Explicit rationing within the NHS quasi-market: the experience of health authority purchasers, 1996-97

Abstract

This thesis analyses the findings of empirical research carried out in three case study UK health authorities in 1996-97, using repeat interviewing of senior managers. It aimed to test three competing hypotheses: i. Markets are one possible system for allocating scarce resources. The process of contract specification in a complex quasi-market is likely to make rationing more explicit than it would be in a hierarchical system ii. In the complex context of the NHS the quasi-market may fail to produce clear contracts and unambiguous allocations, because of prohibitive transaction costs, political costs and ethical costs of greater explicitness iii. Other pressures in favour of explicitness (e.g. rising expenditure, effectiveness evidence and the Patient's Charter) may be irresistible, whatever structural form the NHS takes. The complex relationship between explicit rationing, the internal market and other factors is discussed. Results suggest the quasi-market has contributed to the growth in explicit rationing, notably by decoupling purchasers and providers from their previously shared responsibility to manage resources. In other respects the market has speeded up or magnified the effect of other factors which would or could have happened anyway. Concern to control rising expenditure has led to more explicit decisions but is now rekindling interest in the value of fixed budgets for providers and implicit clinical decision-making. Factors such as the Patient's Charter have also had an independent effect on greater explicitness. Implicit rationing remains significant. The implications for health care rationing of government proposals to abolish the internal market are examined. The results suggest that explicit rationing will probably continue to grow, but with a greater emphasis on explicit criteria to guide clinicians in determining who gets treatment, rather than the exclusion of whole services. The retention of some form of commissioner provider split may also exercise continuing pressure towards explicitness