Rationing has been with us since the dawn of the NHS. We cannot do everything for everyone – it would bankrupt the country. Treatment paid out of the public purse must be based on need, not demand. Ministers, however, shy away from use of the term. Doctors do not like it either, as it runs up against their role as patient's advocate. But they do it, nonetheless. As we report today, primary care trusts are extending the treatments they rate as "low priority" and raising the bar for others by specifying the symptoms that patients must have before they qualify for treatment.
In the coming months, expect to read headlines about grandmothers left immobile and in pain because they do not qualify for a hip replacement. In the past, rationing by PCTs has only generated marginal savings. It has typically applied to treatments like cosmetic surgery, on which spending is low. Now some PCTs are predicting they can save up to £1m.
Savings cannot be made on that scale without slashing services in a manner that the public would regard as intolerable. That is bad rationing. Against that, there is good rationing – that is, cuts to NHS procedures that are outdated, have been superseded or do more harm than good. The National Institute for Clinical Excellence lists almost 800 "do not do" procedures which are nevertheless still being done in some parts of the NHS. If its guidance were followed, care would improve and millions could be saved.
The upshot is that the NHS needs to increase good rationing – aimed at weeding out treatments that do not work – whilst avoiding bad rationing. But this is hard to achieve in a market-based system where every procedure carried out adds to the bottom line of the institution delivering it. Andrew Lansley needs to think carefully how his reforms can help the NHS to dispose of the old and bring in the new.