11 May 2007
Rationing of NHS services is 'inevitable' and with us now, but in future it must be done in a more systematic, transparent and equitable way, the BMA declared this week.
In its report, A rational way forward for the NHS, the powerful doctors' lobby said there should be a national debate as to whether the burden of an ageing population and expensive medical treatments was met by tax increases or NHS rationing.
Speaking at the launch of the report on May 8, Hamish Meldrum, chair of the BMA's GP committee, said: 'The BMA is not advocating rationing and we will continue to press for more resources. But we're realistic. Given the pressures, we do think that rationing may be inevitable. There may be some procedures not available any more. It's not for us to say which, but the process for determining them should be transparent.'
The BMA said that a debate between the public, Parliament and health professionals should lead to the drawing up of an NHS constitution, at the heart of which would be a set of 'core services' the public could expect. In practice, such rationing already happened, said the BMA, but it should be made more explicit.
The decision on precisely what should be excluded from the 'core' list was 'for society, not doctors'.
But the report suggested that 'psychological and lifestyle support' treatments such as cosmetic surgery, IVF and sexual therapy, and 'defensive medicine based on risk-averse risk judgements' – such as elective Caesareans – might be excluded.
Local health economies in surplus would then be able to decide whether to fund additional services. The BMA said that although that would lead to local differences, it would also 'provide an incentive for health economies to manage resources more efficiently'.
BMA chair James Johnson said that in offering additional services, it would be important that local health economies first ensured the needs of their population were addressed.
'It wouldn't be open to a primary care trust to ignore those needs,' he told Public Finance. 'We absolutely wouldn't be talking about bells and whistles at the expense of really important things.'
This, he said, would mean a more thorough needs assessment and would be underpinned by pressure from a new, independent NHS board – another central recommendation of the BMA report.
Contrary to recent claims by outgoing Prime Minister Tony Blair that an independent NHS board would act as a block against reform, Johnson said it was ministers who were under 'huge pressure' to avoid taking the necessary 'tough decisions' about the future of the NHS.
The proposal for an independent board received a muted response from the Department of Health, with health minister Andy Burnham saying: 'Further independence within the NHS should be considered only if it improves services and delivers major benefits for NHS patients.'
Burnham was more adamant on the BMA's calls for rationing. 'We resist any call to make the NHS a slimmed-down emergency service, because that's what it would become if we started rationing care,' he said. 'The only losers would be the poorest people. The NHS should continue to be comprehensive and universal.'
Nigel Edwards, policy director at the NHS Confederation, said the BMA's report was 'worthy of further discussion' but doubted the organisation's assumption that rationing, rather than tax increases, was the solution.
'We need to confront the reality that if the public do not want cost to be a factor in NHS decisions then they may have to be prepared to pay more in order to have every treatment funded,' he said. 'We agree with the BMA that the public is ready for this debate.'
Those thoughts were echoed by Neal Lawson, director of the pressure group Compass, thought to be close to Gordon Brown. 'Many of these ideas about rationing have come in by stealth, rather than proper public debate about what levels of public service we want and the right level of taxation to support that,' Lawson told PF. 'We need a conversation about this. We are an incredibly rich country and a lot of this is about political will rather than economics.'
Mike Dixon, chair of the NHS Alliance, said a further BMA recommendation – that the commissioner/provider split be removed in favour of collaborative integration – was 'understandable but mistaken'.
'If you take out commissioning and contestability you will lose the advantages of value for money… and a more primary care-focused NHS that we're beginning to see,' he told PF.
PFmay2007
