee per item’ approach) tended to encourage dentists to accept patients with high dental needs, although a gradually widening gulf between the cost (to the dentist) and the fee paid by the state became an increasingly limiting factor.
In 2006 ostensibly the same rules applied, but by confusing fee-per-item with a totally untried new currency, the UDA, the water became thoroughly muddied. Clinicians were dissuaded from treating the high-needs patient, as they were held back by the vagaries of a crude banding arrangement.
Now, it seems, we are moving into the second camp: providing preventively oriented care for those who will demonstrate the greatest measurable health gain. A system of iterative health reviews, measuring health improvement, allied to a capitation system favouring the less well-off, is another amalgam (excuse the pun) of philosophies intended to level the playing fields of inequality and justify rationing of care using a different set of metrics.
All systems have their failings, especially when they are applied (experimentally, it seemed in 2006) to whole populations, and all systems have the potential to change clinicians’ behaviour. A survey by the National Institute for Health Service Research and Organisation in 2010 showed that not only dentists, but GPs andpharmacists as well, changed their overall pattern of care delivery after their payment systems were reformed over the past decade.
Whatever ‘big’ system is in place, there will be inequalities, and, worse still, inequities (unfairnesses). We see extreme examples of that in the United States, and moreover, the reluctance of vested interests, largely the health industries and to an extent the professionals, to see that changed. The US looks at times enviously to the UK but acknowledges that here too we struggle to find the elusive ‘system’ that is fair to all, while controlling public expenditure, and being answerable to the people – most of us - who fund it.
It’s not surprising then that many clinicians choose to turn their backs, either to some extent or completely, on the ‘big’ system and revert to the simplest system of all – the direct relationship between a clinician and a patient. That may be expressed as a fee per item regime in private practice, or a capitation plan, or something in between.
The Office of Fair Trading (‘fair’ again, in a different context) justified its review of the dental market in 2011 by a consideration of whether that market was ‘failing’. Given that health, together with, for example, housing and education, is a ‘good’ which is arguably fundamental to a civilised society, we have to accept that independent scrutiny is inevitable. Equally, society has to decide how much it will spend to support it, and that in turn implies that such funding is limited in each sector. Limitation means rationing and we are back to the original question – is it fair? As the old quote has it: “Life ain’t fair, but at least it’s fairer than death.”