Education And Debate

The case against

BMJ 1997; 314 doi: (Published 15 February 1997) Cite this as: BMJ 1997;314:503
  1. Rudolf Klein, professorial fellowa
  1. a King's Fund Policy Institute London W1M 0AN


    Traditionally the National Health Service has relied on implicit rationing by clinicians within budgetary constraints set by central government. Neither the founding fathers, nor any of their successors, defined the scope and limits of the NHS's responsibilities. The statutory responsibility of ministers of health is to provide an “adequate” service. But the frontiers of adequacy have never been defined, and the courts have resolutely refused to rule on what should be provided to whom. The package of health care offered has thus varied, in terms of its composition and its generosity, both over time and geographically. It is for individual health authorities to decide what package of healthcare services to provide for their populations and for individual clinicians to decide between the competing claims on the resources available to them.1

    Unsatisfactory state of affairs

    In many ways this is an unsatisfactory state of affairs and not surprisingly has increasingly come under challenge. There are two main grounds for criticism. Firstly, the present situation allows ministers to duck responsibility for the consequences of their decisions when setting the NHS's budget. If “adequacy” remains an elastic and fuzzy notion, there is no way of establishing whether the budget is sufficient to meet the NHS's commitments. Without any definition of what those commitments are in the first place, the debate about whether or not the NHS is “underfunded” becomes a meaningless dialogue of the deaf and accountability is fudged. Secondly, the lack of any defined package means that in practice there can be no equity, if by equity is meant that everyone should have the same opportunity of treatment for any given degree of need for a particular healthcare intervention. A considerable degree of arbitrariness remains in the chances of getting treated in the NHS: even if equity were achieved in terms of ensuring that all …

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