At present services are often allocated on a first-come, first served basis. Those who do not come do not receive services. There is considerable under-use of effective health interventions and considerable failure to comply with treatments which are provided, for example, drugs not taken as directed. It would clearly be unacceptable to allocate scarce service by giving patients random numbers. But the use of very advanced procedures could be restricted to those who could benefit most from them. Such criteria could be medical or social. Social criteria might be age, occupation, family status or economic status. Only the first deserves some consideration. Should the wish of the patient and the family to withhold life-prolonging treatment from an elderly person in pain with only the prospect of a few more weeks of life be respected? In some countries there is already denial of some treatments to elderly persons on the grounds that they are unlikely to survive the intervention or have diminished capacity to withstand post-operative complications. Are such decisions best left informal? Should treatment be denied when a psychiatric illness or behaviour pattern is likely to interfere significantly with compliance?
There are many potential ways of limiting the services provided. Should governments avoid financing research into the development of new technologies? Should there be stringent assessments of new technologies before they are allowed to be disseminated? Should all Member States have effective means of preventing the dissemination of technologies in response to market forces not only in hospitals but outside?
Should the services which are publicly financed be restricted to «core» services, leaving other services wholly for private payment? There already have been moves in this direction as mentioned earlier. They include the removal of spa treatment from the fee schedule, cutting out cosmetic surgery, not financing dental bridges or spectacles for adults unless they have very bad sight, not reimbursing a range of over-the-counter drugs, and heavy increases in cost-sharing for dentistry or «comfort» drugs and reductions in subsidies to travel costs.
If the restriction to core services is to go deeper, there need to be explicit criteria to define the «core». The question arises of whether consideration should be given to the possibility of excluding some services or only new treatments, high cost treatments or high volume low cost treatments. The implicit criteria behind the actions so far taken are that the costs are low, that the condition cannot be life-threatening, that the medical value is not clearly established or the provision can be readily abused and that, as there is no urgency, patients can be expected to save up to pay the cost e.g. for adult dentistry. These criteria are used unevenly between countries. The criterion of low cost raises the possibility of targeting on those for whom the cost, though low for the average family, could be a burden for those with very low incomes or not so low incomes and large families. The difficulty with this is that, while a distinction can be made for those receiving social assistance, not all those eligible claim and it would be administratively difficult to find those in an income range just above this level.
In many countries governments have set up committees to define the core health services for private payment. These committees have recognised that, if transfers to private became substantial, this would raise serious problems of equity. The first example comes from the United States and attempts to apply cost utility analysis - the Oregon Medicaid reform. The others are the basic package of care defined in the US national health insurance plan, reports of committees on priorities in Norway and Sweden, the report of the New Zealand committee set up to define core services, proposals to establish priorities in Spain and Germany and the report of the Dunning committee in the Netherlands. They are going far less than the Oregon Medicaid reform which attempted to place in rank the importance of all health services.