How to afford a just health service.

British Journal ofGeneral Practice, February 2012 105 The argument is now, always has been, and always will be about rationing. From the inception of the NHS until quite recently, rationing was mostly achieved by the rough and ready system of waiting. The last government in its days of largesse decided this was intolerable. They threw a lot of money at the problem, created extra capacity by importing staff from overseas, opening new treatment centres, and setting targets, with the result that waiting times have dropped dramatically. However, the 7 years of plenty are over and we are facing 7 years (at least) of famine. Rationing, what we ration and how we do it, will once again be top of the agenda for commissioning authorities, whatever efforts our political masters make to present the debate in alternative language. It’s not clear, at least to me, what this is going to mean. We have increasing expectation from patients, and the ability to domore for them by using better, andmore expensive medical technology. If past experience is a guide, the National Institute for Health and Clinical Excellence will continue to approve at least some of the new technologies that it considers and that will oblige commissioning authorities to provide them. The Department of Health will do its best to ensure that waiting lists don’t get longer again, and the Care Quality Commission will do its best to ensure that wedon’t rush to diminish the quality ofwhat is being commissioned. All of this is to be contained within reduced budgets. It is looking inevitable that the only way to keep within budget will be to restrict what is provided. Not to make patients wait for longer, but to declare that some services or procedures will no longer be available.