Review

The return of the ration book

Research Paper 6: Priority setting in purchasing
Research Paper 8: Rationing dilemmas in health care
National Association of Health Authorities and Trusts, 1993

Talk of rationing - or ‘priority setting’, as we are encouraged to call it by Mrs B - is all the rage in health policy circles. That this should be at a time when the green shoots of recovery have yet to distinguish themselves from weeds, and when ministers are coming to regard parts of the welfare state as a luxury they prefer us not to afford, is unsurprising.

It seems that the arguments for the necessity of rationing - that is, sharing out scarce resources when demand exceeds supply - have been won, except in the public rhetoric of opposition politicians, and the debate now centres on the appropriate and most legitimate method to do it.

These two ‘research papers’ from NAHAT, written primarily as digestible reviews for health authority members and senior managers, examine this knotty area of policy from differing perspectives, and the contrast between the two is instructive.

The first, Priority setting in purchasing, is written by health economists from the Health Economics Research Unit in Aberdeen. It offers a quick and lucid introduction to the key concepts in health economics: efficiency, equity, the margin, cost-utility analysis and the like. In a heretical section on needs assessment, the authors argue that, as currently practised, assessing needs is of no help in prioritising health service spending and is little more than a waste of time.

Overall, the health economists make rationing appear easy, clean and, if not positively attractive, at least uncontentious. What is remarkable is their political and practical naivety; indeed, health economists always come across as innocents abroad.

The second report, Rationing dilemmas in healthcare, is the more sceptical and wordly-wise of the pair. Written by Professor David Hunter of the Nuffield Institute in Leeds, it faces up squarely to the reality that rationing, by its nature, will always be not a technical but a political process. The questions at issue are the traditional ones of political philosophy: legitimacy, power, representation and the limits of democracy.

Hunter reviews briefly the history of implicit rationing of NHS care by doctors, the Oregon experience and the pitfalls of transplanting the American experience to the UK. He examines attempts to involve ‘the public’ in decisions about health care provision - attempts which too often appear to substitute for any real local democracy in health care.

Hunter questions whether the much-heralded shift to explicit rationing is really such an improvement on the past. As he points out, even the best of systems designed to encourage overt rationality leave plenty of scope for the players, each following their own economic interests, to adopt covert strategies which ‘work the system’ to their advantage.

‘We should resist abandoning an admittedly imperfect though workable irrationality in favour of a spurious and possibly risky rationality’, says the pragmatic Hunter, keeping his feet firmly on the ground.