Ageism in the Health Service: Rationing 'old as NHS': 'Victims' speak out as experts criticise narrow criteria determining treatment - Ministers attempt to shift blame for the curbs, reports Colin Brown

HEALTH rationing is at the centre of the row over the case of the elderly man who was denied treatment because he was over 65.

Ministers insist that rationing has been with the NHS from the moment it was established after the Second World War, through waiting lists and charges for treatment.

Patients have also faced other forms of rationing: delay - the appointment system may delay patients being seen; dilution - spreading the service more thinly by increasing caseloads so that less time is given to individual patients; deterrence - an awkward location or inconvenient times may stop some patients seeking treatment; diversion - shifting the cost to other agencies, such as social services; ignorance - not all patients know their rights; non-provision - the ultimate form of rationing is not to provide a service at all.

Rationing was brought to a head by the Government's changes to the NHS and the pledge under the patient's charter to guarantee all patients treatment within two years. As patients were told to expect more from the NHS, ministers had to devise more formal ways of managing rationing. Some health experts urged them to adopt a system which was tried in Oregon in the US, for those on Medicaid.

A total of 709 illnesses were listed according to priority and the Oregon State legislature agreed to fund down to line 587. Illnesses that were above that line and fully covered included appendicitis, asthma, hernias, cataracts, and most forms of cancer and back pain, which was ranked 586. Treatments no longer covered included breast reconstruction after mastectomy and cancer where the treatment resulted in less than 10 per cent survival after five years.

One key reason for rejecting the Oregon system was that Virginia Bottomley believed priority-setting at the centre would lead to ministers getting the blame for excluding some patients from treatment. Instead, Mrs Bottomley opted for an arm's length approach. She told the clinicians they would have to set their own priorities.

Last year, the new priorities began to bite, when a patient who smoked cigarettes was denied a heart by-pass operation by his doctors on the grounds that the treatment would be wasted until he stopped smoking. Brian Mawhinney, the Minister of State for Health, stood by the decision.