Education And Debate

The rationing debate: Central government should have a greater role in rationing decisions – The case for

BMJ 1997; 314 doi: (Published 29 March 1997) Cite this as: BMJ 1997;314:967
  1. Jo Lenaghana
  1. a Institute for Public Policy Research London WC2E 7RA


    Rationing decisions in the NHS have largely been controlled by the medical profession and have tended to be implicit, with little reference to agreed systems or criteria.1 Central government is responsible for deciding how resources for health care are distributed around Britain and sets the legal context, but should it do more and develop a national framework for rationing health care? A recent spate of reports and articles revealing variations in the provision of and access to healthcare services highlight the urgent need to address this question.

    The House of Commons Select Committee on Health surveyed the priority setting practices of 49 health authorities, noting: “We have been struck by the seemingly enormous variation in access across the country.”2 Redmayne revealed that one in six health authorities are now excluding treatments from public provision,3 while a recent survey has shown that couples in Scotland are seven times more likely to get NHS in vitro fertilisation than those in the south west region.4

    Variations in healthcare provision are nothing new, but the purchaser-provider split has made them more explicit, and, more importantly, revealed variations in the criteria used to justify these decisions. For example, in Humberside fertility treatment is provided to women until the age of 40, whereas Liverpool provides it until the age of 35.2 As New and Le Grand have observed, explicit rationing has not been accompanied by an explicit or shared understanding on how such decisions should be made.1

    It has been argued that if the government increased the amount of resources available to the NHS, then this would remove the need to ration. However, this ignores the fact that decisions about whether to provide a treatment are not always determined by financial considerations alone. For instance, the new genetic technologies may …

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