Healthcare is a limited resource. Healthcare providers across the world must make difficult decisions about who gets access to what treatment, medication or procedure. This process of prioritisation is known as rationing.

The NHS is no exception, and what many may not realise is that rationing is happening already.

The challenge is to make this process more explicit and to engage with the public in an open and transparent way – so there is more co-ownership of the implications.

This requires politicians having an open and honest conversation about how healthcare is currently rationed, both in the NHS and throughout the world.

The mention of the word rationing can lead to a reflex deafness. Perhaps if we began with the importance of assessing need and how to deliver a desired level of care for everyone.

One way to make this conversation more politically attractive is to frame it in terms of evidence-based healthcare. The UK should be doing the things that evidence tells us are right.

There is a positive trend in health self empowerment, with over 50 per cent of patients having already accessed the internet for information on their potential illness or ailment prior to a consultation.

We should embrace this trend, provide reliable information to patients, so they can make evidence-based decisions and informed choices on costs versus benefits.

A conversation about the future of healthcare would be more ‘healthy’ if the public were involved more extensively in the process of setting priorities and managing resources. This currently happens a bit, with patient representation on NICE committees and the like.

 But these expert patients  represent a tiny minority of the public.

We should consider a large expansion of meaningful engagement, creating clinical senates with citizens’ panels, where clinicians and the public can discuss what the priorities and service standards should be, and critically the trade offs, what should come first.

More broadly, the public should be given more information and decision-making influence at every stage of the healthcare journey, through shared decision-making.

It’s also important to consider the role of technology in the rationing process. AI is beginning to be used as a filtering system to determine what care is necessary. 

It is critical this is properly tested and regulated and tested to avoid biases and unintended consequences.

Finally, it’s important to acknowledge that major disparities in health exist, particularly in terms of socio-economic status.

Access to healthcare is inversely related to need. The conversation about resource allocation needs to be open and honest about these issues and the non-rational distribution of resource that we currently have.

This will require changes to structure and incentives. A revolution in addressing the determinants of health is also required. For the biggest postcode lottery of all in health is the environment in which you live. This can equate to a difference of 20 years of healthy years lived.

Are we blind to this scandal ?

In conclusion, rationing in the NHS is already happening, so politicians need to engage with the public in an open and transparent way about how we could manage care and deliver better healthcare.

Frame the conversation in accessible language, involve the public in setting priorities and most critically, establish a mission to address the Grand Challenge of the postcode lottery of propensity to ill-health.

This post reflects the discussion at last week’s Radix seminar on the NHS.