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"Ruling in" and "ruling out": two approaches to the micro-rationing of health care
1Department of Nursing, University of Wales, Swansea, UK.
Insights
Implicit healthcare rationing in the UK involves doctors allocating resources. This study reveals how social and moral factors influence patient selection for cardiac surgery and neuro-rehabilitation, impacting healthcare access.
Area of Science:
- Health Services Research
- Medical Sociology
- Clinical Decision-Making
Background:
- Implicit rationing is a key feature of healthcare resource allocation.
- Doctors' decisions on resource allocation significantly impact patient access to care.
- This study investigates patient selection processes in two distinct medical settings.
Observation:
- Analysis of cardiac catheterisation and neuro-rehabilitation admissions conferences.
- Discourse analysis reveals shifts from clinical to social/moral patient characteristics.
- Patient information is used for "ruling out" (poor prognosis) or "ruling in" (deserving of care).
Findings:
- "Ruling out" is more prevalent in cardiac surgery selection.
- "Ruling in" is more prominent in neuro-rehabilitation admissions.
- Differences in specialty work organization, including waiting list management and patient agency, influence these patterns.
Implications:
- Understanding these selection dynamics is crucial for equitable healthcare resource distribution.
- Organizational factors within medical specialties shape patient access to advanced treatments.
- Further research into the interplay of clinical, social, and organizational factors in rationing is warranted.
Abstract:
Much of the implicit rationing said to characterise British health care occurs as doctors decide what resources to allocate to individual patients. This paper examines this process using data from case studies of selection of patients for cardiac surgery and admission to a specialist neurological rehabilitation centre. The analysis focuses on cardiac catheterisation conferences in which cardiologists present surgical candidates to a cardiac surgeon, and neuro-rehabilitation admissions conferences in which a multidisciplinary team assess the suitability of head injury and stroke patients referred by hospital doctors. For much of the time participants in both settings discuss patients within a clinical discourse that relies on technical assessments of coronary anatomy, ADL scores and the like. However, there are many examples where the discourse "frame" shifts to address patient characteristics of a social or moral nature. Information of this kind tends to be deployed in two ways: it can be used to signal the patient's unsuitability, usually on the basis that past behaviour implies poor prognosis ("ruling out"), or it can be used to suggest that a patient is especially deserving of help ("ruling in"). Analysis of the data suggests that "ruling out" is more salient within the cardiac catheterisation conferences, and "ruling in" within the neuro-rehabilitation admissions conferences. The authors suggest that this reflects differences in the work organisation of the two specialties, including the division of labour, the organisation of waiting lists as a queue or a pool, and the putative significance of patient agency in the genesis of disease and recovery.