These articles in the Britain section are published in the UK printed edition only, and are published here for the benefit of readers of non-UK editions.

National Health Service

Handing out the rations

FOR the past 50 years decisions about who would live and who would die were mostly taken behind closed doors by consultants. In theory, access to treatment was determined solely on the basis of clinical need. In practice, it was often determined by age, geography, marital status and the personal prejudices of the consultants making the decisions.
     This will no longer wash, according to "Rationing and Rights in Health Care", a study published on November 20th by the Institute for Public Policy Research (IPPR). There are several reasons why. The purchaser-provider split, central to the government's health reforms, has made purchasing decisions more transparent. The Patients' Charter, which lays down maximum waiting times for operations, has also focused public attention on lack of resources. Many health authorities have had to make drastic changes to their priorities to reduce queues for operations. One in six authorities now excludes certain treatments such as cosmetic surgery, sex change and tattoo removal. Berkshire Health Authority has specifically excluded 12 treatments from NHS provision, among them treatment of varicose veins, snoring, and the removal of wisdom teeth.
     Access to the most expensive care, such as fertility treatment, depends largely on geography. In some parts of Britain, in vitro fertilisation is provided free of charge. In others, such as Somerset, couples have to pay £500-£1,500 per treatment. Different places have different age thresholds. In Liverpool, treatment is restricted to women under the age of 35, in Humberside to those under the age of 40. Care for terminally-ill patients varies widely. Ealing and Hammersmith, for instance, provide in-hospital care for all patients who are diagnosed as likely to die within a year; in Bromley, by contrast, the threshold is two weeks.
     The more sensitive the rationing decisions, the more covert they tend to be. In some health authorities, if your kidneys fail and you are over 65, you will quietly be allowed to die. Only 8% of patients receiving renal dialysis in Britain in the mid-1980s were aged over 65, compared with a quarter in Germany, France and Italy. There is no clinical justification for such ageism. The five-year survival rate for pensioners on renal dialysis is 62% compared with 44% for those aged 55-64, according to a study published in the British Medical Journal. Similar unjustified discrimination on age grounds can be seen in treatments for certain types of cancer and heart disease.
     There is a strong case, as the IPPR study argues, for bringing such decisions out into the open. "Priority setting", as the politicians prefer to call rationing, involves many, often ad hoc, decisions taken by ministers, health authorities, hospital consultants and doctors. The NHS spends £100m every day. Those who pay for it have a right to know rather more than they do about how this money is being spent, and why.