Leading article: Health needs healthy debate

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The Independent Online

Cancer holds a special place in the nightmares of an increasingly health-conscious nation. It differs from many illnesses in that, the moment it is diagnosed, the clock is ticking. Unlike many conditions that are self-limiting or that can resolve themselves spontaneously, it can only get worse in the absence of treatment. Thus the urgency with which the Government has been trying to improve cancer treatment and shorten waiting times. In this, much has been achieved, if not quite as much as claimed, and with, as ever, much still to be done.

Meanwhile, medical science has been advancing apace. Herceptin, as discussed on this page, is the best-known example but, as we report today, there are other cancer drugs that are effective, that have been tested, that are known to be safe, that can be obtained privately by those who can afford them - and yet are not generally available on the NHS. Or they are available for the later stages of cancer but not for the earlier stages, when patients, given the countdown of mortality, are most keen to have them.

No one pretends that the dilemmas thrown up by such advances are easy to resolve. There will always be some treatments that are so expensive that a publicly funded healthcare system could not justify taking money away from cheaper life-saving procedures to pay for them. And this Government deserves some credit for setting up Nice, the National Institute for Clinical Excellence, in 1999 to bring some consistency to the difficult judgements that have to be made.

But the pace of change in medical science and, more importantly, in citizens' expectations of the NHS is such that Nice is already falling behind. The spread of the internet and the explosion in access to knowledge about medicine means that Nice's slow-moving procedures already need to be overhauled. By the time Nice has approved a drug, new ones have often been developed.

This is an aspect of healthcare in which the Government's rhetoric of devolving power to patients has not kept pace with the demands of the better informed consumer. Given that all possible treatments cannot be funded, even if public spending could be hugely increased, we need quick, responsive and democratic ways to secure a consensus on where the cut-off line should fall. The Liberal Democrats have suggested local referendums to decide priorities for treating various conditions. Last year, the Department of Health carried out an important consultation, assembling 1,000 members of the public in Birmingham to debate such issues in depth. These kinds of initiative need to be taken further.

There are dangers in this type of democracy. It could be argued that people power would further bias NHS priorities towards "popular" conditions, such as breast cancer, leukaemia or heart disease, and away from "unpopular" ones, such as bowel cancer, lung cancer, arthritis or mental illness. We do not agree. The answer to such difficulties is always more openness, and more information, not less.

Ultimately, the only way to be sure that the boundary of free treatment on the NHS is drawn in such a way that is regarded as fair and that will command people's confidence is to involve people as much as possible in the process. The Independent on Sunday, by its campaign for better provision for the mentally ill, and by today's focus on health issues throughout the paper, hopes to promote a wider understanding of the difficult choices that we all, as a society, sometimes have to make.