Some authorities are now "teetering on the edge" of more explicit rationing, proposing for example to exclude the treatment of warts and inpatient traction for acute back pain, the report from the National Association of Health Authorities and Trusts showed.
"More commissioners than ever ... are listing procedures that they will not purchase unless clinical need can be demonstrated", according to the survey by Sharon Redmayne of the University of Bath.
Almost a quarter of authorities - 26 out of 110, an increase of more than 100 per cent on two years ago - now exclude at least some services unless clinical need can be demonstrated.
The most common exclusion is reversal of sterilisation - a position taken by 15 authorities - with at least ten refusing to fund sex-change operations, reversal of vasectomy, in-vitro fertilisation, breast augmentation and nose reductions.
But while most of the procedures involve either infertility treatment or cosmetic procedures such as face-lifts, even these "rationed" procedures will usually be performed if a doctor makes an overriding case for them for a particular patient, the report says.
Some health authorities, however, are "teetering on the edge" of more explicit rationing. North West Anglia is considering excluding wart treatments. North and Mid Hampshire may end inpatient treatments for psychotherapy, chronic fatigue syndrome and complementary medicine.
Some authorities are resisting buying Beta-interferon, a new pounds 10,000- a-year drug which reduces the frequency of relapses in some cases of multiple sclerosis, but does not affect the long-term course of the disease. Croydon has said it is unlikely to purchase it until better evidence of its effectiveness is available.
Others are reducing spending on ineffective procedures to boost treatments known to work - for example, reducing X-rays for back pain and some routine Caesarians, and aiming to concentrate on well-proven artificial hips rather than buying more modern, unproven ones. These changes, however, cannot be termed "rationing" as patients are not denied something from which they wouldbenefit, the report says.
Many more authorities are now drawing up clinical protocols with doctors on how particular conditions should be treated, making clinical effectiveness a key determinant of purchasing decisions.
The report shows that health authorities are getting better at purchasing health care, shifting the emphasis from acute hospitals to primary care, but still changing "cautiously and incrementally".
There is, however, "much experimental innovation as commissioners pilot new ways of organising primary care".
n Small Steps, Big Goals: Nahat, Vincent Drive, Birmingham B15 2SQReuse content