Chapter 77 Setting priorities and rationing

The medical profession often has to prioritize treatment and ration services at a patient level. Any practising doctor can tell a personal story of having to choose between patients because resources are limited – whether staff, money, theatres or organ donors.

Rationing of health care has always taken place, however wealthy the country, but until recently it was done implicitly and was often invisible and inequitable (see pp. 150–151). As spending on health services has increased in most countries, discussion about priorities and rationing has become more explicit. Thus, the question is not, ‘Will we have rationing?’, but ‘How will we organize rationing?’ (Box 1).

Box 1

1. A BBC survey suggests that a quarter of local health groups in England are asking patients to wait longer for hospital care to bring down NHS deficits.

2. Family doctors have been told they cannot send patients to hospital for a long list of treatments for non-urgent conditions for the last 3 months of the financial year. These include in vitro fertilization (IVF), vasectomies, varicose vein treatment, wisdom teeth and other minor operations.

This story from the BBC (9 February 2007) illustrates two typical ways of rationing in the UK: (1) increased waiting time for funded treatments; and (2) not funding selected treatments.

Setting priorities

Setting priorities implies choosing a limited number of options from a wider range and ranking these in order of importance. Following on from priority-setting is a process of rationing. Rationing is often defined as allocating scarce resources by some criteria other than the price mechanism. This does not mean that the price is not an important consideration, but that the price (or cost, which may not be the same as price) of a service, say a hip replacement, is not the only factor in the decision whether or not a patient who is in need of such surgery will receive treatment. Priority-setting is a dynamic process, and in every budget cycle new technologies and information on health outcomes are taken into consideration in setting new priorities.

Forms of rationing

Rationing is a trade-off between providing all services to a limited number of people and providing a limited number of services to all people. Rationing often involves a limitation of both the range and the volume of service provision (Box 2). Decisions regarding rationing also have to be made at different levels: at an individual, local/regional and national level.

Box 2

Neonatal care may become too expensive: Doctors at Sheffield’s main maternity unit have been told that if demand for neonatal services continues to rise an ‘arbitrary ban’ may have to be introduced according to Panorama, a British television documentary programme. This could mean that babies born more than 15 weeks prematurely could be refused treatment.

This cutting from the British Medical Journal (1994; 309: 282) highlights limited availability of resources and the ever-growing demand for medical services.

A variety of rationing mechanisms have been identified (Klein et al., 1996):