Letter: Rationed care

Sir: Bupa's move towards managed care was planned well before the Ledward case came to light ("Bupa curb on knife-happy surgeons", 26 August).

Managed care systems require tight fiscal and clinical control over doctors in order to control costs and the rate at which patients go through the system. In some cases the participating doctors are required to give advice and opinion according to protocols devised by the healthcare organisation rather than that based on their own knowledge and experience.

The process denies patients choice in certain circumstances and makes the role of the general practitioner redundant in terms of acting as the patient's advocate and gatekeeper to the system.

Bupa will produce dispossessed patients who will presumably have to use the NHS to gain access to treatment just as those Bupa- insured patients requiring unexpected intensive care already do.

It is a great way to ration health care. There is already evidence of managed care in the NHS and public sector, especially in social services.

In essence one is instructed not to assess need which cannot be met. Waiting lists could be eliminated using this process, satisfying both fiscal and political needs. Why pay to be rationed when it is free on the NHS? If Dr Vallance-Owen, Bupa's medical director, has evidence of patients who have undergone unnecessary surgery without their general practitioner's knowledge and with inadequate explanation or consent then he should take action to inform the patients involved.

STEPHEN R SWINDELLS

Consultant Anaesthetist

Harrogate

North Yorkshire