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FROM WEDNESBURY UNREASONABLENESS TO ACCOUNTABILITY FOR REASONABLENESS

Published online by Cambridge University Press:  22 August 2017

Daniel Wei L. Wang
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Abstract

Over the last decades, rationing of medical treatment in the National Health Service (NHS) has moved from implicit to being increasingly explicit about what is being denied and about the procedures and reasons for such decisions. This article argues that the courts have had an important role in this process. By applying a heightened scrutiny of rationing decisions, courts have forced health authorities to make better-informed decisions and to take procedural justice more seriously to comply with, respond to and avoid judicial review. The analysis in this article reveals that litigation has contributed to incremental, but significant and enduring, changes in a social policy. It also offers insights to the paradoxes of judicial accountability in health care policies.

Keywords

judicial reviewhealth caresocial rightsrationingNHS
Type
Articles
Information
The Cambridge Law Journal , Volume 76 , Issue 3 , November 2017 , pp. 642 - 670
Copyright
Copyright © Cambridge Law Journal and Contributors 2017 

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Footnotes

*

Lecturer, School of Law, Queen Mary University of London. The author is grateful to Conor Gearty, Thomas Poole, Carol Harlow, Peter Littlejohns and the two anonymous reviewers for their useful comments on previous versions of this article. The usual disclaimer applies.

References

1 See e.g. Exter, A. and Buijsen, M. (ed), Rationing Health Care: Hard Choices and Unavoidable Trade-offs (Maklu 2012)Google Scholar; Flood, C. and Gross, A. (eds.), The Right to Health at the Public/Private Divide: A Global Comparative Study (Cambridge 2014)CrossRefGoogle Scholar; Yamin, A. and Gloppen, S. (eds.), Litigating Health Rights: Can Courts Bring More Justice to Health? (Cambridge MA 2011)Google Scholar; King, J., Judging Social Rights (Oxford 2012)CrossRefGoogle Scholar.

2 I use “England” to mean “England and Wales”.

3 See however Flood, C. and Gross, A., “Litigating the Right to Health: What Can We Learn from a Comparative Law and Health Care Systems Approach” (2014) 16 Health and Human Rights 62 Google ScholarPubMed.

4 See Amos, M., “The Second Division in Human Rights Adjudication: Social Rights Claims under the Human Rights Act 1998” (2015) 15 H.R.L.R. 549 Google Scholar; King, J., “The Justiciability of Resource Allocation” (2007) 70 M.L.R. 197 CrossRefGoogle Scholar; Pillay, A., “Economic and Social Rights Adjudication: Developing Principles of Judicial Restraint in South Africa and the United Kingdom” [2013] P.L. 606 Google Scholar. See also Krajewska, A., “Access of Single Women to Fertility Treatment: A Case of Incidental Discrimination?” (2015) 23(4) Med.L.R. 620 CrossRefGoogle ScholarPubMed, at 627.

5 See Newdick, C., Who Should We Treat: Rights, Rationing, and Resources in the NHS (Oxford 2004), 93 Google Scholar; Syrett, K., “The English National Health Service and the ‘Transparency Turn’ in Regulation of Healthcare Rationing” (2011) 3 Amsterdam Law Forum 101 Google Scholar; Syrett, K., “Impotence or Importance? Judicial Review in an Era of Explicit NHS Rationing” (2004) 67 M.L.R. 289 CrossRefGoogle ScholarPubMed, at 297.

6 See e.g. Hertogh, M. and Halliday, S., Judicial Review and Bureaucratic Impact: International and Interdisciplinary Perspectives (Cambridge 2004)CrossRefGoogle Scholar; Sunkin., M. “Impact of Public Law Litigation” in Elliot, M. and Feldman, D. (ed.), The Cambridge Companion to Public Law (Cambridge 2015)Google Scholar.

7 Daniels, N., Just Health: Meeting Health Need Fairly (Cambridge 2009)Google Scholar. See also Daniels, N. and Sabin, J., Setting Limits Fairly: Learning to Share Resources for Health (Oxford 2008)Google Scholar.

8 Some authors exclude from the definition of rationing the cases in which funding is denied because a treatment is considered not effective for a cohort of patients or an individual (see e.g. Herring, J., Medical Law and Ethics, 6th ed. (Oxford 2008), 63 Google ScholarPubMed). The definition of rationing in this article does not exclude these cases. When it comes to an administrative decision about the provision of a treatment, it is normally difficult to disentangle reasons of effectiveness from those of cost. In an ideal world where resources are unlimited, it would be perfectly rational to provide treatments which have low or questionable effectiveness. However, given the reality of any health system, every treatment carries opportunity costs and thus treatments’ effectiveness, alongside their cost, has a central role in priority-setting (see Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage (WHO, 2014)Google Scholar.

9 This section covers all the court cases on this topic found in the specialist literature; among the precedents cited by the courts; and in the Bailii, Westlaw and LexisLibrary databases. Given the scope of the article, cases concerning service reconfiguration that do not directly result in the denial of funding for health treatment, the provision of social care, statutory interpretation, end-of-life decisions and compensation for medical negligence were not covered.

10 On synoptic decision-making, see M. Shapiro, “The Giving Reasons Requirement” (1992) University of Chicago Legal Forum 186.

11 R. v Secretary of State for Social Services and Ors ex parte Hincks [1980] 1 B.M.L.R. 93.

12 R. v Ethical Committee of St. Mary's Hospital (Manchester), ex parte Harriot [1988] F.L.R. 512.

13 R. v Central Birmingham Health Authority, ex parte Walker [1988] 3 B.M.L.R. 32.

14 R. v Central Birmingham Health Authority, ex parte Collier [1988], 151.

15 R. v Sheffield Health Authority, ex parte Seale [1994] 25 B.M.L.R. 1.

16 Central Birmingham Health Authority, ex parte Collier [1988], 151.

17 Secretary of State for Social Services and Ors [1980] 1 B.M.L.R 93.

18 Ethical Committee of St. Mary's Hospital [1988] F.L.R. 512, 514.

19 Ibid., at p. 519.

20 R. v Cambridge Health Authority, ex parte B [1995] 2 All E.R. 129; [1995] 1 W.L.R. 898.

21 Ibid., at p. 906, per Sir Thomas Bingham.

22 R. v North and East Devon Health Authority, ex parte Coughlan [2001] Q.B. 213.

23 Ibid., at p. 89.

24 R. v North Derbyshire Health Authority, ex parte Fisher [1997] 8 Med L.R. 327.

25 See also R. v Thanet Clinical Commissioning Groups, ex parte Elizabeth Rose [2014] EWHC 1182.

26 R. v North West Lancashire Health Authority, ex parte A, D and G [1999] All E.R. (D) 911.

27 R. v Swindon NHS Primary Care Trust, Secretary of State for Health, ex parte Rogers [2006] EWCA. Civ 392; R. v Bromley NHS Primary Care Trust, ex parte Gordon [2006] EWCA Civ 392; R. v Barking & Dagenham NHS PCT, ex parte Otley [2007] EWHC 1927; R. v West Sussex Primary Care Trust, ex parte Ross [2008] EWHC B15; R. v Salford Primary Care Trust, ex parte Murphy [2008] EWHC 1908.

28 Swindon NHS Primary Care Trust, Secretary of State for Health, ex parte Rogers [2006] EWCA Civ 392.

29 Barking & Dagenham NHS PCT, ex parte Otley [2007] EWHC 1927.

30 West Sussex Primary Care Trust, ex parte Ross [2008] EWHC B15.

31 Salford Primary Care Trust, ex parte Murphy [2008] EWHC 1908.

32 R. v NICE, ex parte Eisai Ltd. [2007] EWHC 1941; R. v NICE, ex parte Bristol-Myers Squibb Pharmaceuticals Ltd. [2009] EWHC 2722; R. v NICE, ex parte Servier Laboratories Ltd. [2010] EWCA Civ 346.

33 See also R. v NICE, ex parte Fraser and Another [2009] EWHC 452.

34 NICE, ex parte Servier Laboratories Ltd. [2010] EWCA Civ 346.

35 See also NICE, ex parte Fraser and Another [2009] EWHC 452.

36 R. v Secretary of State for Health, ex parte Pfizer [2002] EWCA Civ 1566. See also R. v North Staffordshire Primary Care Trust, ex parte Condliff [2011] EWCA Civ 910.

37 Art. 7 of Council Directive 89/105/EEC.

38 R. v Secretary of State for Health, ex parte A and B [2017] UKSC 41.

39 R. v Secretary of State for Health, ex parte Watts [2003] EWHC 2228 (Adm).

40 See Montgomery, J., “Law and the Demoralization of Medicine” (2006) 26 L.S. 185 Google Scholar, at 198.

41 Secretary of State for Health, ex parte Watts [2003] EWHC 2228 (Adm) 148.

42 R. v Secretary of State for Health, ex parte Watts [2004] EWCA Civ 166.

43 See also Syrett, K., Law, Legitimacy and the Rationing of Health Care: A Contextual and Comparative Perspective (Cambridge 2007)CrossRefGoogle Scholar, ch. 6; Palmer, E., Judicial Review, Socio-Economic Rights and the Human Rights Act (Oxford 2007), 209 Google Scholar; Newdick, Who Should We Treat, p. 93; Syrett, “The English National Health Service”, p. 107.

44 Barking & Dagenham NHS PCT, ex parte Otley [2007] EWHC 1927.

45 North Derbyshire Health Authority, ex parte Fisher [1997] 8 Med L.R. 327.

46 West Sussex Primary Care Trust, ex parte Ross [2008] EWHC B15; Bromley NHS Primary Care Trust, ex parte Gordon [2006] EWCA Civ 392; Barking & Dagenham NHS PCT, ex parte Otley [2007] EWHC 1927.

47 See Newdick, Who Should We Treat, p. 93; Syrett, “The English National Health Service”; Syrett, “Impotence or Importance?”, p. 297.

48 Syrett, “The English National Health Service”, p. 108.

49 This hypothesis was discussed by Daniels and Sabin, Setting Limits Fairly, p. 50; Daniels, Just Health, p. 122.

50 The possibility that changes in English administrative law could impact courts’ level of scrutiny and medical decision-making had been suggested by Newdick, Who Should We Treat, p. 119; and Stewart, C., “Tragic Choices and the Role of Administrative Law” (2000) 321 BMJ 105 CrossRefGoogle ScholarPubMed.

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57 M. Elliot, “Has the Common Law Duty to Give Reasons Come of Age Yet?” [2011] P.L. 56, at 58; P. Craig, “The Common Law, Reasons and Administrative Justice” [1994] C.L.J. 282.

58 See the 1987, 1994, 2000 and 2006 editions of this document.

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62 Ibid., at p. 69. See also R. v Ministry of Defence, ex parte Smith [1995] EWCA Civ 22.

63 Cambridge Health Authority, ex parte B [1995] 2 All E.R. 129; [1995] 1 W.L.R. 898; see also North and East Devon Health Authority, ex parte Coughlan [2001] Q.B. 213, 93.

64 Barking & Dagenham NHS PCT, ex parte Otley [2007] EWHC 1927.

65 Thanet Clinical Commissioning Groups, ex parte Elizabeth Rose [2014] EWHC 1182, 95.

66 The High Court decision in Secretary of State for Health, ex parte Watts [2003] EWHC 2228 (Adm) can be seen as an exception given the court's individual-centred and rights based approach.

67 Poole, “Tilting at Windmills?”, p. 709.

68 See Amos, “The Second Division”; King, “The Justiciability”, p. 197; Pillay, “Economic and Social Rights Adjudication”. See also Krajewska, “Access of Single Women”, p. 627.

69 See King, “The Justiciability”, p. 199.

70 See Daniels, Just Health, p. 109.

71 Sunkin, M. and Richardson, G., “Judicial Review: Questions of Impact” [1999] P.L. 79 Google Scholar, at 90.

72 See G. Richardson, “Impact Studies in the United Kingdom” in Hertogh and Halliday (eds.), Judicial Review and Bureaucratic Impact, p. 103; P. Cane, “Understanding Judicial Review and Its Impact” and M. Sunkin, “Conceptual Issues in Researching the Impact of Judicial Review on Government Bureaucracies” in the same volume, pp. 15 and 43; Harlow and Rawlings, Law and Administration, pp. 95–96, 713; Pick, K., “The Changing Impact of Judicial Review: The Independent Review Service of the Social Fund” [2001] P.L. 736 Google Scholar, at 760; The Judge Over Your Shoulder.

73 Cambridge Health Authority, ex parte B [1995] 2 All E.R. 129; [1995] 1 W.L.R. 898.

74 Secretary of State for Health, ex parte Pfizer [2002] EWCA Civ 1566.

75 See Sunkin and Richardson, “Judicial Review”. See also J. Barnes, “Courts and Social Policy” (2016) Oxford Research Encyclopedia of Politics, available at <http://politics.oxfordre.com/view/10.1093/acrefore/9780190228637.001.0001/acrefore-9780190228637-e-90> (accessed 20 July 2017).

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77 New and Le Grand, Rationing in the NHS, p. 6.

78 See Klein, R., The New Politics of the NHS: From Creation to Reinvention (Milton Keynes 2006), 213 Google Scholar; Coulter, A., “NICE and CHI: Reducing Variations and Raising Standards” (1999) Health Care UK 1999/2000, 122–23Google Scholar; Klein et al., Managing Scarcity, p. 68; Locock, L., “The Changing Nature of Rationing in the UK National Health System” (2000) 78 Public Administration 91 CrossRefGoogle Scholar.

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82 Klein, The New Politics of the NHS, p. 214; Daniels, Just Health, p. 134; Spiers, J., “The Realities of Health Care Rationing in the NHS” in Spiers, J., The Realities of Rationing: ‘Priority Setting’ in the NHS (IEA Health and Welfare Unit 1999), 5 Google Scholar; Ham, C. and Pickard, S., Tragic Choices in Health Care: The Case of Child B (King's Fund 1998), 33 Google ScholarPubMed.

83 See Sunkin, “Conceptual Issues”, p. 67.

84 Cambridge Health Authority, ex parte B [1995] 2 All E.R. 129; [1995] 1 W.L.R. 898.

85 Ham and Pickard, Tragic Choices, p. 49; Entwistle, V., Watt, I., Bradbury, R. and Pehl, L., “The Media and the Message: How Did the Media Cover the Child B Case” in Marinker, M. (ed.), Sense and Sensibility in Health Care (BMJ 1996)Google Scholar; Barclay, S., Jaymee: The Story of Child B (Viking, 1996)Google Scholar; Price, D., “Lessons for Health Care Rationing from the Case of Child B” (1996) 132 BMJ 167 CrossRefGoogle Scholar, at 167.

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87 Klein, The New Politics of the NHS, p. 78; Mullen and Spurgeon, Priority Setting, p. 3; J. Kneeshaw, “What Does the Public Think about Rationing” in New (ed.), Rationing, p. 58; New and Le Grand, Rationing in the NHS, p. 1; Entwistle et al., “The Media and the Message”.

88 Barclay, Jaymee, pp. 139–40.

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90 Ibid., at p. 30.

91 See Klein, R., “Has the NHS a Future?” (1999) Health Care UK 1999/2000, 1 Google ScholarPubMed.

92 Sheldon, T. and Maynard, A., Rationing in Action (BMJ 1993), 13 Google Scholar; Ham, C., “Tragic Choices in Health Care: Lessons from the Child B Case” in Coulter, A. and Ham, C., The Global Challenge of Health Care Rationing (Open University Press 2000), 113 Google Scholar; Ham and McIver, Contested Decisions, pp. 55–56.

93 Klein, “Defining a Package”, p. 53.

94 The Patient's Progress towards a Better Service (NHS Executive's Value for Money Unit 1994)Google Scholar.

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96 North Derbyshire Health Authority, ex parte Fisher [1997] 8 Med L.R. 327.

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100 Pickard and Sheaff, “Primary Care Groups”, p. 48.

101 Klein, “Defining a Package”, p. 124; New and Le Grand, Rationing in the NHS, p. 12; Lenaghan, “Central Government”, pp. 125–26; Spiers, “The Realities of Health Care Rationing in the NHS”, p. 59.

102 Sheldon and Maynard, Rationing in Action, p. 12; Honigsbaum, F., Holmstrom, S. and Calltorp, J., Making Choices for Health Care (Milton Keynes 1997), 68 Google Scholar.

103 Dewar, S., “Viagra: The Political Management of Rationing” (1999) Health Care UK 1999/2000, 139 Google Scholar; Abbasi, K., “Viagra, Rationed” (1999) 318(7179) B.M.J. 338 CrossRefGoogle ScholarPubMed.

104 Secretary of State for Health, ex parte Pfizer [2002] EWCA Civ 1566.

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106 Dewar, “Viagra”, p. 148. See also J. Appleby, “Appraising NICE Appraisals” in Health Care UK: The King's Fund Review of Health Policy (2000).

107 Department of Health (1997).

108 Department of Health (1998).

109 Department of Health (1997), 3.

110 Coulter, “NICE and CHI”; Klein, R., “Viagra: A Successful Story for Rationing?” (2002) 21 Health Affairs 177 CrossRefGoogle ScholarPubMed, at 182; Syrett, K., “A Technocratic Fix to the ‘Legitimacy Problem’? The Blair Government and Health Care Rationing in the United Kingdom” (2003) 28 J. Health Pol., Pol'y & Law 715 CrossRefGoogle Scholar, at 729.

111 Social Values Judgements: Principles for Development of NICE Guidance, 2nd ed. (NICE 2008), 9 Google ScholarPubMed; see also Guide to the Methods of Technology Appraisal (NICE, 2013)Google ScholarPubMed; NICE Charter (NICE), 2–3.

112 Rawlins, M., “Playing Fair on Treatments” (2012) Health Service Journal S13 Google ScholarPubMed.

113 Social Values Judgements.

114 See Daniels, Just Health; see also Daniels and Sabin, Setting Limits Fairly.

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116 The Evaluation of the Dissemination, Implementation and Impact of NICE Guidance: Final Report (NICE 2004)Google Scholar.

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118 See Klein, R. and Maybin, J., Thinking about Rationing (King's Fund 2012), 9 Google ScholarPubMed; Syrett, “The English National Health Service”.

119 Robinson, S., Dickinson, H., Williams, I., Freeman, T., Rumbold, B. and Spence, K., Setting Priorities in Health: A Study of English Primary Trusts (London 2011)Google Scholar.

120 Ibid., at p. 7.

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122 Ford, A., “The Concept of Exceptionality: A Legal Farce?” (2012) 20 Med.L.Rev. 304 CrossRefGoogle ScholarPubMed; Klein and Maybin, Thinking about Rationing, p. 24; Priority Setting: Managing Individual Funding Requests (NHS Confederation 2008)Google Scholar; Directions to Primary Care Trusts and NHS Trusts Concerning Decisions About Drugs and Other Treatments (NHS 2009)Google Scholar.

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124 Ibid., at pp. 7–8.

125 Defining Guiding Principles for Processes Supporting Local Decision-Making about Medicines (Department of Health 2009)Google Scholar; Supporting Rational Local Decision-Making about Medicines (and Treatments): A Handbook of Practical Guidance (Department of Health 2009)Google Scholar.

126 Directions to Primary Care Trusts. The duties to provide reasons for not funding a health care intervention and to consider exceptional circumstances were also set out in the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 (SI 2012 No. 2996).

127 Newdick, C., “Rebalancing the Rationing Debate: Tackling the Tensions Between Individual and Community Rights” in Nagel, E. and Lauerer, M., Prioritization in Medicine: An International Dialogue (New York 2016), 125 Google Scholar.

128 Some authors argue that this is the role of judicial accountability in issues of resource allocation in health care, see Daniels, N., Charvel, S., Gelpi, A., Porteny, T. and Urrutia, J, “Role of the Courts in the Progressive Realization of the Right to Health: Between the Threat and the Promise of Judicialization in Mexico” (2015) 1 Health Systems & Reform 229 CrossRefGoogle Scholar; Syrett, Law, Legitimacy and the Rationing of Health Care; Syrett, K., “Health Technology Appraisal and the Courts: Accountability for Reasonableness and the Judicial Model of Procedural Justice” (2011) 6 H.E.P.L. 469 Google ScholarPubMed.

129 Sunkin, “Conceptual Issues”, p. 52; Kapiszewski, D. and Taylor, M., “Compliance: Conceptualizing, Measuring, and Explaining Adherence to Judicial Rulings” (2013) 38 Law & Soc. Inquiry 803 CrossRefGoogle Scholar.

130 Short, J., “The Political Turn in American Administrative Law: Power, Rationality and Reasons” (2012) 61 Duke L.J. 1811 Google Scholar; see also Platt, L., Sunkin, M. and Calvo, K., “Judicial Review Litigation as an Incentive to Change in Local Authority Public Services in England and Wales” (2009) 20 Journal of Public Administration Research and Theory 243 CrossRefGoogle Scholar.

131 Mashaw, J., “Bureaucracy, Democracy, and Judicial Review” in Durant, R. (ed.), The Oxford Handbook of American Bureaucracy (Oxford 2010)Google Scholar.

132 See Harlow and Rawlings, Law and Administration, p. 671.

133 See Gallanter, M., “Why the ‘Haves’ Come Out Ahead: Speculations on the Limits of Legal Change” (1974) 9 L. & Soc'y Rev. 95 CrossRefGoogle Scholar.

134 See Ford, “The Concept of Exceptionality”.

135 Ibid., at p. 188; Harlow and Rawlings, Law and Administration, p. 124.

136 See e.g. K. Kieslich and P. Littlejohns, “Does Accountability for Reasonableness Work? A Protocol for a Mixed Methods Study Using an Audit Tool to Evaluate the Decision-Making of Clinical Commissioning Groups in England” (2015) BMJ Open.