Politicians, not doctors, must make the decisions about rationing

EDITOR—Klein acknowledges that rationing is “inescapably a political process,”1 yet he accepts “muddling through,”2 albeit elegantly, as a way out of the dilemma. The practice of muddling through—for which read ad hoc decision making by unelected managers and doctors—is, however, far from elegant. In a paper at the conference to which Klein refers I pointed out that the present fudge has several drawbacks and that NHS managers and doctors should have nothing to do with rationing until elected politicians take firm decisions. (J N Rao, international conference on priorities in healthcare, London, October 1998).

The more successfully we contain rising demand without stoking public unrest the less is the pressure on elected politicians to reconsider the overall resources directed at health care. If politicians took the decisions they would be compelled to view them as part of a wider state policy that included taxation, spending on other services, and new ways of raising revenues.

Managers ration within an arbitrarily defined budget and according to its dictates. Managers in charge of the drug budget may deny a patient an effective treatment; meanwhile, at the same time elsewhere in the district, another budget may be spent on less worthwhile pursuits. This is inherently inefficient.

Health officials are not directly accountable to the population they are supposed to serve. Their main pressure to ration is to balance the books; their chief criterion is simply that public protest must not reach unmanageable levels. The only recourse open to aggrieved members of the public is to seek judicial review—a lengthy …