Intended for healthcare professionals


“No decisions about us without us”? Individual healthcare rationing in a fiscal ice age

BMJ 2011; 342 doi: (Published 13 June 2011) Cite this as: BMJ 2011;342:d3279
  1. Jill Russell, senior lecturer1,
  2. Trisha Greenhalgh, professor of primary healthcare 1,
  3. Andrew Burnett, director for public health2,
  4. Jonathan Montgomery, professor of healthcare law3
  1. 1Centre for Health Sciences, Blizard Institute, Barts and The London School of Medicine and Dentistry, London E1 2AT, UK
  2. 2NHS Barnet, London, UK
  3. 3University of Southampton, Southampton, UK
  1. Correspondence to: J Russell j.russell{at}
  • Accepted 22 May 2011

Jill Russell and colleagues examine whether patients and the public should be involved in rationing decisions about individual patient access to healthcare interventions

Healthcare rationing is high on the political and public agenda in the United Kingdom. The English National Health Service (NHS) is undergoing major restructuring aimed at improving efficiency. From 2013, responsibility for commissioning NHS services look set to shift from primary care trusts (PCTs) to general practitioner (GP) commissioning consortiums, which will also take over funding decisions on new clinical interventions from the National Institute for Health and Clinical Excellence (NICE). The coalition government’s comprehensive spending review (which demands savings of £20bn (€23bn; $32bn) over four years will take the NHS into a “fiscal ice age.”1 Patient and public involvement in decision making remains a central part of the NHS mission and is a statutory responsibility for commissioners of NHS care.2 However, although patient and public participation in national and local decisions is widely accepted, there is a lack of consensus on whether and how they should be involved in rationing decisions at the individual level,3 and uncertainty about what involvement means in practice.

Tough decisions about individual treatments

Rationing decisions involve hard choices. A particularly tough subset of decisions comprise individual funding requests (IFRs) for NHS services which fall outside agreed contracts between local commissioning bodies and healthcare providers (table). These requests are to fund an investigation or treatment as a one-off for a particular patient even though it is not routinely funded by the NHS. The request is submitted by the patient’s doctor (consultant or general practitioner) and is usually considered by a panel comprising PCT staff, local clinicians, and (sometimes) lay people or their advocates. Some requests (such as those for cancer or loss of vision) attract substantial media attention, often articulated in the language …

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