The doctor might see you now: Healthcare rationing in the NHS before and after the Covid-19 pandemic

The Adam Smith Institute’s latest paper, by Dr Robert Sutton, a junior doctor in Wales and recent graduate of the University of Oxford Medical School, explains how the NHS is failing to meet its central goal:

• The National Health Service Constitution promises universal access to care, free of charge, based solely on clinical need. This premise is extremely popular with the British public. No major British political party has indicated any intention of changing this promise. 

• This popular goal is a fiction. It is impossible for any healthcare system to provide unlimited care. Rationing, of some description, is inevitable because of limited resources. The NHS hides the extent of rationing by using indirect means, often avoiding the associated difficult ethical questions.

• Some systems ration healthcare through prices. The NHS rations healthcare through opaque criteria such as waiting times, clinical criteria and administrative hurdles. The end result for patients is near identical to a system that rations through prices.

• Despite claims that treatments are made based on best-value, there are often arbitrary, political decisions made by politicians and the NHS regarding which diseases and treatments to prioritise. These decisions are made with limited disclosure of reasoning or public involvement. This rewards the loudest and best-connected lobbyists. 

• The rationing of healthcare has grown steadily with an ageing population, increasing treatment costs and limited financial resources. The Covid-19 pandemic has magnified rationing pressures. 

• Indirect rationing of healthcare resources by the NHS will likely continue to a greater degree after this pandemic, with cancelled and deferred treatments and diagnostic procedures necessitating more severe rationing. Waiting lists, already unwieldy, have grown dramatically. As of February 2020, there were 4.7 million people in England waiting on routine operations, a record number. It is unclear whether the NHS will be able to fulfil its constitutional obligations.

• The promises of increased spending made ahead of the 2019 UK general election will have only a marginal impact on patient access and outcomes. Healthcare has unlimited potential demand, meaning no matter how much money is spent there will always be rationing.

• There is evidence that the NHS is not using its resources efficiently. The UK has fewer practising physicians per 100,000 population than 26 of the 27 EU member states, despite above average spending levels. The UK has more medical graduates per capita than Germany, yet has fewer practicing physicians because of the NHS’ difficulty in retaining staff.

• If the Government wants to ensure high quality healthcare outcomes for the United Kingdom they should: 

  • (1) increase transparency by disclosing the extent and nature of rationing in the NHS, including the patients who are refused care; 

  • (2) undertake structural reforms, learning from global best practice, with the aim of increasing competition, productivity and efficiency, thereby reducing the need for rationing;

  • (3) revisit the long-term plan for the NHS to ensure it is able to fulfil its obligations to the British public.