Explicit rationing of health care could be put on the NHS agenda by Virginia Bottomley, Secretary of State for Health, as part of the spending review announced in the Commons yesterday by Michael Portillo, the Chief Secretary to the Treasury.
Mrs Bottomley has privately ruled out a scheme, pioneered in the American state of Oregon, which would mean some treatments, such as tattoo removal and cosmetic surgery, would no longer be available on the NHS.
The scheme has some supporters in the Tory party. Liam Fox, secretary of the Tory backbench health committee, advocated the idea, but Mrs Bottomley believes it would be too controversial.
However, in a speech to the BMA next month, Mrs Bottomley is expected to raise the prospect of more explicitly giving patients priority according to clinical need. That could leave some patients seeking cosmetic surgery no realistic hope of early treatment on the NHS.
Such decisions would be left to the purchasers of health care for NHS patients, the district health authorities and the fund-holding GPs, allowing ministers to avoid the responsibility for drawing up a central list of treatments which may not be dealt with on the NHS within a reasonable time.
Mrs Bottomley believes that rationing has always been part of the NHS, because patients have been forced to join waiting lists. But the next stage could undermine the comprehensive commitment in the Patients' Charter to treatment within two years for all NHS patients.
That could prove highly controversial, but Labour leaders are also exploring the use of priority listing for treatments to resolve some of the anomalies caused by the Patients' Charter.
The health budget is protected by election pledges that health spending would be increased in real terms each year. But the Treasury is looking for more savings. The options include squeezing the NHS drugs budget, possibly by extending cash limits to all GPs, and raising new charges, which Mrs Bottomley has insisted are not on her agenda.
Areas where the private sector will be encouraged to invest more in the NHS include the building of private 'patient hotels' next to NHS hospitals - where patients can upgrade bed accommodation - and the leasing of expensive equipment, such as kidney dialysis machines, from private firms.
More money for roads could be raised in tolls on new roads and on existing motorways, John MacGregor, the Secretary of State for Transport, confirmed yesterday. He said the proposal, to be included in a transport green paper, would affect roads where building, including road widening, had already taken place, such as the M25.
Mr MacGregor said the record road-building programme was costing pounds 23bn and it was right to raise private finance by tolls to offset the cost.
Ruling out tolls in return for road repairs, Mr MacGregor said: 'What we are talking about is where there is new road construction. . . it is reasonable to see whether we can get private finance. It is not government policy. We are putting forward some suggestions as a way of getting the road programme completed as fast as we can.'
John Prescott, the Labour spokesman, accused Mr MacGregor of proposing a double tax on road users by raising revenue through income tax and tolls for the road-building programme.
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