Abstract

Rationing health care is not new. As governments world wide struggle to contain the costs of health care, health policy analysts debate how rationing should be done. However, they too often neglect how the mechanisms for funding and allocating health care resources are themselves vehicles for rationing treatment. In the UK, where health care rationing debates currently abound, there has been no formal evaluation of the role of the market in allocating scarce health care resources.The market in health care has increased administration, fragmented services, eroded local accountability, and decreased choice.This fragmentation, and the associated competition between purchasers and providers, means that resource allocation can no longer be monitored and evaluated in a national context. The loss of a population focus has left a vacuum in planning. Services cannot be planned rationally, and so are not able consistently to avoid duplication or to respond cogently to estimates of need.The loss of accountability means that decisions about the allocation of health care resources are no longer open to scrutiny by local people. Increasingly, especially in social and long term care the cost of care is being transferred to the individual. The new mechanisms for resource allocation are distributing resources unfairly: away from the poor, the sick and the elderly.The great myth of the market is that it has enabled decision-making to become explicit. This is not the case. To make health care resource allocation appear rational and acceptable to the public, health authorities have resorted to exercises in consumer consultation, and value laden guidelines where clinical cloaks are used to disguise political decisions on funding. In the UK, until the true role of the internal market is acknowledged, myths and subterfuge will conceal the winners and losers in the new system of rationing health care