Rationing in UK health care – signal or noise?

The NHS in England appears to be rationing access to vital non-emergency hospital care, a review suggests.

This was the rather weaselly BBC headline last Friday. It referred to a report from Dr Foster Intelligence which appears to be a trading arm of Imperial College London.

The analysis alleged that the number of operations in three categories (cataract, knee and hip) had risen steadily between 2002 and 2008 but then “plateaued”. As evidence for this the BBC reproduced the following chart.


Dr Foster Intelligence apparently argued that, as the UK population had continued to age since 2008, a “plateau” in the number of such operations must be evidence of “rationing”. Otherwise the rising trend would have continued. I find myself using a lot of quotes when I try to follow the BBC’s “data journalism”.

Unfortunately, I was unable to find the report or the raw data on the Dr Foster Intelligence website. It could be that my search skills are limited but I think I am fairly typical of the sort of people who might be interested in this. I would be very happy if somebody pointed me to the report and data. If I try to interpret the BBC’s journalism, the argument goes something like this.

  1. The rise in cataract, knee and hip operations has “plateaued”.
  2. Need for such operations has not plateaued.
  3. That is evidence of a decreased tendency to perform such operations when needed.
  4. Such a decreased tendency is because of “rationing”.

Now there are a lot of unanswered questions and unsupported assertions behind 2, 3 and 4 but I want to focus on 1. What the researchers say is that the experience base showed a steady rise in operations but that ceased some time around 2008. In other words, since 2008 there has been a signal that something has changed over the historical data.

Signals are seldom straightforward to spot. As Nate Silver emphasises, signals need to be contrasted with, and understood in the context of, noise, the irregular variation that is common to the whole of the historical data. The problem with common cause variation is that it can lead us to be, as Nassim Taleb puts it, fooled by randomness.

Unfortunately, without the data, I cannot test this out on a process behaviour chart. Can I be persuaded that this data represents an increasing trend then a signal of a “plateau”?

The first question is whether there is a signal of a trend at all. I suspect that in this case there is if the data is plotted on a process behaviour chart. The next question is whether there is any variation in the slope of that trend. One simple approach to this is to fit a linear regression line through the data and put the residuals on a process behaviour chart. Only if there is a signal on the residuals chart is an inference of a “plateau” left open. Looking at the data my suspicion is that there would be no such signal.

More complex analyses are possible. One possibility would be to adjust the number of operations by a measure of population age then look at the stability and predictability of those numbers. However, I see no evidence of that analysis either.

I think that where anybody claims to have detected a signal, the legal maxim should prevail: He who asserts must prove. I see no evidence in the chart alone to support the assertion of a rising trend followed by a “plateau”.


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