Gatekeeping in Britain's "new" National Health Service.

Abstract

Physicians have been important gatekeepers in Britain's National Health Service, the NHS, since its inception. At the level of macro allocation, it was the profession that set the priorities for the uses made of the NHS' global budget; at the level of microallocation, it was individual physicians who decided who did and did not receive expen sive, especially in-patient, therapies. Within governmentally set fiscal limits, it was the doctors who rationed health care (Kessel, 1990). While this still remains true, the introduction of market mechanisms by the Thatcher government has fundamentally altered the nature of the rationing process and the interactions among the players who carry it out at both the macroand the microallocational levels. My intention in this essay is to continue to explore the way in which Britain's National Health Service straddles two contrasting views of how a just health care delivery system ought to be constructed. In Britain the arguments are over whether the Health Service ought to be fundamentally communitarian, consensual, and egalitarian in nature?in a word, Rawlsean (Daniels, 1985)?or whether it ought to be libertarian, regulated by market forces, and tolerant of inequality?in a word, Nozickian (Engelhardt, 1986, 1991). The arguments are also over how this distinction bears on questions of health care allocation, that is to say, of rationing. As I explore this distinction I hope to avoid polemic, seeking rather to describe the changes occurring in the NHS as I see them. This on-going argument should be of value not only to those interested in British health care, but to those elsewhere, including in