Intended for healthcare professionals

Education And Debate

The rationing debate: Defining a package of healthcare services the NHS is responsible for The case for

BMJ 1997; 314 doi: (Published 15 February 1997) Cite this as: BMJ 1997;314:498
  1. Bill Newa, senior research officer
  1. a King's Fund Policy Institute London W1M 0AN


    The use of tattoo removal as an example of NHS rationing is now so common that it is in danger of trivialising an important debate. Behind such questions as “Should the NHS be devoting resources to tattoo removal?” lies a more fundamental issue: what kinds of benefit should the NHS provide?

    Most readers will assume that defining a healthcare “package” is a means of rationing healthcare resources. In other words, faced with the task of managing the limited NHS budget one option is to exclude some services altogether. But my case rests on a different interpretation of a package and involves asking a preliminary question. Before deciding how to ration, we need to know what to ration: What is the range of services relevant to the role of the NHS? What “business” is the NHS in? Is it the NHS's job to provide fertility treatment, physiotherapy for sports injuries, long term nursing care, gender reassignment, adult dentistry, and cosmetic surgery? Or should these services be provided by local authorities, voluntary agencies, or the private sector? The question does not rely on clinical judgment. It is about the boundary of a public institution's responsibilities. And it is a question which has been muddled up with issues of rationing proper.

    Defining the boundaries

    The need to address this question derives from a growing sense of confusion and uncertainty about what it is reasonable to expect from the NHS. For example, where one lives can have a decisive effect on whether or not NHS treatment is available. The 1991 NHS reforms were an important catalyst in this process: purchasing authorities now concentrate on commissioning health care for their resident populations, rather than on management issues. Wishing to be seen to be making the best use of financial allocations, some took the view that certain services were …

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