Jeremy Laurance: The NHS should think twice before rationing care

To make real savings, you have to think as the Romanians do. And that means facing unpalatable choices
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The Independent Online

If the British Medical Association is serious about rationing treatments on the NHS, it might care to examine what is happening in Romania.

In a report to be published this morning, the BMA will launch its plan for the future of the NHS in England. It will say that despite the billions of pounds poured into the health service over the past six years, there is still not enough cash to pay for everything. We must, therefore, kiss goodbye to the idea of a universal service available, free to all on the basis of need, and accept that some of what the NHS does it must cease doing.

This is a conclusion the Romanian government reached last year when it took radical action to curb health spending. In September, it eliminated medical oncology as a separate specialty, slashing at a stroke one of the high-cost areas of medicine, on the grounds that cancer patients are not economically productive. In future, oncology services will be provided as part of the broader specialty of internal medicine, reducing expertise and limiting access to treatment. Yesterday, the decision brought some of the country's 370,000 cancer sufferers on to the streets of Bucharest in protest.

The BMA report, when it is unveiled this morning, is unlikely to contain anything so radical. Newspaper reports listed the usual suspects as candidates for the chop - fertility treatment, plastic surgery, varicose veins, glue ear in children. This is the easy stuff, trotted out in every debate about rationing for the past 20 years (though the examples cited are not specifically mentioned in the BMA report). Should the NHS be shelling out to help infertile couples get pregnant when people are dying of cancer for want of the right drug? Should it be paying for breast enlargements which offer no known health benefit?

Even if the NHS were to cut these services, the savings would be imperceptible. In the context of the £90bn a year we spend on health, they are the loose change. If you want to make real savings, you have to think as the Romanians do. And that means facing unpalatable choices. No medical organisation or political party in the UK would contemplate cutting access to care for cancer patients. Apart from being inhumane, it would spell political suicide.

So if not cancer, then what? Six years ago, the BMA's inquiry into the future of the NHS concluded in February 2001 that some services would have to be cut and called for an "open, honest approach" to rationing, in which the public must be involved.

After the years of plenty, during which the NHS saw its funding double in real terms, readers of today's report will experience a powerful sense of déjà vu. Pessimists will take this as confirmation that no matter how much is spent on health, demand will always rise to exceed supply.

Today's proposal from the BMA is that an independent NHS board - floated by allies of Gordon Brown but dismissed as an irrelevance by Tony Blair last week - should issue advice on NHS "core" services and priority setting.

Local areas, with locally appointed, or elected, boards, would determine their own priorities. There would be a funding mechanism to help reduce inequalities (which, shamefully, are wider than when Labour came to power). The result would be a more locally diverse NHS, but one that was, ultimately, more sustainable. The BMA's thinking seems to be that cuts hurt, but they hurt less if they are self-inflicted.

Would such a plan for "local rationing" work? Dozens of campaigns to save local hospitals across the country suggest otherwise. Even Labour ministers have been caught facing both ways, backing the principle of cuts but opposing them in their own backyards.

Efforts to draw up lists of "core services" have been tried and failed in Oregon, US, and in New Zealand. When faced with the challenge, both the public and politicians have proved unable to draw the line.

The Conservatives rejected the BMA's analysis, before it had been published, as too "pessimistic". The Lib Dems noted that rationing was already a reality and commended the BMA for "putting this taboo subject on the agenda".

Mention of "the R word" was taboo at the Department of Health until December 1999, when Alan Milburn became the first health secretary to utter it in a speech to the first conference of the National Institute for Clinical Excellence (Nice).

Nice has since gone on to establish an international reputation for itself as arbiter of cost effectiveness in health, and Sir Michael Rawlins, its chairman, is said to be keen to extend its role beyond assessing individual treatments to advising health authorities on the range of services they provide. The organisation is already examining obsolete treatments from which the NHS might disinvest - hysterectomies, surgery for glue ear, and the like.

In a world in which the entire GDP of a country such as the UK could be spent on health, the NHS cannot provide everything it is theoretically possible to provide. But, as Mr Milburn noted in his speech, to call that rationing is meaningless. After the seven years of unprecedented growth he ushered in, the NHS has to set priorities and make choices once again, like every other healthcare system in the world. It will need all the help Nice and the BMA can offer it to do so.

j.laurance@independent.co.uk

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