Introduction: A sociological perspective on rationing: power, rhetoric and situated practices

Abstract

The analytic power of sociology stems from examining closely the deep structures and power relations that underlie the rhetorics and practices of individuals, groups and organisations, by assuming a radical disengagement from them. Such is the analytic promise of sociological research into rationing, where unexamined rhetoric prevails and detailed empirical studies are thin on the ground. Intellectuals and policy makers, as well as those who pay the bills ± be they governmental bodies, employers, insurers, or individuals ± need the unclouded gaze of the sociological eye more than ever, as the rhetorics of rationing swirl around them. For rationing has become a predominant issue in the economic, moral and political discourses on health care. Yet as Conrad and Brown (1993:3) observed,`rationing has received little sociological attention'.The sociological perspective has much to offer. At a time when scholarly thinking about rationing is dominated by the discipline of economics, sociology can help us to understand how economic transactions are embedded in social relations (Granovetter, 1985), which place limits on calculative rationality. Rationing provides a valuable array of social practices for exploring power relations in health care systems, particularly the linkage between resource allocation, rhetoric and the interests of different parties. Sociological studies can also complement and extend philosophical and ethical work on rationing by providing empirical case material grounded in the practical circumstances of real-world decision making, and investigating whether the ethical issues recognised by actors in the health care system correspond with those described in the scholarly literature. Our aim as editors was to put together a volume that would start to address some of these issues, and we think that a decade from now one will find that an important body of research has been achieved.

Rhetoric, Evidence and Policymaking: a Case Study of Priority Setting in Primary Care*

“…integrated into routine decision-making through mechanisms such as non-availability, primary care gate-keeping and waiting lists (Heginbotham quoted in Robert) rather than explicit (Coast, 1997). However, since the 1980s the development of the purchaser/provider split in health care (requiring purchasers to be explicit about what services to commission), together with the trend towards more open and accountable forms of government, has prompted the development of more explicit systems of priority setting (Joyce, 2001;Light & Hughes, 2001).…”

“…However, the studies also suggest gaps in our knowledge and indicate an agenda for further research into the social practices of priority setting. A paradox of the body of existing research on priority setting and rationing in health care is that whilst it describes the dynamic and complex reality of policymaking, the wide range of influences, the locally contingent nature of evidence use, and the requirement to get inside 'the black box' of priority setting through 'fine-grained' analysis of the factors that shape not only 'decisions' but what can be thought and acted upon (Light & Hughes, 2001;Tensebel, 2000), in the main the methodologies being drawn upon fail to provide the analytic frameworks to support this. If we wish to understand better the deliberative processes of priority setting, and how evidence actually gets talked into practice at a micro-level of social interaction, how problems and evidence are socially constituted and represented through deliberation, then we require a framework of ideas and research methods that address the role of language, argument and discourse.…”

Still Elegantly Muddling Through? NICE and Uncertainty in Decision Making About the Rationing of Expensive Medicines in England

“…9 Yet behind this discourse or policy talk 10 of objectivity and rationalism in the pursuit of explicit rationing, the influence of socially-constructed assumptions and subjectivity may still prevail. 11,12 Evidence from statistical analyses suggests that while the demonstration of clinical and economic value is central to NICE decisions, the variability in these decision-outcomes about whether they recommend a technology or not can also be explained by other process and socio-economic factors. 13 This may be due, at least in part, to the very nature of bureaucratic judgements amidst uncertainty, where reliance on and correspondingly trust in people and systems is unavoidable.…”

The responsibility principle. Contradictions of priority-setting in Swedish healthcare

“…There are many critical academic accounts of responsibility in the context of health (Beck-Gernsheim, 2000;Light and Hughes, 2001;Jolanki, 2008;Wikler, 2002).…”