Hellish decisions in healthcare

Abstract

After a decision has been made about how much should be allocated to healthcare, as opposed to other ways in which society could spend its wealth, on education or defence for example, there are three other prioritisation decisions that need to be made before the clinician and the patient make a decision about whether the treatment is right for that individual. Firstly those who pay for healthcare for populations need to decide on the allocation to different sub groups of that population. The sub groups can be determined by condition, for example allocation between people with cancer and people with cardiovascular disease or by age group. Secondly within each of these programmes there is a need to allocate to different systems of care. For example how should the spend on cancer be divided between people with lung cancer and people with colorectal cancer. Thirdly, within each system there is a need to prioritise between fro example, prevention, screening, treatment and terminal care for people with or at risk of colorectal cancer. The second and third levels of prioritisation will be the responsibility of clinicians with patient involvement as need and demand outstrip the growth of resources.