Purchasing in the British NHS: does contracting mean explicit rationing?

Abstract

Early commentators on the British NHS reforms argued that the new requirements for health authorities to carry out formal assessments of the health needs of their local populations and contract for clinical services, would force them to be clear about what they purchased and did not purchase. It was predicted that implicit rationing by doctors would give way to explicit rationing by health authorities. Apart from the rationing question per se, there were suggestions that contracts might be used to channel resources towards clinically effective treatments and exclude treatments that are of little benefit. This article draws on a qualitative study of the work of a health authority contracting team to suggest that the picture is more complex. We argue that, rather than occasioning a shift to explicit rationing, contracting has resulted in new forms of implicit rationing. In this connection we discuss: (a) the authorization of ‘extra-contractual referrals’– cases not covered by contracts; (b) health authority pressure on hospitals to limit activity where they seem likely to exceed contracted activity levels; and (c) the impact of the UK Government's Patient's Charter initiative, which sometimes diverts resources to achieve waiting times guarantees at the expense of other clinically urgent cases.