Introduction

Much recent discussion has revolved around whether the rationing of health care that is occurring within the NHS should be explicit or implicit.1 Many commentators argue in favour of implicit rationing, for a range of reasons. Opinion appears to be divided between those who claim that implicit rationing will (a) be inevitable since there are no clear criteria on which to base explicit rationing, (b) make patients and providers happier, (c) make the administrative and political processes of healthcare provision run more smoothly. I provide reasons for rejecting each of these contentions, arguing instead that explicit rationing is vital for the moral management of health care.

The argument from confused criteria

The creation of an internal market in the NHS appeared to place explicit rationing on the agenda of healthcare providers. Rationing had always occurred within the service but previously it had been camouflaged under clinical judgment. Now purchasers were to draw up plans showing how much was to be allocated to what type of care and why. Providers were to audit clinical staff to ensure that their work conformed to agreed criteria of effectiveness and all was to be open to public scrutiny.

The expected transparency has not occurred. Health authorities have generally not come clean about their inability to meet demand and have awarded block contracts primarily on the basis of past expenditure, with shortfalls shared between existing clinical services. As a result, the realities of rationing within the NHS have remained where they always were–with clinicians making decisions on the basis of varied and conflicting criteria, often dressed in the guise of clinical necessity.2

These developments have led to a weary resignation that any ambition to make rationing explicit within the NHS is hopelessly optimistic. It is argued that there are no clear rules according to which rationing should occur …