Perfect as the enemy of good: resource allocation in the 21st century 

In an imperfect world, hard decisions and sacrifices must be made in order to maintain equity when it comes to allocating the finite resources of our health care system, writes Will Cairns …

IT is not often that the challenges of resource allocation make it on to the front pages of the paper, into current affairs programs, or on the TV evening news (here, here and here). 

At the height of the coronavirus disease 2019 (COVID-19) pandemic, funding for consultations with psychologists under the Better Access for Mental Health program increased from ten to 20 sessions per patient to address the distress being generated. In December 2022, the Health Minister, Mark Butler, announced that this temporary funding would not be extended. A study of the program as a whole found that the additional consultations were taken up disproportionately by those already receiving treatment, on relatively higher incomes, and/or living in major cities (here and here). Even though patients and psychologists felt the consultations were valuable, the clinical outcomes for this group as a whole were not significantly altered by the additional visits. 

It seems likely to me that in some cases more affluent people who could afford to pay simply applied the additional subsidies to consultations that would have happened anyway. At the same time, between 2021 and 2022, patients’ average co-payment for such consultations increased from about $74 to $90 (+21%). 

However, the report also noted that as the number of clinical psychologists had not increased significantly, any increase in the absolute number of consultations could only occur if psychologists worked harder by seeing more people or, more likely given the subsidy, some patients were seen more often. 

An increase in the number of subsidised consultations for each patient could only serve to divert more of the finite resource of psychologists to those already receiving treatment, resulting in decreased access for those seeking first appointments, and an increase in the number of people who did not receive any consultations. 

The numbers of new patients able to have consultations declined by 7%. Access for poorer people and particularly those who live in rural and remote areas was reduced even further than before the change. Members of these communities are known to have more significant mental health issues, including higher rates of depression and suicide, and less access to mental health care generally (here and here). 

In summary, and as identified by the panel on ABC program The Drum on 12 December, the Minister’s action was not about the money. The rate-limiting resources for services are the size of the psychology workforce and the number of consultations they provide, and both are concentrated in the more affluent areas of larger communities. The Minister had decided to ration/reallocate a finite resource in the interest of equity (like food in Somalia or electricity in Ukraine). 

The best individual health care outcomes are produced when clinicians allocate the optimum amount of time and attention to each patient independently, often by following best practice guidelines. 

It is scarcely surprising, and in line with the duty of clinicians to advocate for their individual patients, that the Australian Psychological Society and many individual psychologists objected to the Minister’s decision (here and here). I would expect that doctors would (will) respond in a similar manner if (when) their work was (is) rationed. 

And yet, we also know that perfection is not possible and that clinicians need to set achievable goals and share their time equitably between their patients, and when possible, avoid taking on more than they can handle within the time available. The code of conduct for doctors in Australia is very clear that doctors have a duty to our community to support “the transparent and equitable allocation of healthcare resources”. 

In times of severe shortage, particularly during disaster, the pendulum of responsibility swings much more towards the broader interests of the community as a whole, a goal that may require deliberate inequities and sacrifices. 

In other words, our duties to our patients and our community are sometimes in conflict. 

The Health Minister has the unenviable task of finding a position of equipoise in the jumbled complexity that lies between the best outcomes for every individual and those for the whole community. If they have done their job well (perhaps best judged by an outside observer), almost everyone else will feel short-changed if they assess their personal outcomes using the best practice guidelines for all individual patients that we have been encouraged to embrace. And governments as a whole also have a duty to provide resources to other areas of community need, some of which also affect health indirectly (eg, roads, water reticulation, environmental protection, etc.). 

As he described very clearly in his public statement, the Minister assessed the report and realised that although some patients almost certainly obtained benefits from more consultations, a program that increased the number of subsidised consultation per person to those already receiving care without increasing the total number providers of consultations, or changing the geographical and socio-economic distribution of their availability, had produced a net harm to the population as a whole because it decreased access for more marginalised poor and rural and remote communities. 

This particular issue is not complex, being within one small domain of health care. To my mind, it is just an entrée for an infinitely more complex discussion about equity in the allocation of finite resources across the full range of diseases and our expectations of health care in Australia, not to mention the necessary allocation of resources to activities outside of health. 

So where to start? 

As clinicians and as a community we have all allowed ourselves to be sucked into a quagmire of unfulfillable expectations: 

• that as clinicians we will treat all of our individual patients to the standard of the best practice guidelines that we have written for ourselves; 
• that as patients and members of our community all of us will receive the latest and best treatment available for whatever illnesses we develop; and 

• that our elected leaders will fund (from our community’s resources) such treatments, almost irrespective of the financial cost, the opportunity costs, or likelihood of benefit. 

The reality is very different. Few disagree with the view that we do not have sufficient resources to provide all of the expensive molecular cancer treatments, high technology surgery, routine preventive and primary care, compassionate and dignifying aged-care, public health measures and disability care that would deliver best practice outcomes to every individual. Nor can we sustain the workforce and infrastructure that might allow us to avoid the need to make the hard choices necessitated by pandemics and the other disasters that will at times overwhelm our health care services. 

And yet, as we saw around the world during the COVID-19 pandemic, many leaders were fearful that we (the community) would blame them for making hard choices. As a result, many failed to fulfil the responsibility of their role as leaders. Their duty had been to engage in the resource allocation decisions of disaster triage, long before such decisions were required to be made in emergency departments and intensive care units everywhere, including in Australia (here, here and here). And yet as a general rule, they did not, even when the pandemic was in full flight. 

Fortunately, for the most part the members of our community are wiser and more pragmatic than our leaders believe us to be. Newspaper reports from the height of the pandemic repeatedly showed that most people accepted the need for hard choices. Some even anticipated their own priority for exclusion from treatment by volunteering not to receive ventilation, removing from doctors some of the burden of having to choose. Whenever I ask, people understand that difficult choices must be made, and that the duty of leaders is to be transparent about the decisions that they make about us and on our behalf. Most communities have demonstrated in recent elections that they support leaders who have been open and honest as they addressed the choices that they have made. 

Mark Butler’s press conference was the only time I can remember having heard a politician in Australia openly and explicitly describe a health care resource allocation decision that withdraws a payment that was bringing benefit to some as being based on the need to redistribute a finite resource in the interests of equity. 

So perhaps the door is ajar for revising our goals for health care starting with a reappraisal of our roles: 

• Our community needs to be supported in an open discussion about the limits to resources. This means facing the inescapable reality that already some people do not have access to basic services, and that health care should be distributed equitably in the interests of the community as a whole. This means that priorities might change and some people will gain or lose access to some treatments and interventions from which they might benefit. 
• The clinician’s roles are to deliver the best available care to the patients in front of them and also to support their community to understand the limits to the quantity of treatments that can be afforded. Clinician engagement is essential for an open and informed communal debate about equity in resource allocation for health care. Any meaningful redistribution of finite resources is likely to change the scope of the health care that they provide and redistribute their remuneration. 
• Our elected leaders must “bite the bullet” and lead a broad public discussion about the allocation of finite resources in the interests of the community. Only then can they fulfil their role to make resource allocation decisions in an open and transparent manner and in line with community preferences. 

Voltaire is often given credit for the statement “Perfect is the enemy of good”, but earlier variants on the theme have been ascribed to Shakespeare and Aristotle, among others. However, it is fair to say this advice has been generally ignored in our efforts to improve the outcomes for our individual patients and their personal diseases, and in overly aggressive efforts to prevent death. 

We are all challenged by our growing awareness of the complexity of our individual biology and its interconnectedness across the multiple dimensions of our behaviour, as well as that of our communities and their cultures, including the drivers of the workings of health care systems. 

Many clinicians feel overwhelmed by the plethora of well-intentioned guidelines, standards and regulations that dangle the promise of perfection. They understand that many of these increase the cost and complexity of health care delivery. Sometimes they even become obstacles to good care, and are ignored by clinicians struggling just to get through a day of caring for all their patients. I believe that a significant proportion of the burden of distress and burnout of contemporary clinicians stems from the realisation, conscious or otherwise, that it is impossible to achieve the perfection that is written into our standards and guidelines, and our expectations of ourselves. 

The candour of the Minister’s short statement offers us the opportunity to reorientate health care. Our challenge is to support leaders with the wisdom and patience to guide our community from our current shallow focus on perfect care for the individual towards a broad acceptance of the equally important goal of good/best possible health care outcomes for all members of the community. 

Dr Will Cairns OAM has retired from clinical practice and is a Consultant Emeritus in Palliative Medicine based in Townsville and Associate Professor at James Cook University. 

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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