Leading article: The hard choices on health can no longer be avoided

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Some responsibility for the problems of the National Health Service lies not just with the failure of managers to manage money, but the failure of politicians to manage expectations. Today, we focus on the unfairness of inconsistent fertility treatment on the NHS. Last week, we reported on the inconsistent availability of drugs known to be effective in the treatment of cancer.

In both cases, the issue is one of rationing limited resources. That some form of rationing will occur is inevitable, in health care as in almost anything else. What is not inevitable, however, is that politicians should seek to give the impression that such hard choices can be magicked away. That, unfortunately, is precisely the mistake made by Tony Blair and John Reid, when he was health secretary. Two years ago, Mr Reid promised that, within a year, all infertile couples in which the woman is under 40 would be offered one cycle of in-vitro fertilisation (IVF) treatment. As we report today, that promise has, a year late, still not been kept.

It was not unreasonable of Mr Reid to try to equalise the provision of a service that was available in some parts of the health service and not others, under rules that differed from area to area and even from doctor to doctor. But those rules still vary widely across the country, restricting access to Mr Reid's promise. And the deeper problem is that Mr Reid's promise raised expectations. It reinforced the perception that it is a woman's right to have children and therefore the state's duty to provide the means to exercise it.

It may be that this is a view that would command broad support. But it cannot be pretended that it is uncontroversial. Mr Blair's promise to "increase provision of IVF" implied that it was a treatment for illness like any other, when it is, philosophically, in a different category. Professor the Lord Winston tells The Independent on Sunday today that "infertility is every bit as painful as osteoarthritis". But it is simply not so: the two kinds of suffering may both be real enough, but they are not on the same scale. And it could be argued that the anguish of childlessness is made worse by holding out the prospect that it is curable, when the success rate of this treatment can be very low.

In any case, to compare the two forms of suffering is to make a value judgement - one that should be made explicitly, out in the open, rather than by default. To state it crudely, if an NHS trust has £6,000 to spend, should it offer one cycle of fertility treatment with a 20 per cent chance of success, or a few months' supply of a monoclonal antibody, a drug that can reverse cancer? Or should it go on less glamorous and high-technology treatments that could arguably secure more "quality of life" per pound spent, such as in mental health?

These are priorities that have been set in the past by an uneasy combination of historical accident and medical paternalism. A further problem with Mr Reid's fertility pledge is that it strengthened the paternalist instincts of many in the health service. It seemed to be framed in terms of what "we" the NHS can do for "you" the patient, which runs counter to much of the New Labour thinking about empowering people to take responsibility for their choices.

It will not be easy to drag many of the hidden choices made by the NHS over the years into the light. Decisions about the rationing of treatments are analogous to the current problem of financial deficits, which Cole Moreton analyses on pages 28 and 29. Much of the red ink in NHS trusts' accounts has been forced into the open by the Government's reform programme, which requires more transparency. Previously, deficits that were run up to meet targets could be hidden by borrowing from next year's budget or by transfers from underspenders. But that appeared to reward failure and has been stopped. The result is that some trusts have to make hard choices, including job losses that seem puzzling at a time of record increases in overall NHS spending.

But the principles are right - that local managers must be accountable for their spending. Just as the NHS generally must be accountable for the decisions as to which treatments it will offer free, under what conditions. The court cases against NHS trusts from patients demanding particular treatments are the equivalent of financial deficits - they are evidence that the health service is being forced to account for itself in a new era of transparency. Doctors can no longer expect their clinical decisions to go unchallenged, especially when they have resource implications. They are increasingly and rightly required to account for their decisions to NHS managers. But managers have to be accountable too, ultimately to us through politicians. The trouble with some politicians - and the Prime Minister is a serial offender - is that they are tempted to deflect hard choices by pushing the problem on to experts. In this case, Nice, the National Institute for Clinical Excellence, is used as a subcontractor for moral dilemmas where politicians fear that a clear stance might offend too many voters. But, as we said last week in relation to the development of new cancer drugs, the speed of technological change and the moral complexity of the choices presented require Nice to throw some of those choices back at us, the people.

It may be that it would help to focus the public debate if there were a category of "grey" treatments that are considered either lifestyle choices or too expensive for the NHS to fund in full. Part of the cost of these treatments would have to be met by the patient. But even this would not get away from making difficult choices that would leave some people feeling they have been denied treatment to which they feel they should be entitled.

This is a classic example of where politicians might gain in credibility if they engaged in a more mature dialogue with the electorate instead of making easy promises that raise expectations they cannot meet. We all know that a taxpayer-funded NHS cannot meet all the demands upon it, and, increasingly, we do not want politicians or bureaucrats, however expert, deciding such things for us. As we argued last week, openness is all.