The limits to demand for health care Commentary: An open debate is not an admission of failure

# The limits to demand for health care {#article-title-2} There are a number of historical, political, and economic explanations for the tradition of underinvestment in the NHS, but one insidious disincentive will provide a continuing brake on expansion. This is the expectation that in a publicly funded healthcare system any increase in expenditure will be followed only by further failure, although at an increased cost. Further, the imbalance between demand and supply is assumed to be deteriorating as the population ages, new technologies appear, and expectations rise.1 This orthodoxy has become so pronounced that questioning the linkage between particular aspects of failure in healthcare delivery and an overarching mismatch between supply and demand can be dismissed as an idealistic act of denial. These problems are most commonly discussed in the idiom of rationing. In rationing the concern is to curtail access to health care through measures that may be, according to the perspective of the commentator, most likely to enhance effectiveness; be efficient, equitable, ethical, or beneficial to the independent sector; or be politically feasible. The rationing debate came to the fore during a period of recession, so that “choices” in health care involved choosing to offer less. The conventional, but implausible, insistence that the term rationing has a neutral meaning will be tested in the welcome new circumstance in which healthcare expenditure in the United Kingdom is set to expand substantially. But what are the grounds for the view that legitimate demand in most areas of provision must exceed realisable supply? #### Summary points The rationing debate has been conducted almost exclusively through assertion and political analysis Conventional assumptions of an imbalance between demand and supply are not supported by evidence Pessimism about adverse future trends in demand arising from an ageing population, the costs of innovation, and rising public expectations are similarly unsupported by good evidence Many perceived deficiencies …