Health ration decisions `must be made public'

NHS resources: From Didcot to New Zealand reports show doctors are struggling with priorities

Every day, Dr David Ebbs, a fundholding GP of Didcot, Oxfordshire, decides not only what treatment to give but who will receive it. Like most general practitioners and hospital doctors in Britain he is no stranger to the concept of rationing healthcare. Constrained by the limits imposed on the National Health Service, he has even produced his own draft policy on making those choices. "I ration and prioritise on a daily basis," he said.

There is no doubt that rationing of healthcare already exists. But the wider problem, according to the Rationing Agenda Group, a leading group of healthcare specialists, is that, so far, the public has not been involved in the debate.

The group's concern, voiced yesterday, came as the Royal College of Physicians renewed its demand for the Government to create an independent National Council for Health Care Priorities to provide guidelines on selecting services and choosing those to be treated.

The Rationing Agenda Group - involving leading health academics, doctors, managers and members of health think-tanks such as the King's Fund - stressed that the issue now affects healthcare systems worldwide, not just the NHS. But while more money might ease the constraints, "proposing other forms of finance is no escape from the fundamental issue" that has seen governments in Sweden, Norway, New Zealand and the Netherlands, set up studies on how to decide priorities. In Oregon, in the United States, the group said, there is even today a system of lists detailing excluded treatments for the poor.

Richard Smith, editor of the British Medical Journal which convened the group, stressed that rationing and priority setting are the same thing. "Rationing has always been the case in the NHS. But there needs to be proper debate on the issue - rationing means denying to people treatments which are proved to be beneficial."

Adult dental care and long-term care of the elderly are "falling away", he said, andBritain's mental and geriatric health services were "absolutely threadbare". Meanwhile, some treatments cost so much they could not possibly be available to everyone. The cost of saving one year of life for a middle-aged woman with a raised cholesterol level, for example, would be pounds 360,000. "So, somebody, somewhere, has to make decisions about what will be available."

Dr Ebbs believes that the United Kingdom's fundholding system especially demands openness in place of the secretive, implicit decisions taken in the past about patients' treatment. His practice, he said, had to choose whether to spend spare money on cataracts or tonsil removals and then decide which patients would benefit ahead of others - even whether self-inflicted conditions, such as those related to smoking, should sway the decision.

The agenda group's report will examine decision-making methods practised by the Royal College's national council and public opinion surveys. Robert Maxwell, secretary of the King's Fund, said: "There's no single solution, but the secretive way it was done in the past is not good enough."

Leading article, page 17