Rationing and prioritising are not the same

MHF president Professor Ian Banks who has worked as both a GP and in hospitals argues that a serious debate on how we should cut the NHS cake is being clouded by confusion over rationing and prioritising. He says it is about doctors understood the difference.

When it comes to dividing up the national health cake, there are some who would have it and eat it. The BMA has just produced its response, 'The NHS: A Rational Approach' to the ARM motion calling on Council to address creeping NHS fragmentation and privatisation.

It might not be the definitive document stopping a Bevan rotating in his grave but it at least addressed the difference between rationing and priority setting. These two words are routinely used interchangeably despite their total opposite in meaning. On BBC Radio 4 the two terms are used in the same breath, unfortunately by those who are supposedly protecting the NHS.

It's more than just words or clever semantics. Getting the distinction right is crucial to the debate over NHS future and for that matter the BMA suffering a low percentage junior doctor membership despite an overall increase in numbers. Rationing is the totally equal distribution of a limited resource. Priority setting is the distribution of a limited resource only to those deemed most needy.

During World War II, King George VI supposedly waved his ration book while in line for his 2 oz scrag end. Rationing was taken seriously, so seriously that as an equal distribution of limited resources notwithstanding the bombs, it actually reduced children's mortality. This more reflected the horrendous inequality between social classes rather than prioritising. People and police took a very dim view of anything that undermined rationing. The black market was so illegal that people went to jail and much worse. But these days, who provides the black market for health care? Us. It's called private medicine. No queuing for the medical equivalent of scrag end when if you can afford fillet.

Learn from the Zulus

Rationing is not always effective. During the Anglo-Zulu Wars in South Africa at the Battle of Isandlwana, an overwhelming force of Zulus wiped out an entire British force (along with their support personnel, mainly black men and women). Their quartermaster, conscious of saving the Queen's Purse, rationed each soldier with the amount of rounds he deemed necessary for the conflict. This he based on the number of Zulus, the speed at which they could run, and the rate of fire from a Standard British Soldier. He got it all correct except the number of Zulus. Queen Victoria's quartermaster was out by a factor of 100.

Soon after, the remaining Zulus turned on Rorke's Drift. This small outpost had far fewer infantry and even less ammunition than Isandlwana but both were distributed according to the maximum threat of attack. Zulu courage and bravery is without doubt, but as the Great War demonstrated sending troops into concentrated and withering fire will always result in horrendous casualties. More so when armed with nothing more than a large dinner knife. An assegai is no match for a rifle, unless you can get close enough to use it.

Today's UK health professionals face a number of contradictions. They are expected to deliver their services on an equal basis rather than prioritising which would give a far better impact. Using out of date equipment and drugs based only on economy not efficacy—for many front line workers NICE is no longer seen as an independent body—and worse, much worse they feel infantry pawns for a government more concerned with internal political struggle (not least an illegal war in Iraq) rather than fighting the true common global enemy, public ill-health.

Get the things clear

If the BMA enshrines rationing in its policy it will be perceived as the government's NHS quartermaster. By championing prioritising of care it will however continue to rightfully be the patient's advocate. It is more than just words. Never in the history of the NHS, and the BMA, has there been such a chequered NHS when it comes to delivering care to the most needy.

Getting the picture clear is vital. Young doctors entering the NHS are looking to the BMA for leadership. Give them the tools to fight ill-health and they will support and defend the NHS Let them feel a part of the war against poverty related ill-health while developing their careers and they will join the BMA. Then they will button up their tunics and resist drinking brandy from the medicine cabinet. It is after all a flogging offence. Ask Hooky.