A chapter of this book explains who does what in prioritisation (resource allocation and rationing).
I've found of interest this classification of rationing:
- Rationing by denial. Exclusion of specific services or treatments from the National Health System portfolio (often explicitly) or from one healthcare provider (near always implicitly) that believes that such treatment or service is inappropriate.
- Rationing by selection. Exclusion of some patients of some treatments because they do not meet certain eligibility criteria fixed by the regulator (often explicitly) or the provider (near always implicitly).
- Rationing by delay. The demand that cannot be met by a rigid offer remains on hold (waiting list) and the wait acts as a barrier to access and, in many cases, as a de facto denial of care.
- Rationing by deterrence. Barriers placed, either consciously or unconsciously, by the healthcare providers that make it difficult for patients to find out about, and book appointments with, some healthcare services.
- Rationing by deflection. Patients being shunted off to another institution, agency or programme.
- Rationing by dilution. Services continue being offered to patients, but with fewer resources, and the quality of care gets worse
In conclusion, adequate priority setting is not about choosing either to muddle through implicit rationing or to be corseted by an exhaustive, rigid and explicit interventionist structure at the macro, meso and micro decision-making levels. This dichotomy fails to capture the complexity of priority setting in practice. We need more and better explicit priority setting, not to substitute but to improve implicit priority setting.
Weegee by Weegee
