Prognosis is grim for the NHS

Whichever party wins the general election, there will be little money for the health service. Senior managers tell Jack O'Sullivan how they will makes cuts to match their budgets

For more than a year, Stephen Murray, a 44-year-old former Sheffield steel worker, has tried to obtain beta interferon, a revolutionary new drug, on the NHS. Designed to prevent relapse in the early stages of multiple sclerosis, it could save him from being in a wheelchair. Mr Murray knows people in Manchester who have already been prescribed the recently licensed treatment. So why not him, too?

The doctors keep saying "no". The NHS in his area, he has been told, cannot afford the pounds 10,000 a year the drug costs. Mr Murray is in despair. "Every day, my situation is deteriorating," he says. "When I started asking for the drug, I could walk a mile or more. Now I'm finding it difficult to walk 50 yards. By the time they say I can have beta interferon, it might be too late for me."

Stephen Murray's blighted life is the price of today's cash-strapped NHS, where tough choices are being made about priorities. His dilemma could soon becoming increasingly familiar. Hidden in public spending plans accepted by all the main political parties is a well-disguised decision that NHS will be severely squeezed until the next century. That means little money will be available to fund technical and pharmaceutical advances such as beta interferon. Worse, top managers say that even existing services will have to be cut if current spending plans become reality. In short, a vote for any of the main parties means a weakened NHS.

Few of those responsible for spending NHS money will go public about their concerns, but across the country they are discussing the closure of hospitals, the lengthening of waiting times, the halting of certain kinds of treatment and the suspension of planned improvements, regardless of which party wins the general election. These are not outspoken doctors, shroud-waving for their own narrow departmental needs. These are the managers, the people who think it is their job not to complain but to make budgets work.

The problem is that the NHS - to meet the extra financial demands of an ageing population, wage increases and technical advances - is assumed to need, and has customarily received, about 3 per cent extra every year above inflation. But, according to Andrew Dilnot, director of the Institute for Fiscal Studies, the government has budgeted for, and Labour has endorsed, negligible real growth over the next few years. At today's prices, they plan to spend pounds 33bn on the NHS in England and Wales in the year 2000, just pounds 0.6bn more than this year. The Independent asked heads of hospital trusts and health authorities and GP fundholders - the people who control the purse strings - how such plans would affect them.

"We would see a major programme of hospital closures under these spending plans," said the director of commissioning for one north London health authority. "We would have to cut national programmes such as medical education and quietly reverse the new deal that reduces junior doctors' hours. The government's commitment that no-one should wait longer than 18 months for an operation would have to go. Some people would have to wait longer and those dealt with more quickly would be treated according to clinical need, rather than, as now, time on the waiting list. Some people, with varicose veins, for example, would never get them treated at all.

"We would also have to be much tougher with hospitals about nailing down priorities that we wanted our money spent on. But, frankly, I don't think we have the management capacity to do that - particularly since the number of managers is going to be cut back if Labour is elected."

Alan Randall is chief executive of Worthing Hospital, near Brighton, which serves one of the largest elderly populations in Britain. He thinks the survival of smaller hospitals is threatened by these spending plans. "People would have to travel more rather than go to outreach hospitals nearby. Locally, to raise more money, Worthing hospital would compete more vigorously for private patients so a private hospital would probably go under in this area ... It is almost inevitable that people would have to dip into their pockets for minor operations such as cataracts and maybe joint replacements."

Some health economists hope that a funding shortfall could be made up by squeezing NHS salaries. But managers are already having trouble recruiting staff because of low wages. "We've just recruited 35 nurses from Australia to fill the nursing gaps," says Alan Randall. And no-one thinks that Labour's war on bureaucracy would produce the necessary savings.

This threatened crisis comes against the background of a bad winter in the NHS. Earlier this year, for example, a stroke victim at St Helier hospital in Surrey waited on a trolley for 54 hours before a bed could be found for him. And there are tales of lives at risk because of delayed operations around the country. Annette Donegani of Stockport Community Health Council says, "We had a letter from a man recently who said we had saved his life. He had been told by consultants at Manchester Royal Infirmary that he needed cardiac surgery, but there was no money to pay for it. The problem was only solved when we intervened. He was taken into hospital and they operated immediately. Apparently, he was just on the brink - he had a serious life threatening condition."

Then there are all those operation cancellations which produce great inconvenience and stress. "We had another patient," says Ms Donegani, "who was told before Christmas that her operation would be in seven months, then nine months, then 12 months; now the hospital can't tell when it will be. It isn't a life-threatening condition, but people get worked up about a date, arrange child care for the family and then at the last minute find the operation is postponed. It's terribly distressing."

The post-election NHS will have to become more ruthless. "We would have to consider cases such as keeping a patient on drugs for a heart-lung transplant," says the finance director of a large south London hospital. "Those drugs can cost pounds 500,000 in a year. That's a lot of hip operations. That's not a decision I could take - the Department of Health would have to take a lead."

A major rethink in services would also be required by GPs. "We need 3 per cent extra a year because the population is getting old and there are new procedures," says Dr Erl Annesley, a GP fund holder in Keyworth, Nottingham. "I've saved as much as I can on drugs unless more people are going to pay for their own. If someone comes to me wanting beta interferon, I can't give it to them."

The message to whomever runs the Department of Health in a few months is that tough decisions will be required. And, much as the new Health Secretary might wish local areas to take responsibility for the impact of tight spending, real savings may demand clear central directives limiting services. At this rate, it looks as though Health Secretary Stephen Dorrell or his shadow Chris Smith, for all their reassuring language, are heading for a political storm.

Next week, Polly Toynbee asks Stephen Dorrell and Chris Smith to respond to the above indictment.