Search tips
Search criteria 


Logo of bmjThis ArticleThe BMJ
BMJ. 2007 May 26; 334(7603): 1114.
PMCID: PMC1877931
Personal View

Assegais are not enough

Ian Banks, part time general practitioner, Northern Ireland, and BMA Council member

Rationing and priority setting are not the same thing

When it comes to dividing up the national health cake, there are some who would have it and eat it. The BMA has just produced “A Rational Way Forward for the NHS in England,” its response to a motion at its annual representative meeting calling on the BMA Council to address creeping NHS fragmentation and privatisation. It might not be the definitive document stopping a Bevan rotating in his grave but it at least addressed the difference between rationing and priority setting. These two words are routinely used interchangeably, despite meaning the opposite of each other. On BBC Radio 4 the two terms are used in the same breath, unfortunately by those who are supposedly protecting the NHS.

It's more than just words or clever semantics. Getting the distinction right is crucial to the debate over the NHS's future and for that matter the BMA suffering a low percentage of junior doctors among its membership, despite an overall increase in numbers. Rationing is the equal distribution of a limited resource. Priority setting is the distribution of a limited resource only to those deemed most needy.

During the second world war, King George VI supposedly waved his ration book while in line for his 2 oz scrag end. Rationing was taken seriously, so seriously that as an equal distribution of limited resources it actually reduced children's mortality, notwithstanding the bombs. People and the police took a dim view of anything that undermined rationing. The black market was so illegal that people went to jail and much worse. But these days, who provides the black market for health care? Us. It's called private medicine. No queuing for the medical equivalent of scrag end if you can afford fillet.

Rationing is not always effective. During the battle of Isandlwana, South Africa, an overwhelming force of Zulus wiped out an entire British force (along with their support personnel, mainly black men and women). Their quartermaster, conscious of saving the Queen's Purse, rationed each soldier with the amount of rounds he deemed necessary for the conflict. This he based on the number of Zulus, the speed at which they could run, and the rate of fire from a standard British soldier. He got it all correct except the number of Zulus. Queen Victoria's quartermaster was out by a factor of 100.

Soon after, the remaining Zulus turned on Rorke's Drift. This small outpost had far fewer infantry and even less ammunition than Islandlwana but both were distributed according to the maximum threat of attack. Zulu courage and bravery is without doubt, but, as the Great War demonstrated, sending troops into concentrated and withering fire will always result in horrendous casualties. More so when armed with nothing more than a large dinner knife. An assegai is no match for a rifle, unless you can get close enough to use it.

Today's UK health professionals face a number of contradictions. They are expected to deliver their services on an equal basis rather than prioritising, which would give a far better impact. Obsession with “targets” further exacerbates the problem. Using out of date equipment and drugs based on economy rather than efficacy, and worse, much worse, they feel that they are infantry pawns for a government more concerned with internal political struggle (not least an illegal war in Iraq) rather than fighting the true common global enemy, public ill health. Targeting limited resources to those patients who would benefit most (priority setting) rather than dishing them out irrespective of need (rationing ) makes sense even if it is not politically attractive. For any government really wanting to address inequalities there is no other option.

If the BMA enshrines rationing in its policy it will be perceived as the government's NHS quartermaster. By championing prioritising of care it will however rightfully continue to be the patient's advocate. Never in the history of the NHS, and the BMA, has there been such a chequered NHS when it comes to delivering care to the most needy. Getting the picture clear is vital. Young doctors entering the NHS are looking to the BMA for leadership. Give them the tools to fight ill health and they will support and defend the NHS. Let them feel a part of the war against poverty related ill health while developing their careers and they will join the BMA. Then they will button up their tunics and resist drinking brandy from the medicine cabinet. It is, after all, a flogging offence.

Give young doctors the tools to fight ill health and they will support and defend the NHS

Articles from The BMJ are provided here courtesy of BMJ Group