BMJ  2007;334:1068-1069 (26 May), doi:10.1136/bmj.39218.599109.80

Editorials

Rationing in the NHS

The BMA asks the right questions but answering them will be difficult

Over the past two decades or so rationing has been debated more than almost any other area of health policy. However, the debate has been punctuated by periods of relative silence when policy makers have been reluctant to tackle the key problems. The past few years have been one such period as new money appeared to have flushed away old concerns. Now, however, those concerns are back, underlined by the hectic race to balance the National Health Service's books and the realisation that the days of rapid growth in its budget are almost over.

A new factor is adding to these concerns. If in the past the NHS was a model of economy, it was partly because no one had an incentive to maximise activity. But as the new model NHS emerges, payment by results to hospital providers will provide such an incentive. As the NHS inevitably becomes a demand generating machine, so the challenge of accommodating competing demands within a constrained budget will become more acute.

The BMA has therefore rightly made rationing one of the themes of its report on the future of the NHS, published on 8 May 2007.¹ The main point of the report is the need to separate national politics from the everyday running of the NHS. The report recognises that "priority setting and, hence, rationing is inevitable," as it is in all healthcare systems. But if hard choices are inevitable, how are they to be made? The BMA's report suggests a double headed strategy. Parliament "informed by expert professional and public opinion" would determine the "core services" that should be available nationally, and set priorities for the whole NHS. Local health economies, however, would then decide what additional services should be provided from within their budgets.

It appears to be a neat formula. But is it realistic? The report recognises that decisions about who should get what involve social and political choices, as well as professional expertise. However, it also proposes machinery for protecting the NHS from day to day politics, with an independent board accountable to parliament and a much diminished role for the Department of Health. It is not likely that we can have it both ways. If decisions about resources are inevitably political, can the NHS really be protected? Putting parliament centre stage would complicate rather than solve the dilemma. It presumes a constitutional revolution. The House of Commons is a decision reviewing body, not a decision making one. Giving it responsibility for defining core services would imply a new relation between executive and legislature.

But assuming that there are no major institutional changes, and that the Department of Health retains at least a strategic role, the notion of core services—that is, identifying both entitlements and exclusions—remains highly contestable. Many countries have tried to define the menu of entitlements, but in practice excluded services have tended to creep in by the back door.^{2 3} More troubling still, the concept of a core service is flexible as it does not necessarily imply a particular level or depth of service; for example, staffing ratios, drug budgets, or the number of diagnostic tests. No doubt some of these can be specified in national service frameworks, but only at the risk of reducing scope for the local professionally led initiatives that the BMA proposals are designed to encourage.

So we come to the second leg of the BMA's strategy—giving more freedom to local health economies. This is a welcome recognition of the central role of primary care trusts. Many trusts have set up the machinery for prioritising competing claims on resources, deciding what drugs are to be prescribed, and scrutinising referrals.^{4 5} Their methods for doing so vary, as do the decisions taken. Furthermore, we know that there are large unexplained variations in what different primary care trusts spend on particular services, such as cancer and mental health.⁶ So we come to some crucial questions. When does local discretion become postcode rationing? If central prescription is at odds with local priorities—as in the case of some National Institute for Health and Clinical Excellence recommendations⁷—which should prevail?

The answers to such questions will largely depend, as the BMA recognises, on the perceived legitimacy of local bodies. For it is at the local level, if anywhere, that there is a democratic deficit in the NHS. Hence the BMA's proposal for elected local health councils. The notion may sound appealing, but it risks compounding the confusion of accountabilities in the NHS. Elected governors of foundation trusts are still in search of a role⁸ and local authority committees are flexing their muscles,⁹ all on top of a raft of patient involvement initiatives. The danger is that the NHS may become caught in a web of mechanisms, none of which is effective but all of which clog up policy and practice processes. Moreover, the question remains of how to make individual clinicians—who take crucial decisions about whom to treat and how—accountable for the decisions they make¹⁰ without inhibiting professional discretion and introducing an extra layer of regulatory bureaucracy.

Whatever the reservations about the details of the BMA proposals, they have breathed fresh life and new ideas into an old debate in danger of going stale. Although the proposals can be criticised, it should be recognised that they pose an urgent challenge.

London School of Economics, London WC2A 1AE

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. British Medical Association. A rational way forward for the NHS in England: a discussion paper outlining an alternative approach to health reform. London: BMA, 2007. www.bma.org.uk/ap.nsf/Content/rationalwayforward
2. Ham C, Coulter A. Conclusion: where are we now? In: Coulter A, Ham C, eds. The global challenge of health care rationing. Buckingham: Open University Press, 2000: 233-50.
3. Jacobs LR, Marmor T, Oberlander J. The political paradox of rationing: the case of the Oregon health plan. Cambridge, MA: John F Kennedy School of Government, Harvard University, 1998: occasional paper 5-98.
4. Iqbal Z, Pryce A, Afza M. Rationalizing rationing in health care: experience of two primary care trusts. J Public Health 2006;28:125-32.[CrossRef]
5. Wilson E, Sussex J, Macleod C, Fordham R. Prioritizing health technologies in a primary care trust. J Health Serv Res Policy 2007;12:80-5.[Abstract/Free Full Text]
6. King's Fund. Local variations in NHS spending priorities. London: King's Fund, 2006. www.kingsfund.org.uk/resources/briefings/local_variations.html
7. Wells J, Cheong-Leen C. NICE appraisals should be everybody's business. BMJ 2007;334:936-8.[Free Full Text]
8. Day P, Klein R. Governance of foundation trusts. London: Nuffield Trust, 2005. www.nuffieldtrust.org.uk/ecomm/files/100605governance.pdf
9. Day P, Klein R. The politics of scrutiny. London: Nuffield Trust, 2007.
10. Daniels N. Accountability for reasonableness: establishing a fair process for priority setting is easier than agreeing on principles. BMJ 2000;321:1300-1.[Free Full Text]

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Rapid Responses:

Read all Rapid Responses

Is rationing the issue?

stephen black
bmj.com, 25 May 2007 [Full text]

Re: Is rationing the issue?

LS Lewis
bmj.com, 27 May 2007 [Full text]

Well said Stephen Black

steven allder
bmj.com, 27 May 2007 [Full text]

Quality rather than feasibility alone should drive local service redisgn

Kiran CR Patel
bmj.com, 27 May 2007 [Full text]

The limits of rationalism in health care

Robert G Royce
bmj.com, 26 Jun 2007 [Full text]

Rational behaviour is not impossible in health, just uncommon

stephen black
bmj.com, 27 Jun 2007 [Full text]

Doubts remain

Robert G Royce
bmj.com, 13 Jul 2007 [Full text]