Leading Article: Matters of life and death

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ROBERT McNAMARA, the US Secretary of Defense during the Vietnam war, nearly brought his political career to an abrupt end by asking a simple question. Just how many dollars, the former Ford Motor Company president once asked, is a GI's life worth? Although the men at the Pentagon were being forced to choose between lives and money every day, the public had never been taught to think in such terms - and was therefore horrified by Mr McNamara's callousness. So it is with the healthcare debate in Britain: to keep the NHS within its budget, managers must at some point decide to save money rather than lives. Neither side likes to admit it, but rationing is an essential part of any free health service - under both Conservative and Labour governments.

That is why the results of yesterday's King's Fund survey are so depressing. More than half the voters questioned said there should be no limit at all on health spending - implying that the Treasury should write a blank cheque for doctors and hospitals to provide whatever treatments they deem necessary. That cannot be: since demand would be infinite, the costs would continue to rise until there were no longer enough healthy earners to keep alive the growing army of elderly patients. Health budgets paid for by taxes must, therefore, be limited.

Once that is accepted, voters may of course wish to pay more taxes in return for more health spending. But the preference suggested by yesterday's poll - more for the NHS, at the expense of cutting the defence budget, raising taxes and increasing National Insurance - is far short of proof that such higher spending is truly popular. The 1992 general election showed the difference between what people tell pollsters on such emotive issues, and what they in fact do when their own pocketbooks are at risk.

Happily, the survey suggests that voters are becoming aware that the NHS has to choose between different treatments. For instance, respondents preferred health care that improves the quality of people's lives (even if their lives are not immediately threatened) over expensive, hi-tech treatments that create headlines but benefit only a tiny minority of patients. But there is still far to go: the pollsters also found an alarming ignorance of schizophrenia, whose sufferers were thought less deserving of resources than any patients but smokers with cancer.

The trouble is that these questions can only get harder, for health economists are developing new tools to help administrators decide where to spend money. Using the notion of a Qualy, or quality-adjusted life year, they can work out which treatments will provide the most years of comfortable life per pound spent. Qualys may help with choices inside one branch of medicine. Applied more broadly, though, such methods can run into trouble: should hospitals abandon Aids patients to die, for instance, if they think the money could be better spent on looking for a cure than on treating them?

The right people to make such decisions are not doctors or patients but health administrators. They alone know the details of both what medical procedures are possible and what resources are available. But it is the job of ministers to set broader priorities, such as the mix between preventive and curative medicine. So far, they show little readiness to do so. In an uncourageous response to the survey, Virginia Bottomley reiterated old Tory nostrums about spending increases and about care being based on need rather than on the ability to pay. But if the Secretary of State wants health resources to be better allocated, she cannot pander to public prejudices as they are. She must help to change them.