Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices.

Rationing health care in publicly funded health care systems is becoming more challenging because of the growing gap between the possibility of effective medical intervention and limited resources. This poses both an economic challenge and a political puzzle. On the basis of experience in those systems that have adopted a systematic approach to rationing, it can be suggested that the dilemmas involved should be addressed by strengthening both the information base to support decisions and the institutional framework in which decisions are taken. The contribution both of experts and of lay people is needed to inform decision-making, and the processes adopted need to allow for this as well as being transparent and accountable. In practice, rationing is likely to combine explicit and implicit decision-making and to result in the exclusion of services at the margins and the development of guidelines in the mainstream. The politics of rationing may favour muddling through and the evasion of responsibility but this will be difficult to sustain in an environment in which public awareness of decision-making in health care is growing.