On the Oregon trail: rationing health care.

The introduction of the purchaser-provider principle into the NHS will have at least one uncomfortable consequence perhaps not fully expected by its authors. It will direct public attention even more to decisions about the level and distribution of resources, both nationally and locally. In the past decisions about who should (and should not) get what medical treatment have been perceived, and accepted, as matters of clinical judgment-constrained but not shaped by national budgetary policies. In future as health authorities move towards buying packages of health care through contracts, so they will increasingly have to make explicit decisions about what they want (and do not want) to buy on behalf of their populations. Political and managerial resource rationing priorities will therefore be visible instead of being largely hidden under the cloak of professional practices. Hence the interest in the Oregon experiment, seen as the first attempt to develop an explicit system of rationing health care.' What lessons can be drawn for the NHS from the experience of Oregon so far? To answer this question, it is essential to explore first what the Oregon "experiment" is about. It has been widely perceived as an attempt to put medical services in some sort of objective order ofpriority by using the best available scientific methods. Accordingly, it has been either hailed as a pioneering attempt to show that resource allocation can be depoliticised or criticised as showing a naive faith in scientism. In fact, the most discussed and controversial aspect of the Oregon experiment-its ranking of different forms of medical intervention in order of priority-is perhaps its least interesting aspect. The method is now being changed, and a different list of priorities will eventually emerge. The real importance of what has been happening in Oregon lies in the problems that have driven the experiment and the political processes that are shaping its progress. Most importantly, the Oregon experiment represents an attempt to dealwith a specifically American problem: rationing by exclusion. It seeks to "change the debate from who is covered to what is covered" in the words of John Kitzhaber, a doctor who, as the president of Oregon's senate, was the driving force behind the 1989 initiative.2 In the past Oregon sought to contain health care costs by limiting eligibility for Medicaid-the programme of last resort for the poor-and by denying even those eligible access to certain expensive forms oftreatment, notably organ transplantation. The …