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Introduction
Since 1996, the BMJ has published a series of articles about the nature of rationing in health care, several by the Rationing Agenda Group, an influential group of policy advisers. 1 This brief essay will question some of their arguments and then suggest that the real ethics of rationing should first address the sociological and managerial forms of inequality, power, and privilege upstream that force rationing downstream at the point where doctors treat patients.
There is a strange kind of schizophrenia in the arguments about rationing. One part holds that funding for the NHS is adequate and likely to be so for the foreseeable future 2 ; another holds that rationing takes place in the NHS and always will, because rationing is inevitable. 3 Yet these two central themes of policy are not joined. Surely the amount and kind of rationing, affects perceptions of the adequacy of funding. If it does not, then "rationing is inevitable" can be a paternalistic justification for playing Scrooge. It can justify as low a level of funding and supply of doctors and nurses as those in power want. If we conclude from the start that we can never adequately meet all needs, why bother trying to meet them as inadequately as we do already? Why not cut the NHS budget by 10% or 20%?
"NHS funding is fine"
If we examine the funding article 2 of the Rationing Agenda Group 3 more closely, we learn that the extra burdens of aging fall within the projected growth of real NHS expenditures and that changes of morbidity will neither accelerate nor retard expenditures. The authors show that so called efficiency and activity gains are increasing faster than expenditures. Expectations may change, but they are subjective, political, cultural, and impossible to predict; so on balance NHS funding is likely to be adequate for years to come.
Summary points
One part of the rationing debate maintains that NHS funding is adequate by ignoring how much rationing takes place, and another part holds that rationing is inevitable; surely the latter affects judgment of the former
Our goal should be to minimise the need to ration by eliminating ways that entrenched institutional, political, and professional interests lock in waste, not to figure out how...