The changing nature of rationing in the UK national health service

This paper presents findings from empirical research exploring recent developments in healthcare rationing in the UK, and how far these were influenced by the National Health Service (NHS) internal market. Results suggest explicit rationing has continued to spread, but the focus has shifted from exclusions of whole treatments from NHS provision towards a reconciliation of implicit and explicit approaches. There is growing interest in explicit criteria to guide decision making, within which clinicians exercise discretion in individual cases. The market contributed to the growth in explicit rationing, notably by decoupling healthcare purchasers (health authorities and GP fundholders) and providers (hospital and community health services) from their previously shared responsibility to manage resources. However, other factors have been influential, especially concern to control rising expenditure. Having originally prompted more explicit decisions (especially exclusions), resource pressures are now rekindling interest in fixed provider budgets and implicit clinical decision making. The paper concludes by considering the implications for rationing of proposals to abolish the NHS internal market.