A suitable case for treatment; THE FUTURE OF THE NHS

In the first part of a week-long investigation into the condition of the NHS, the Independent looks at current controversies and asks whether rationing is inevitable in a service where the value of many treatments remains unproven

The NHS is again in turmoil: family doctors are on a collision course with Government; Unison, the biggest health union, is to ballot members on industrial action and the Royal College of Nursing still plans to ask members to vote on whether to abandon their no-strike rule.

After four years of change within the NHS, Labour is to disclose in more detail how it will "abolish" GP fund-holding and dismantle the NHS market the Government created four years ago. At the same time, the Government is further extending fund-holding and driving ahead with its private-finance initiative; the use of private funds to design, build, and run NHS units, which could one day see the private sector running entire hospitals for the NHS.

The health service's perennial battle with medical advance, rising expectations and an ageing population - and whether that will lead to overt rationing of health care - has been given a new edge by the decision of Cambridge Health Authority not to offer a second bone-marrow transplant to Child B.

At the other end of the age spectrum, hospitals have been increasingly discharging still heavily dependent elderly patients to means-tested private nursing homes. Ministers acknowledge that has gone too far, and new guidelines will require some health authorities to restore such care. But by drawing more clearly and tightly the blurred line between health and social care, ministers have faced charges that they are ending the "cradle-to-grave" NHS.

In recent months, it has appeared more accident-prone than usual. A hypodermic needle was left inside a baby in Truro, a porter is said to have assisted in an orthopaedic operation in east London, and a woman was discharged from a casualty department last week with a broken neck.

As Virginia Bottomley was lambasted by her own backbenchers over London hospital closures, a man with head injuries died after being helicoptered from Orpington to Leeds because his hospital could find no neurological intensive- care bed in the London area. Shortly after, a husband entered Northwick Park hospital, north London, to discover his wife, who had spent nine hours on a trolley the day before waiting for admission, was dead in bed from her cancer and no one had told him.

Even so, there is still huge public support for an NHS free at the point of delivery. Our Harris poll indicates that nine out of 10 people would be willing to pay 2p more on income tax if they thought it would improve services - and 67 per cent believe dentistry, one of the fast-disappearing parts of the NHS, should remain a free service.

The NHS, the public believes, should always pay for treatment so long as there is the possibility of a cure - a view supported by four out of five people. And the poll shows a tough line on Child B, the 10-year-old refused a second bone-marrow transplant for leukaemia after doctors at two top hospitals had advised it would cause considerable suffering and stand only a 10 per cent chance of success. Two-thirds of those polled believed she should have been treated on the NHS - not privately, which her parents were ultimately forced to accept.

Voters still see limits to what the NHS should provide, however. Those polled split 46 to 45 per cent over whether the NHS should provide all fertility treatment for women, including test-tube babies. Women held the same view as men, but six out of 10 voters under 35 were in favour, against only one-third of those past retirement age. Only one in five supported the idea that such treatment should be available to women over 40.

People were much more censorious about patients whose conditions are brought on by smoking or drinking. Thirty-nine per cent said treatment for them should be available free on the NHS, but 53 per cent were against, with 50 per cent in the top two social classes favouring free treatment compared to between 33 and 44 per cent for other social classes.

Such issues as rationing still dominate the political agenda, with ministers claiming big advances since the reforms took effect. Mrs Bottomley points to figures showing that 118 patients are treated for every 100 before the reforms, with sharp drops in the longest waits for treatment.

Numbers on the waiting-list rose until March this year when they turned down, but more than 1 million are waiting in England alone.

Ministers argue, however, that it is waiting time, not the numbers waiting, that matters. And, a few hundred in-vitro fertilisation cases aside, no patient has been on the list more than two years, compared to 50,000 in March 1990.

Then more than 200,000 had been waiting over a year. But this March the figure was down to 31,000 - a figure Gerald Malone, the Minister of Health, describes as "a spectacular achievement".

Nearly 75 per cent of patients admitted from the waiting-list now enter hospital within three months, according to ministers, and the average wait is down from 7.5 months to just over 4.5.

But the NHS now counts "finished consultant episodes", not admissions and discharges. A patient seen by two or three consultants during one admission will be counted two or three times, so the "patients treated" figure may well be inflated compared to the old count, a group of NHS statisticians argues.

And if patients "self-defer" - cancel their admission - their wait is counted from the most recent date offered, not from when they first went on the list. Their numbers are relatively small but they have been rising up to almost 80,000 by September.

And against these figures, which, despite the double counting, show increased NHS activity and growing efficiency, there is controversy over management costs and numbers and whether the increase has been worth it.

The Conservatives' research shows the public is deeply alienated by government insistence that the NHS should be "run like a business".

John Maples, deputy party chairman, recorded in November that "we can never win on this issue" and "the best result for the next 12 months would be zero media coverage of the National Health Service".

t Harris Research Centre interviewed a representative sample of 1,044 adults by telephone between 30 May and 3 June 1995.

Nicholas Timmins

Public Policy Editor