Priorities and rationing: pragmatism or principles?

Time for Britain to follow the Netherlands, New Zealand, and Sweden's lead and get serious

There is always the danger of assuming that the NHS's problems are unique: that they reflect either the special characteristics of Britain's health care system or the government's niggardliness in funding it. The issue of priority setting--or, more emotively, rationing--is a case in point. This is not some peculiar British obsession. All health care systems have to grapple with the problem of how best to allocate scarce resources. The real difference is between how different health care systems have tried to address this issue: between those countries that, like Britain, tend to diffuse responsibility and those that have sought to develop a national framework for the decisions of health authorities and clinicians.

Britain's Department of Health issues an annual set of priorities, but these are largely a shopping list reflecting the department's current concerns. In contrast, other countries have sought to develop explicit criteria for guiding decisions about allocating resources. While Britain relies (as usual) on pragmatic incrementalism, with policy emerging almost as a byproduct of individual decisions, others have sought to devise a set of principles designed to shape those individual decisions. So which is the right way forward? Should policy be guided by pragmatism or principle? And, in making this choice, what can be learnt from other countries?

In trying to answer these questions we can now draw on the experience of three attempts by governments to devise national criteria for priority setting. In 1992 the Dutch government's Committee on Choices in Health Care produced what has since become known as the Dunning report, named after its chairman.1 The same year …