Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices

Rationing health care in publicly funded health care systems is becoming more challenging because of the growing gap between the possibility of effective medical intervention and limited resources. This poses both an economic challenge and a political puzzle. On the basis of experience in those systems that have adopted a systematic approach to rationing, it can be suggested that the dilemmas involved should be addressed by strengthening both the information base to support decisions and the institutional framework in which decisions are taken. The contribution both of experts and of lay people is needed to inform decision-making, and the processes adopted need to allow for this as well as being transparent and accountable. In practice, rationing is likely to combine explicit and implicit decision-making and to result in the exclusion of services at the margins and the development of guidelines in the mainstream. The politics of rationing may favour muddling through and the evasion of responsibility but this will be difficult to sustain in an environment in which public awareness of decision-making in health care is growing.

Hospital admissions. Just the ticket

Pilot schemes for direct booking of hospital appointments have won support from the consultants involved. Skilled leadership has been crucial to managing changes that enable direct booking to be put into practice. The nursing role is central to the system, particularly in pre-operative assessment clinics. For direct booking to become widespread, management of all acute hospital resources will have to be reviewed.

The third way in health care reform: does the emperor have any clothes?

The Labour government elected in the UK in May 1997 has described its approach to the National Health Service (NHS) as a third way in health care reform. This article seeks to analyse the defining features of the third way. It argues that the government has adopted an approach which combines central direction and local autonomy, sanctions and incentives, and planning and competition. The third way therefore entails a cocktail of different approaches and is both electic and pragmatic. In pursuing this policy, the government is seeking to deal with dilemmas that are as old as the NHS itself and is seeking a synthesis between approaches that in the past have been seen as exclusive. It can be argued that the search for a synthesis is unlikely to succeed and the government will have to decide whether it is really committed to a centralised health service in which the main emphasis is on planning and sanctions or whether it is willing genuinely to devolve power to a local level with reliance on incentives and elements of competition. The alternative interpretation is that by making use of a variety of instruments the government is increasing its chances of delivering its objectives. From this perspective, to insist on absolute consistency is to fail to recognise the complexity of the steering mechanisms required in modern public services. In the international context, the third way may find favour as a rhetorical device among politicians seeking to carve out a distinctive niche in the political market place, but its specific characteristics are likely to vary between systems.

The primary healthcare/hospital interface

In this paper, the author attempts to review the changing relationship between primary care and hospital care. In doing so, he draws on recent experience in the UK which has sought to strengthen the role of primary care services. This has centred on a new employment contract for general practitioners (GPs) and the introduction of the GP fundholding scheme. Both reforms represent a radical change from past practice and illustrate both the opportunities and the risks involved in introducing new financial arrangements in the primary care sector. Not only does he comment on UK experience, but he also make brief references to broader trends in health services reform in various other countries, giving the speech a truly international dimension.

Priority setting in health care: learning from international experience

Priority setting in health care is not new but it is an issue of growing importance. In publicly financed health care systems, the combination of constrained resources and increasing demands has led policy makers to address this issue more directly than in the past. This is exemplified by experience in Oregon, the Netherlands, New Zealand, Sweden and the UK. In each of these systems, policy makers have taken the initiative to set priorities on a more explicit basis. This paper compares and contrasts experience in these systems and identifies a number of emerging themes. The work done so far can be likened to an exercise in policy learning in which policy makers have tried out a range of approaches and have adjusted course several times in the process. Priority setting is not amenable to once and for all solutions and the issues involved must be kept under continuous review.

Managed markets in health care: the UK experiment

The reforms to the United Kingdom national health service initiated in 1989 have unlocked established relationships. Health care providers have come under challenge from an alliance of purchasers and general practitioners. This is resulting in a major rationalisation of acute hospital services in cities such as London. The general practitioner fundholding scheme appears to have produced benefits for patients, although its impact in the longer term remains uncertain. The combination of population based and patient focused models of purchasing within the reforms has created competition between purchasers as well as providers. This has served as a stimulus to purchasers to act as effective agents for patients but it also creates a risk of fragmentation. This paper analyses these developments and draws out their implications for the future of the National Health Service.

International models of managed care

Outside North America health care resources are raised in two main ways: (1) taxation (the Beveridge model) and (2) compulsory social insurance (the Bismarck model). In practice, most European countries rely on a mixture of the two. The author examines the degree to which recent reforms have promoted divergence or convergence of the North American and European systems.