Health rationing comes into the open after patients die: As hospitals struggle with contracts, Judy Jones argues that it is time the Government set out the limits of care

TORY politicians used to sneer at doctors protesting over cuts in National Health Service budgets; they called them irresponsible 'shroud-wavers', and they just about got away with it.

Kenneth Clarke, when secretary of state for health, was strikingly rude about the medical profession, and it never harmed his career. His jibe about doctors 'feeling nervously for their wallets' whenever health service reforms loomed, went down well with those who saw doctors as arrogant and insular.

Four years and one NHS re- organisation later, the political rhetoric is more conciliatory, and with good reason. Government promises about spreading choice, and money 'following the patient', are beginning to look threadbare in many areas. The talk is of health rationing and of possible cuts in budgets. The skies above the Department of Health seem to be darkening with chickens flapping home to roost.

Seriously ill patients have died for lack of treatment, as reported last week, because hospitals are forced into protracted wrangles over internal market contracts. Senior cardiologists at St Bartholomew's and Guy's hospitals have said some patients with serious heart conditions did not survive long waits.

The supply of routine surgery, though not the demand for it, ground to a halt before Christmas in many hospitals, where contracts with purchasers - the district health authorities and GP fundholders - were completed months ahead of schedule. Doctors and administrators are having to fine-tune definitions of 'emergency' and 'urgent'.

Medical treatment has always been a limited resource, but advances in science and technology bring the promise of new cures and better treatments every year.

Demand is almost infinite. There are three main mechanisms for rationing: pricing, queues, or according to need. The NHS has always rationed health services through a mixture of the last two. A patient is placed on a waiting list, and doctors assess the relative needs.

So there is nothing new in rationing health services, only in the degree of openness with which it is discussed. As long as a state health service is cash-limited, not everyone can get as much treatment as they would like. Up to now, waiting lists have been the most obvious and controversial method of rationing.

As Professor David Hunter, director of the Nuffield Institute for Health Services Studies at Leeds, recently pointed out, delay has been supplemented by three other factors. These are: deterring people from making demands on the service; deflecting them to local authorities if their needs are primarily social; and spreading services thinly so that everyone gets something.

These devices have remained fairly obscured, executed by policy-makers with little or no consumer input. At its annual meeting in Nottingham last summer, however, the British Medical Association called for a national debate on whether rationing should be more explicit.

On Thursday, Virginia Bottomley, Secretary of State for Health, will set out the Government's position at a BMA conference in London on rationing. Mrs Bottomley is under enormous pressure to confront the harsh realities of rationing and give a lead.

The United States, with its extremely expensive health-care system, has toyed with the idea of explicit rationing, but has not implemented a rationing scheme. In Oregon in the late 1980s, the public was asked to rank more than 800 treatments in order of priority. State administrators drew a line under the 587th treatment, and planned to withdraw funding from remaining items.

These included drug treatments for people terminally ill with Aids, and care of severely handicapped babies. As one of his last acts in office, President Bush was forced to veto the scheme.

The biggest UK opinion surveys of the public, doctors and managers on the subject will be released at this week's BMA conference. The three groups are expected to have different ideas of what they find acceptable.

Toby Harris, director of the UK Association of Community Health Councils, on behalf of patients, will be among conference speakers. He welcomes the debate, but views it warily. 'Take tattoo removals,' he says. 'Some health authorities have already stopped doing these. Many people would support that, saying 'It's your own stupid fault for having the tattoo done in the first place'. That is not far removed from saying people who smoke have only themselves to blame for their chest problems. There is a 'slippery slope' problem.

'Before long there would be some saying certain groups are less worthy of state health care than others - maybe alcoholics or those with mental-health problems. It's a frightening prospect.'

Chris Heginbotham, fellow in health services management at the King's Fund College, London, supports public consultation but believes that clinical matters must be for doctors to decide. He also thinks that 'responsibility' arguments make for bad policy. 'Yes, one can talk about smokers and personal responsibility. But then what do you do about someone injured in a car crash on the motorway who was travelling at more than 70 mph?'

Mrs Bottomley's speech is said to have gone through several drafts already, but it is not yet clear whether she will actually use the R-word, never mind acknowledge its appropriateness. The BMA originally wanted to use 'rationing' in the title of the meeting. Instead, after discreet pressure from the Department of Health, it will have the more anodyne name of 'Priority Setting in the Health Service'.

If Mrs Bottomley fails to give clear signals of government policy on rationing and the future of the NHS, doctors and health workers will undoubtedly use every opportunity to criticise that failure.