Education And Debate

The limits to demand for health careCommentary: An open debate is not an admission of failure

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7252.40 (Published 01 July 2000) Cite this as: BMJ 2000;321:40

The limits to demand for health care

  1. Stephen Frankel, professor, epidemiology and public health medicine (stephen.frankel@bris.ac.uk),
  2. Shah Ebrahim, professor, epidemiology of ageing,
  3. George Davey Smith, professor, clinical epidemiology
  1. Department of Social Medicine, University of Bristol, Bristol BS8 2PR
  2. 9 Countess Road, London NW5 2NS
  1. Correspondence to: S Frankel
  • Accepted 8 June 2000

There are a number of historical, political, and economic explanations for the tradition of underinvestment in the NHS, but one insidious disincentive will provide a continuing brake on expansion. This is the expectation that in a publicly funded healthcare system any increase in expenditure will be followed only by further failure, although at an increased cost. Further, the imbalance between demand and supply is assumed to be deteriorating as the population ages, new technologies appear, and expectations rise.1 This orthodoxy has become so pronounced that questioning the linkage between particular aspects of failure in healthcare delivery and an overarching mismatch between supply and demand can be dismissed as an idealistic act of denial.

These problems are most commonly discussed in the idiom of rationing. In rationing the concern is to curtail access to health care through measures that may be, according to the perspective of the commentator, most likely to enhance effectiveness; be efficient, equitable, ethical, or beneficial to the independent sector; or be politically feasible. The rationing debate came to the fore during a period of recession, so that “choices” in health care involved choosing to offer less. The conventional, but implausible, insistence that the term rationing has a neutral meaning will be tested in the welcome new circumstance in which healthcare expenditure in the United Kingdom is set to expand substantially. But what are the grounds for the view that legitimate demand in most areas of provision must exceed realisable supply?

Summary points

The rationing debate has been conducted almost exclusively through assertion and political analysis

Conventional assumptions of an imbalance between demand and supply are not supported by evidence

Pessimism about adverse future trends in demand arising from an ageing population, the costs of innovation, and rising public expectations are similarly unsupported by good evidence

Many perceived deficiencies …

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