Leading Article: Hard choices on health

ANEURIN BEVAN created a national health service, rather than developing the patchwork of local services that preceded it, because he thought that 'when a bedpan is dropped on a hospital floor, its noise should resound in the Palace of Westminster'. Noise certainly resounded in the Commons last week when Labour highlighted the cases of two men in their seventies, who were reportedly refused hospital treatment because of their age. The Prime Minister accused the Opposition of 'peddling untruths'. Why the Speaker allowed John Major to get away with what usually counts as unparliamentary language is a question only she can answer. Why the Prime Minister lost his rag is a more important question. Health care has to be rationed. Nobody argues (or should argue) about that. Ministers are no longer prepared to leave rationing decisions to doctors. Their NHS reforms are shifting the onus to managers, operating within an artificially constructed 'market'. The decisions will appear cruder, more coldly bureaucratic, because they are not disguised under the mystique of clinical freedom. Mr Major had better get used to people asking questions. As the reforms move on, bedpans, kidney machines and hip replacements will flow through Norma Major's drawing room as Suez flowed through Lady Eden's.

The debate is muddied because politicians and health service professionals confuse two separate issues. One is how much the nation spends on health; the other is how health care should be rationed. The left argues that rationing is only necessary because we do not spend enough. Wrong. Public demand for health care is almost infinite; whatever the level of spending, there has to be rationing in some form. The right argues that new types of rationing, based on market disciplines, are necessary to stop us spending too much. Wrong again. The United States has a largely private system, with severe rationing by price. Yet it spends about twice as much of its national product on health as this country does. Americans are not therefore healthier, though they may be more health-obsessed, which is a different thing.

Health services in the US are a perfect example of market inefficiencies. Much of the extra spending goes on inessential operations, such as cosmetic surgery. Much of it also goes on the administrative costs of insurance schemes. Far from stripping away bureaucracy, markets may increase it. This appears to be exactly what is happening here. In the three years after the start of the NHS reforms, the number of nurses employed fell by 20,000 while the number of managers increased by 16,000 and administrative and clerical staff by 28,000.

Once, the NHS had a simple, guiding principle. It was called caring for people; doctors and nurses tried to do their best for patients. Some employees fell well short of the expected standards and got away with it. Now, everything must be measured. Duties are defined and performance assessed. No doubt the lazy and incompetent are whipped into action or sacked. But others may well decide to play by the book, and not care more than required by contract. Why should they, when they see salary and car bills for NHS managers soaring and when they know that job prospects depend on keeping the forms circulating?

Does the patient gain? It may be too early to judge but all the evidence suggests not. Virginia Bottomley is rated the most unpopular minister, and it is hard to believe that this is entirely down to her irritating manner. Most people believe that the NHS is falling apart. Ministers, borrowing an old Marxist trick, put this down to some sort of false consciousness. But all of the people cannot be wrong all of the time.

Is there a better way? Only if ministers are brave enough to go much further in making health care rationing decisions explicit. Once, the choices were hidden behind doctors' clinical freedom; now, they are hidden, less successfully, behind the supposed imperatives of a market-based system. If they were brought into the open, every citizen would be given a minimum health care entitlement: we would all know what treatment we could expect, and how quickly. The entitlement might well exclude some treatments for people in their seventies. There would be fierce debate; the sound of clashing bedpans would deafen Westminster. But at least it would impose some form of democratic accountability on ministers' stewardship of our most precious public service.