Leading article: Cack-handed, but correct

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The Independent Online

The ban on fat people having hip and knee surgery imposed by Ipswich Primary Care Trust this week is right for the wrong reasons. The directors of the trust have highlighted an essential truth about the NHS, but they have done so in a way that was cack-handed, ill-judged and insensitive.

Rationing is inevitable in a cash-limited health service, however generously funded and however reluctant ministers may be to admit it. It was evident within months of the foundation of the NHS in 1948, to Aneurin Bevan's chagrin, and has remained true ever since. There will always be more patients in need of care, and more that can be done for them, than any health service can reasonably afford.

But how is care to be rationed? The most obvious and fairest method is by queue. NHS waiting lists ensure that care is parcelled out no faster than the country can pay for it. Each specialty schedules its surgical load to match its available budget, with the most urgent cases treated first.

Clinical need must determine which patients get treated. But in some cases there are good clinical reasons why treatment should not be given. The 10 conditions on which Ipswich PCT has agreed new clinical criteria - including varicose veins, haemorrhoids, grommets for glue ear in children - are all the subjects of dispute among doctors about when the risks of intervening exceed the risks of doing nothing.

In the case of hip and knee surgery, there is little point in operating on obese patients - those with a body mass index above 30 will not get referred for the operation - if the new joint is likely to fail under stress of the excess weight. Far better to get the patient to lose weight and then operate. This will reduce the risks for the patient (of further surgery) as well as saving cash for the health service.

In making this plain, Ipswich PCT was reminding us that the NHS has a responsibility to use its resources efficiently, to bring the largest benefit to the largest number, as well as to provide the most appropriate care for each patient. But they presented it as if they were punishing fat people for their failure to control their weight by denying them medical care - which is indefensible.

This is not just a matter of presentation. It risks undermining the principles that underpin the NHS. If the fat are denied care, what of smokers and drinkers? What of rock climbers, racing drivers and players of contact sports?

There can be only one rule for the NHS: that of universal access for all to treatment according to need - within the limits of the available budget.