Given the unprecedented financial pressures on the NHS, difficult decisions have to be made about how to allocate and use resources. It is important to be clear about the different rationing strategies employed and the various, often conflicting criteria used when judging the acceptability or otherwise of the decisions taken.
Thinking about rationing provides a guide to the practicalities and controversies surrounding the issue and identifies what is known about how it works in practice. It offers examples and illustrations, drawing on the available evidence and conversations with clinicians and managers.
Rationing can take various forms:
rationing by denial, when specific treatments are denied to patients on the grounds of lack of effectiveness, high cost or a combination of the two
rationing by selection, where service providers select those patients who are most likely to benefit from interventions or raise the threshold of eligibility for treatment
rationing by delay, where access to the system is controlled
rationing by deterrence, when barriers are put up by, for example, by limiting information about a service
rationing by deflection, when 'difficult cases' are referred to another hospital or specialist
rationing by dilution, where services are offered but with, for example, fewer staff.
Contrasting principles can be invoked to justify rationing. On the one hand, there is the utilitarian principle of maximising the health of the population. On the other hand there are ethical principles centred on the characteristics of individual patients. The tension between these two approaches lies at the heart of many of the controversies about rationing.
This paper seeks to put complex concepts in plain language, and thus to create greater understanding of the issues.