Five: Priority setting in health systems

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A recurring policy dilemma for health systems concerns the rationing of health care, or, as some prefer to call it, priority setting. The discourse here is about the extent to which rationing health care should (or can) be explicit or whether the implications of this are too painful to contemplate, which makes implicit rationing a more attractive option. This chapter reviews the arguments on both sides. These continue to preoccupy commentators. Taking issue with Mechanic’s (1995) argument that explicit approaches to rationing are ‘too damaging to public and patient trust in services’, and one with which this author has much sympathy (Hunter 1997), Williams and colleagues are convinced that implicit rationing is both ‘ethically and politically unacceptable.’ They proceed from the assumption that ‘explicit priority setting is a legitimate and necessary feature of contemporary policy and practice in health care’ (Williams et al 2012: 125). For their part, Light and Hughes consider that critics of explicit rationing make important points about the limitations of formal attempts at rationing but that implicit rationing can cover up poor professional practice and quality of care. They favour a solution that ‘lies in re-conceptualising professionalism around accountability rather than autonomy’, thereby ensuring that ‘the use of power in both explicit and implicit rationing are subject to transparent review’ (Light and Hughes 2002: 12). They also make a plea for a sociological perspective to counter-balance and challenge the dominant economic view with its tendency to frame the issues ‘in a narrow and misleading way’ (Light and Hughes 2002: 17) and ‘set up an over-blunt dichotomy between treatment and denial, when what is at issue is more nuanced and uncertain’ (Light and Hughes 2002: 15).

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