Dodgy hip? Hope you didn’t tuck into the turkey too enthusiastically, else the National Health Service might not fix it for you.
Dicky ticker? If you have been at the gaspers, you may not get that bypass. Feeling liverish? Too much Hogmanay spirit may disqualify you from a liver transplant.
That wasn’t quite how Nice, the National Institute for Clinical Excellence, put it when last month it issued its summary of principles for the social value judgements that affect its work. One concerned treatment for illness caused in part by an individual’s lifestyle choices.
On the face of things, Nice was stuck between a rock and a hard place. On the one hand, we have a health service which is supposed to be provided free at the point of use on the basis of clinical need — and that seems to be what the public favours. On the other hand, it seems wrong that those who have chosen the George Best lifestyle should, when it catches up with them, get the finest treatment that the taxpayers’ money can buy.
Nice — consistently impressive in its judgements on issues with an ethical dimension — found a convincing middle course. We ‘should avoid denying care to patients with conditions that are, or may be self-inflicted (in part or in whole). If however self-inflicted case(s) of the condition influence the clinical or cost-effectiveness of the use of an intervention, it may be appropriate to take this into account’.
In less sober language, someone’s lifestyle should be taken into account when deciding on certain treatments — but only insofar as that treatment’s outcomes were affected by that lifestyle. So, for example, a smoker has a greater risk of dying during a bypass operation; and a drinker, as poor Mr Best has shown, won’t get the benefit of a liver transplant for long. It is therefore possible to stick to the principle that decisions on care should be made on clinical grounds, while at the same time ensuring that those clinical judgements take account of relevant lifestyle factors.
Even so, the Nice guidance does help highlight a growing difficulty in social policy. When I was an eager student of welfare policy in the 1970s, debate on state benefits raged round the Right-wing view that a distinction should be drawn between the ‘deserving’ and the ‘undeserving’ poor. Even the Right agreed that there should be generous welfare provision for, say, the mother-of-six widowed by her bank clerk husband’s early death. Their target was the ‘undeserving poor’: scroungers, fiddlers, layabouts and loafers, often visibly coming from foreign parts.
As Left-wing critics pointed out, the distinction between the deserving and undeserving poor dated from the days of the workhouse and the ‘Poor Laws’. Not unfairly, they said that was what the critics wanted to go back to.
That particular debate has largely passed. Everyone now is in favour of ‘welfare to work’, which does not stigmatise welfare recipients but still gives them every incentive to modify their behaviour. But there must be at least a chance that it will move to the health field.
There will be the ‘deserving sick’ and the ‘undeserving sick’. The deserving sick are you and I and all Public Finance readers who, of course, exercise, don’t smoke, and resist chocolates and chips. Then there will be the undeserving sick who aren’t like us at all, who bring ill health on themselves by their sedentary and self-indulgent habits. As the burden of tax to pay for health increases, the Nice line may become less easy to sustain.
It is not fashionable to talk in terms of class politics, but class politics is what this is about. It is fairly obvious to the most casual observer that the further ‘up’ the class structure you look, the more people are doing to look after their health. Nor is this surprising. Life at the top of the heap is much more pleasant than life for those at the bottom. So top people are making a rational decision in sacrificing short-term pleasures to prolong that life.
If things do move that way, it will have an important but often unnoted implication for social policy.
Another debate was going on in the 1970s. It concerned whether public expenditure really was doing what it was supposed to be doing, namely to redistribute from the rich to the poor. The general conclusion was that it was, but to a much smaller extent than had previously been believed.
Suppose as time goes by the ‘deserving unhealthy’ get more and the ‘undeserving healthy’ get less. Since the better off are on the whole the ‘deserving’ and the worse off on the whole the ‘undeserving’, public spending will become less redistributive.
Health inequalities are by common consent the biggest blot on our health care systems. Nice is holding a thin line against developments that could yet end up with them becoming worse.
