Week 4 Flashcards
The national health service
Founded in 1948 in the aftermath of WW2
Aneurin Bevan minister for health labour government
The first such system in the western world
Beatrice Webb
The minority report on the poor law 1909
-challenged the principle that supporting the poor was encouraging ‘indolence and vice’
-advocated the prevention, rather than cure of poverty
A public health service
Deep roots
None of this can be understood without understanding the deep seated class prejudice of the time
Poverty was genuinely believed to be divine punishment
Increased incidence of disease and disability among the poor was seen not as the result of overcrowding or inadequate hygiene but as conformation of this
The poor often self medicated (eg alcohol or laudanum for pain ) and this was seen as further evidence of their depravity
The poor represented a social and political threat
The UK in this period
Most of the population could not vote excluded on the grounds of lack of property ownership (universal male suffrage was achieved in 1918)
1900-1910 represents the peak period of wealth inequality in Britain the top 10% owning 94% of national wealth the top 1% owning 70%
Patchwork of medical care made up of charitable hospitals subscription services for workers, and cash in hand GPs
Illness often meant destitution and the workhouse
Growling public health movement since 1842 fuelled by militarism and eugenics
Lloyd George brought in a national insurance scheme in 1911 (did not cover family members)
Democratisation
Number of factors- universal benefits (eg NHS, education) progressive taxation
Today it has been calculated that universal benefits would account for 60% of the disposable income of the poorest 20% of out population, were they lost
The national health service- founding principles
Universal
Equitable
Comprehensive
High quality
Free at the point of delivery
Centrally funded
A profoundly humanist position
Human beings matter and human experience matters
Science and reason are valuable tools to promote human interests
Human beings have inherent worth
All human beings have the same worth
The ‘just world’ fallacy
Different groups of people think about social hierarchy in different ways
In general those at the bottom think about it quite differently than those at the top
A popular image of the world by some of those at the top is the idea of a ‘just world’
If you make good choices, good things happen to you, if you make bad choices you end up in a bad situation
Therefore if you’re in a good position its because you deserve to be there
-its not just the wealthy (and not all the wealthy) who adopt this position- certain personality types do too the just world position has been linked to preference for simple, casual explanations and certainty
But lots of arguments against:
- unequal opportunities
- unequal resources from birth
- exhausted parents who can give less input
- poor education
-poor nutrition
- lower expectations
Health is an exposer of the ‘just world’ fallacy
Theories of distributive justice
Egalitarian- everyone gets the same
Meritocratic- everyone gets according to their desserts
Socialist- “ from each according to their ability to each according to their need”
Libertarian- “ from each as they choose, to each what they have made or happen to be given”
Fairness- (john Rawls) as you would choose from behind the ‘veil of ignorance”
Egalitarian
All human beings are equal and have exactly equal rights
Resources should be equally allocated among all members of society
More modern formulations focus on removing the influence of luck in the allocation of resources or on social equality
- everyone has the same right to healthcare, everyone is allocated the same resources, when its used up its used up
-lottery allocation of resources has also been advocated from an egalitarian perspective eg, allocation of organs- everyone has the same opportunity to avail of resource
Criticisms of egalitarianism
None seem to actually deliver equality
Eg luck egalitarianism says that chance shouldn’t be allowed to affect people’s share of resources only their resources
But are bad choices always your fault?
Meritocratic
Sometimes called desserts
Rewards should be given in proportion to merit
But what is merit
Social systems based on merit
Competitive rather than collaborative by nature
Proponents maintain that competitive systems drive up performance
Opponents consider that competition produces loss for the majority favouring collaborative social models
Many advantages in competition are not earned
Meritocracies
Those who believe the system is meritocratic generally favour low taxation and low distribution of wealth
The rationale being that those at the top of society have earned it
Meritocratic healthcare
Those who have worked hard (therefore can afford it) can pay for better treatment
Those who have lived healthily should get better/more treatment
‘Bad’ behaviour should mean limited access to treatment
socialist
We all benefit from living in a functional, regulated society
Those who have benefitted most should contribute most
Resources should go where they are most needed
Taxation is an example of socialist mechanism
You contribute in proportion to your income (i.e in proportion to how much you have benefited from the system)
This money maintains the system:
-administration, legal system, business regulation, consumer protection, roads, drinking water, subsidised childcare, education, emergency services
It also maintains those at the bottom of the system:
-its the responsibility of the system to provide employment
-its also the responsibility of the system to provide for those who cannot provide for themselves
“No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means” aneurin bevan
Criticisms of socialist models
Criticisms include the burden of bureaucracy
Is industriousness in your interests
Promotes helplessness and stifles initiative
Libertarian
Emphasis on personal freedom, choice and responsibility
Each individual is responsible for their own future
The role of government is very small:
-maintains a free market, preventing monopolies
-emphasis on property rights
Libertarian healthcare models
It’s entirely up to you how much of your income you dedicate to your health- you could pay for health insurance or take the risk of a huge bill
You are responsible for your own decisions in relation to your health eg smoking, and no one else should be expected to pay for the consequences
Criticisms of libertarian models
Ignores the role of luck- which has significant impact on individual successes
Ignores the role of unearned advantage
Freedom is a spectrum- it requires starting with significant resources to be truly free we are all bound by material need
Fairness
Each position in society will be associated with some privileges and some burdens
The role of society is to ensure that burdens and resources are distributed fairly
In order to achieve fairness we need to imagine that we are laying the rules at foundation of a system from behind a veil of ignorance
The rules refer to who gets what and what burdens they must bear
Equality of access to healthcare
Rejection of Unitarianism “they greatest good for the greatest number”. As this would lead to those with, for example rare diseases, being sidelined, this is seen as a preference for equity over strict equality
Equity and equality
Equality is giving everyone the same access to a system or resource- everyone is treated the same
Equity allows different in order to allow all to have the same opportunities eg additional resources to the disadvantaged to allow them to have the same opportunity as the better off
Limitations of the fairness model
Still doesn’t really take account of luck
As originally described relates primarily to goods and services and assumes that welfare proceeds form those
Criticised for its inattention to health- in particular to palliative care:
-healthcare is seen as a means to restore lost opportunity
-those at the end of life have no opportunity to restore
How does the NHS distribute
NHS constitution (England) 2015
-comprehensive service available to all
-access based on clinical need
-highest standards of excellence and professionalism
- patient centred
-works across organisational boundaries
-committed to providing best value for taxpayers money
-accountable to the public, communities and patients that it serves
Rationing
Resources are limited
Demands on the system continually increase
This means that clinical need cant be the only deciding factor into how money is spent
Novel treatments cost more
Pharmaceutical companies seek to recoup the costs of research and development before the patient on their product expires
Many new medications cost more to produce
New cellular therapies are very expensive (eg CAR-T therapy)
Overall medication costs in hospital have been increasing at ~12% per year. Whereas the NHS budget has only been increasing by around 1% per year
ICU bed rationing
ICU beds are a finite resource in high demand and only occupiable by one patient at a time- therefore a decision to take a patient to ICU potentially prevents another patient subsequently accessing that bed
ICU doctors when making the decision about whether or not to accept to patient, follow a first come first serve system- a form of egalitarian distribution as in theory everyone has an equal chance of needing a bed when one is free
But they also have mind of the utility of the resource itself - where a finite resource can do most good
In normal times if your ICU is full the patient if suitable will be able to be transferred to another ICU nearby to receive the same care
Who is suitable:
-someone with good chance of recovery
-and fairly quickly
Abnormal times
During COVID there was the real prospect of ICU saturation that there would be no ICU beds available to transfer to elsewhere
The BMA issued ethical guidance arguing that in these circumstances it was permissible to follow a first come first serve policy but if someone subsequently arrived who had a better chance of survival they should be put on the ventilator instead. In effect age was the key discriminator
This raises issues:
-equalities act
-withdrawal of treatment when it would still be in the best interests of the patient
-prioritarian reasoning: prioritarians would argue that theres ethical justification in promoting the interests of the young as by definition they have had less opportunity to benefit in life than old
Double jeopardy
Those who are already disadvantaged then find themselves further disadvantaged
Eg saving the life of someone with a chronic condition that decreases QOL will always generate a smaller gain in QALYs then saving the life of a person in perfect health- they’re ‘unlucky twice’
rare diseases
Those who have a rare disease have less chance of an effective treatment being available
And a pure utilitarian approach would not justify investment to save such a small number of people
Uk strategy for rare diseases
Improved recognition- training for clinicians
Internationally coordinated research
Review of how cost effectiveness is considered in the case of rare diseases
Improve access to international experts
Strategic funding of research in rare diseases
Orphanet- European network dedicated to orphan drug and rare diseases
What is an orphan drug
Drugs for rare diseases that would not be commercially viable for development
Development and trials are subsidised by governments
But generally they still pan out very expensive
Is it just to have a different threshold for cost per QALY for rare diseases
What about costs other than medications
Many rare diseases are fatal in early childhood are there arguments here about futility? About prolonging suffering ?
What is just
“A just society is a society that if you knew everything about it, you’d be willing to enter it in a random place”
John Rawls
Test of capacity
Decision and time specific
Understand info
Retain info
Weigh up
Communicate decision
Diagnostic test
Acute/sudden loss of capacity- temporary?
Long term loss of capacity
Is it recoverable? If so within the time frame to make a decision
Doctrine of necessity
Life saving treatment in their immediate best interests dont need consent
Lasting power of attorney
Completed by a person to appoint said person to make decisions on their behalf in the event they lose capacity
Healthcare or social/welfare or both
Must be registered (office of public guardian) and you must see it
POA decisions should be considered same as the patient
Advanced decision to refuse treatment
Legally binding
Sets out refusal to future treatment in the event of losing capacity
Can be written or verbal
For life sustaining treatment it must be written, signed, witnessed and contain statement that says it applies even if the persons life is at risk
Decisions should be made in the persons best interest
Decision taken is least restrictive to persons rights and freedom of action
Best interest decisions should take account of: patients prior wishes, patients current wishes, balance risk vs benefit
Court of protection
Can decide whether someone has the mental capacity to make a particular decision for themselves
Can appoint a deputy to make ongoing decisions for people who lack mental capacity
Can action urgent or emergency applications where a decision must be made on behalf of someone else without delay
Can make decisions about a lasting power of attorney or enduring power of attorney and considering any objections to their registration
Can make decisions about when someone can be deprived of their liberty under the mental capacity act
