Education And Debate

The case against

BMJ 1997; 314 doi: (Published 12 April 1997) Cite this as: BMJ 1997;314:1118
  1. Joanna Coast, lecturer in health economicsa
  1. a Department of Social Medicine, University of Bristol, Bristol BS8 2PR,


    This paper must begin with some definitions. Implicit rationing of health care occurs when care is limited and where neither decisions about which forms of care are provided or the bases for those decisions are clearly expressed.1 Hence it is the unacknowledged limitation of care. Explicit rationing is, unsurprisingly, the opposite: decisions about the provision of health care are clear, as are the reasons for those decisions. Nevertheless, the term explicit has been used in various ways, from Klein's version of explicit rationing as rationing by exclusion2, to a more general concern with honesty and openness surrounding the context of healthcare rationing.3

    Both types of rationing decision can be made at different levels. Various taxonomies have been used, but this paper will assume four distinct levels of priority setting: across whole services; within services but across treatments; within treatments; and between individual patients.1 It is at the last level, particularly, that explicit rationing may be most troublesome.

    Currently, rationing in the United Kingdom at all levels is predominantly implicit.4 5 It is carried out by doctors who are aware of the resources available and who ration by telling patients that they cannot help them, rather than explicitly stating that resources are not available.4 6 7 8 9 The denial of care is instead made to seem optimal or routine.4 10 Hence there is little sense among the public that healthcare rationing takes place on a daily basis. Indeed, on those occasions when explicit rationing is perceived (particularly at the level of the individual patient)–for example, in the case of child B11 12–there tends to be public outcry about the introduction of rationing.

    The proposition put forward, that rationing should be made explicit at all levels of NHS decision making is …

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