Leading Article: Healthy debate on NHS priorities

IT WAS easy to sympathise with Dr Brian Mawhinney, the health minister, when the BBC's Today programme challenged him yesterday to explain the handling of two contentious cases out of the 40 million or so that the National Health Service deals with every year.

Had there been no need to be politic, the minister might easily have admitted that in at least one of the cases, an elderly patient seemed to have been discriminated against. 'If this impression turns out to be right,' Dr Mawhinney could have said, 'we shall discipline those responsible, and reiterate that it is not our policy to deny treatment to patients just because they are old.'

The argument against such discrimination is straightforward. It may well be true that, in general, old people with chronic arthritis derive less benefit from physiotherapy than do young accident victims - and that, in general, taxpayers' money is better spent on younger patients. But it would be inefficient as well as inhumane for the NHS to impose a simple age limit on certain treatments. Decisions cannot possibly be made on such a crude and uninformed basis.

But the fact remains that in any health system whose consumers do not pay directly for treatment, there will always be scarcity. No matter how much money is available - the pounds 38bn that was spent last year, twice that, or three times that - the NHS must at the margin choose between two different operations, where it can afford to do one but not both.

Under the command economy that used to be the guiding principle of the NHS, these rationing decisions were made in secret and often with inadequate information. Sometimes there was also an alarming element of randomness: patients lucky enough to live in a part of the country that had spare capacity in the therapy they needed would be treated much more quickly than others.

The introduction of an internal market into the NHS has reduced this element of unfairness. But the NHS reforms also bring out into the open the fact that public health care is rationed, and force policy- makers to answer difficult questions previously left to healthcare professionals alone. Who can tell, for instance, whether it is better to give a liver transplant operation to a 45-year-old alcoholic than to give hip replacements to half a dozen men of 65? As NHS funding decisions become more transparent, such questions are becoming a more familiar matter for public debate. To that extent, the fact that Dr Mawhinney was asked about two hard cases may be more a cause for quiet optimism than alarm about the future of the NHS.